Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs

Nicola M. Zetola, Kyle T. Bernstein, Ernest Wong, Brian Louie, Jeffrey D. Klausner

Research output: Contribution to journalArticlepeer-review

67 Scopus citations


BACKGROUND:: It is hypothesized that sexually transmitted diseases (STDs) increase the risk of HIV acquisition. Yet difficulties establishing an accurate temporal relation and controlling confounders have obscured this relationship. In an attempt to overcome prior methodologic shortcomings, we explored the use of different study designs to examine the relationship between STDs and HIV acquisition. METHODS:: Acutely HIV-infected patients were included as cases and compared with (1) HIV-uninfected patients (matched case-control), (2) newly diagnosed chronically HIV-infected patients (infected analysis), and (3) themselves at prior clinic visits when they tested HIV negative (case crossover). We used t tests to compare the average number of STDs and logistic regression to determine independent correlates and the odds of acute HIV infection. RESULTS:: Between October 2003 and March 2007, 13,662 male patients who had sex with men were tested for HIV infection at San Francisco's municipal STD clinic and 350 HIV infections (2.56%) were diagnosed. Among the HIV-infected patients, 36 cases (10.3%) were identified as acute. We found consistently higher odds of having had an STD within the 12 months [matched case-control, odds ratio 5.2 (2.2-12.6); infected analysis, odds ratio 1.4 (1.0-2.0); and case crossover, odds ratio 1.3 (0.5-3.1)] and 3 months [matched case-control, odds ratio 34.5 (4.1-291.3); infected analysis, odds ratio 2.3 (1.1-4.8); and case crossover, odds ratio 1.8 (0.6-5.6)] before HIV testing among acutely HIV-infected patients. We found higher odds of acute HIV infection among patients with concurrent rectal gonorrhea [17.0 (2.6-111.4), P < 0.01] or syphilis [5.8 (1.1-32.3), P ≤ 0.04] when compared with those HIV-uninfected patients. CONCLUSIONS:: Acute HIV infection was associated with a recent or concurrent STD, particularly rectal gonorrhea, among men at San Francisco's municipal STD clinic. Given the complex relationship between STDs and HIV infection, no single design will appropriately control for all the possible confounders; studies using complementary designs are required.

Original languageEnglish (US)
Pages (from-to)546-551
Number of pages6
JournalJournal of Acquired Immune Deficiency Syndromes
Issue number5
StatePublished - Apr 2009
Externally publishedYes


  • Acute HIV infection
  • Case crossover
  • HIV acquisition
  • Nested case-control, STD

ASJC Scopus subject areas

  • Infectious Diseases
  • Pharmacology (medical)


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