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. 2023 Dec 24;3(2):100180. doi: 10.1016/j.focus.2023.100180

Cumulative Lifetime Violence and Bacterial Vaginosis Infection in Sexually Transmitted Infections: Findings From a Retrospective Cohort Study Among Black Women at Risk for HIV

Yordanos Tesfai 1, Marguerite B Lucea 2, Erica Chan 1, Theresa Asuquo 3, Helen Zhu 4, Tommi L Gaines 4, Jacquelyn C Campbell 5, Jamila K Stockman 4, Kiyomi Tsuyuki 4,⁎
PMCID: PMC10912451  PMID: 38445027

HIGHLIGHTS

  • •

    Bacterial vaginosis (BV) and sexually transmitted infections (STI) are disparately prevalent among Black women.

  • •

    Cumulative violence experience was significantly associated with increased adjusted odds of lifetime BV diagnosis.

  • •

    Lifetime BV diagnosis and past-year BV diagnosis were significantly associated with increased odds of lifetime STI diagnosis. Lifetime BV diagnosis and past-year BV diagnosis were significantly associated with past-year STI diagnosis.

  • •

    More education and support are needed for Black women who experience cumulative violence for BV to reduce the risk of untreated BV and STIs.

Keywords: Bacterial vaginosis, sexually transmitted infections, cumulative violence, physical abuse, sexual abuse, Black women

Abstract

Introduction

Bacterial vaginosis is the most common vaginal condition among women of reproductive age and has been associated with sexually transmitted infections. This study examines the association between cumulative lifetime violence exposure, bacterial vaginosis, and sexually transmitted infections among Black women at risk for HIV.

Methods

HIV-negative Black women in a retrospective cohort study (N=230) completed survey questions on cumulative violence (exposure to sexual or physical abuse before age 18 years and exposure to intimate partner violence or sexual violence [partner or other] after age 18 years and past year), bacterial vaginosis (lifetime and past year), and sexually transmitted infection diagnosis (lifetime and past year). Logistic regression models estimated the associations between cumulative violence, bacterial vaginosis, and sexually transmitted infections. Bacterial vaginosis was examined as a moderator in the association between cumulative violence and sexually transmitted infections.

Results

Many women reported cumulative violence exposure (40%), lifetime bacterial vaginosis diagnosis (53%), and lifetime sexually transmitted infection diagnosis (73%). Cumulative violence experience was significantly associated with increased adjusted odds of lifetime bacterial vaginosis diagnosis (AOR=1.98; 95% CI=1.10, 3.54). Lifetime bacterial vaginosis diagnosis (AOR=2.76; 95% CI=1.45, 5.22) and past-year bacterial vaginosis diagnosis (AOR=2.16; 95% CI=1.14, 4.10) were significantly associated with increased odds of lifetime sexually transmitted infection diagnosis. Lifetime bacterial vaginosis diagnosis (AOR=2.10; 95% CI=1.19, 3.70) and past-year bacterial vaginosis diagnosis (AOR=3.00; 95% CI=1.70, 5.31) were significantly associated with past-year sexually transmitted infection diagnosis. Lifetime bacterial vaginosis infection significantly increased the odds of lifetime sexually transmitted infection diagnosis with increasing cumulative violence exposure.

Conclusions

Our findings support educating and screening Black women who experience cumulative violence for bacterial vaginosis to reduce the risk of untreated bacterial vaginosis and sexually transmitted infections.

INTRODUCTION

In the U.S., Black women are disproportionately affected by sexually transmitted infections (STIs), including HIV.1 In 2019, the rate of reported cases of chlamydia, gonorrhea, and syphilis among Black women was 5.2, 6.8, and 4.4 times, respectively, the rate among White women.2 In 2019, Black women had the highest HIV prevalence (57%) and the highest rate of new HIV diagnoses (22.2 per 100,000) among women.3,4 Ulcerative and inflammatory STIs significantly increase the efficiency of HIV transmission by increasing both one's infectiousness of HIV and one's susceptibility to HIV infection if exposed.5

Bacterial vaginosis (BV) is a lesser understood inflammatory infection of the female reproductive tract. It is the most common vaginitis among women of reproductive age (15–44 years), affecting an estimated 29% of women aged 14–49 years in the U.S.6 Many women are asymptomatic for BV, but a frequent symptom is thin, odorous discharge. Although the causes of BV are not fully understood, factors associated with an increase in BV infection include being pregnant, practicing vaginal douching, having sex with women, engaging in risky sexual behaviors (e.g., condomless sex), and reporting high stress levels.7, 8, 9

BV is associated with an increased risk of female sexual and reproductive health conditions, such as preterm birth, STIs (including HIV), and increased HIV viral shedding.5,10, 11, 12, 13, 14, 15 The mechanisms linking BV and HIV/STI incidence are the subject of ongoing research. Some research posits that herpes simplex virus Type 2 is a risk factor for BV and HIV acquisition.16 Other research highlights that through an imbalance of the vaginal flora, BV heightens the inflammatory state of the vaginal epithelium, resulting in the recruitment of immune cells vulnerable to HIV infection in the cervix.5,17

Black women experience a disproportionate prevalence of BV compared with their racial and ethnic counterparts.6,17 This disparity persists after controlling for demographic and behavioral factors (e.g., age of sexual initiation).6,18 National studies consistently find that Black women report twice the BV prevalence of White women.8 Although limited studies investigate the connection between BV and STI infection, some posit that BV may fuel STI and HIV disparities among Black women in the U.S.17

In addition, stress is consistently linked to increased BV risk. Moderate to high levels of psychosocial stress were associated with increased risk for BV among women, adjusting for education, number of sexual partners, age, race and ethnicity, use of illicit drugs, and vaginal douching practices.19,20 Data from the Longitudinal Study of Vaginal Flora indicated that for each point increase in perceived stress score, women had 29% increased odds of BV diagnosis, net of risk behaviors.21,22

Violence across the life course is an important chronic stressor for all survivors. As a chronic stressor, cumulative lifetime violence exposure can negatively impact health outcomes more than a single violence exposure.23 Black women are disproportionately affected by sexual, physical, and psychological abuse compared with White women.22 However, little research currently frames cumulative lifetime violence as a chronic stressor,24 and limited research assesses the association between cumulative lifetime violence and BV and STIs among Black women in the U.S.

We apply the minority stress theory (MST) with the concept of toxic stress to guide our examination of the connection between violence and both BV and STIs among Black women.25 MST posits that individuals are embedded within sociostructural contexts, which determine the stress they encounter and their coping resources. This theory provides a practical framework to explain how health disparities based on racial, gender, and socioeconomic inequity confer stress–immune dysregulation and enhanced vulnerability to infection.26 According to MST, Black women confront a disproportionate amount of cumulative violence and stress from their intersecting minority stressors (e.g., gender, race) and have fewer coping resources to manage the violence-related stress than cisgender, heterosexual White men and women, which leads to adverse physical and mental effects.25,27

Toxic stress posits that early stress experiences are built into our bodies, creating a vulnerability to future stressors. This chronic stress produces physiologic disruptions or biological memories that undermine the body's stress response systems and affect the developing brain, immune system, and other regulatory controls.28, 29, 30 Together, minority stress and toxic stress posit associations between increased exposure to cumulative lifetime violence and increased susceptibility of Black women to BV infection and other STIs.25,27

To our knowledge, despite robust findings linking stress and BV, no study has examined violence as a potential chronic stressor and risk factor for BV and STIs among Black women. Yet, trauma and violence have long-lasting consequences on sexual and reproductive health. This study examines the associations across cumulative violence, BV infection, and STIs among a sample of Black women at high risk for HIV. We hypothesize that lifetime cumulative violence exposure is positively and significantly associated with BV and STI diagnosis. In addition, given prior work suggesting that BV increases STI risk, we also hypothesize that the presence of a BV diagnosis strengthens (moderates) the association between cumulative violence and STIs.

METHODS

Study Sample

The data analyzed is from the ESSENCE Project: Examining Stress, Sexual Experiences, and Neighborhood Correlates of HIV Risk among Black Women (NICHD R01HD077891). The ESSENCE Project is a retrospective cohort study (2015–2018) examining the associations between the built and social environment, sexual assault, and HIV risk factors among Black women in Baltimore, Maryland. Black women seeking services were recruited in the waiting rooms of 2 Baltimore City public sexually transmitted disease clinics. After providing informed consent, participants were screened for eligibility using the following inclusion criteria: biologically female, aged between 18 and 44 years, self-identified as Black, reported having sex with a man in the past 6 months, and reported having either 2 or more sexual partners in the past year or a high HIV risk sexual partner (i.e., used injection/noninjection drugs, had sex with men, been to prison, had concurrent sex partner, had a sexually transmitted disease, was HIV positive, or did not know whether their sexual partners had any of these characteristics). By study design, at least one third of women reported sexual violence exposure, defined as someone insisting on having sex; insisting on sex without a condom; or using force or threats to engage in oral, vaginal, or anal sex since age 18 years (hence referred to as exposed). Of the 940 women screened for participation in ESSENCE, 310 women were eligible and given the survey. These women proceeded to full survey completion (60–90 minutes), which was administered through audio computer-assisted self-interview. Each woman received $10 for eligibility screening, $25 for completing the survey, and a list of local community resources. The ethical review boards of Johns Hopkins University and the University of California, San Diego approved the study design and procedures. An NIH Certificate of Confidentiality was issued to protect our study's research participants' privacy.

Measures

Lifetime and past-year bacterial vaginosis diagnosis. Our primary dependent variable was self-reported. Women were asked whether a doctor had told them in their lifetime or the past 12 months that they had BV.

Lifetime and past-year sexually transmitted infection diagnosis. Our secondary dependent variable was measured on the basis of whether a doctor told women that they had chlamydia, gonorrhea, trichomoniasis, syphilis, herpes, hepatitis B, and/or hepatitis C in their lifetime or within the past 12 months. If a woman reported having any STI(s) within the specified time frame, they were considered to have a positive STI status in their lifetime and/or within the past year.

Cumulative violence. Our primary independent variable was a summative measure of the lifetime experience of violence occurring before the age of 18 years, after the age of 18 years, and in the past 12 months. We measured physical and sexual violence before the age of 18 years, intimate partner violence (IPV) (physical/psychological/sexual) and nonintimate partner sexual violence after the age of 18 years, and IPV and nonintimate partner sexual violence in the past 12 months. A woman could score a maximum of 2 points for violence in each life course stage for a maximum score of 6. Violence before the age of 18 years was determined by asking Before you turned 18 (anytime during your childhood or teen years), has anyone done the following: 1) Physically abused you (by physical abuse, we mean slapping, beating, kicking, choking, or threats with weapons)? 2) Sexually abused you (by sexual abuse, we mean forcing or pressuring for sex or physically hurting the sexual parts of your body, including touching that made you uncomfortable)? Violence after the age of 18 years was determined through several questions. IPV included responses to the questions Since you turned 18, has a male sex partner: 1) Been very jealous and controlling? Done something to make you afraid of him? Punched, kicked, slammed you against the wall, or beat you up? Choked you? and/or 2) Used threats to make you have sex when you did not want to? Used force (like hitting, holding down, or using a weapon) to make you have sex? Nonintimate partner sexual violence was determined by asking Since you turned 18, has any other male: 1) used threats to make you have sex when you did not want to? and/or 2) used force (like hitting, holding down, or using a weapon to make you have sex? Violence in the prior 12 months was determined using specific Conflict Tactics Scales items.31 Physical violence by an intimate partner or other person was defined as threatening to hit or throw something, twisting arm or hair, pushing or shoving, grabbing, slapping, using a weapon, punching, choking, beating, burning, and kicking. To determine IPV in the last 12 months, we also asked whether a partner had been very jealous or controlling or done something to make you afraid of them in the past year. Sexual violence by an intimate partner or other person was defined as insisting on having sex; insisting on sex without a condom; or using force or threats to engage in oral, vaginal, or anal sex. A binary cumulative violence variable was created to assess the presence of at least 1 form of cumulative violence.

Statistical Analysis

All statistical analyses were conducted using Stata, Version 15.32 Listwise deletion was performed on the 310 women to include individuals with complete data, resulting in a final analytic sample of 230 women. Upon further investigation, women included in the analysis were similar to women excluded from the analysis on most sociodemographics except for more women who reported current unstable housing were excluded from the analysis.

We began our analysis with univariate descriptive statistics of sociodemographic characteristics, the independent variable of cumulative violence, and the dependent variables of BV diagnosis and STI diagnosis (Table 1). We then compared sociodemographic characteristics, cumulative violence, and STI diagnosis by lifetime and past-year BV. We then estimated bivariate logistic regression models. First, we separately estimated the associations between cumulative violence (independent variable and each type of abuse included in cumulative violence measure) and lifetime BV diagnosis (Table 2: Models 1–8) and past-year BV diagnosis (Table 2: Models 9–16); testing the hypothesis that cumulative violence is associated with greater odds of BV infection. Second, we separately estimated the associations between cumulative violence and BV infection on lifetime STI diagnosis (Table 3: Models 1–4) and past-year STI diagnosis (Table 3: Models 6–9), testing the hypothesis that cumulative violence and BV infection is associated with greater odds of STI. Bivariate logistic regression models with significant associations were adjusted for age, education, and total number of lifetime sexual partners. We applied the false discovery rate (FDR) using the Benjamini and Hochberg method to account for multiple comparisons and report original and adjusted p-value estimates using a 0.05 FDR level for models in Tables 2 and 3.33

Table 1.

Sociodemographic Characteristics, Violence, and STIs by BV Diagnosis Among Black Women in Baltimore, Maryland (N=230)

Lifetime BV
 Past-year BV
 Total
Variables No
 Yes
 p-valuea No
 Yes
 p-valuea
n=107 47% n=123 53% n=130 57% n=100 43% n=230 100%
Sociodemographics
 Age,b years 24 (20–28) 27 (23–32) 0.000⁎⁎⁎ 25 (20–29) 27 (22–32) 0.026⁎ 25 (21–30)
 High school education or more 90 84 104 85 0.927 111 85 83 83 0.622 194 84
 Formally employed 70 65 71 58 0.232 82 63 59 59 0.529 141 61
 Unstable housing 6 6 8 7 0.777 9 7 5 5 0.545 14 6
 Number of childrenb 0 (0–2) 1 (0–2) 0.586 1 (0–2) 1 (0–2) 0.926 1 (0–2)
 Individual income 0.618 0.083
  <$10,000 66 62 68 55 84 65 50 50 134 58
  $10,000–$29,999 32 30 43 35 36 28 39 39 75 33
  >$30,000 9 8 12 10 10 8 11 11 21 9
 Relationship status 0.643 0.448
  Single 72 67 86 70 86 66 72 72 158 69
  In relationship 30 28 34 28 38 29 26 26 64 28
  Separated/divorced/widowed/other 5 5 3 2 6 5 2 2 8 3
 Sexual orientation 0.115 0.303
  Heterosexual 95 89 100 81 113 87 82 82 195 85
  Bisexual/lesbian/gay 12 11 23 19 17 13 18 18 35 15
 Sexual partners (total number)b 2.00 (1–2) 2.00 (1–3) 0.087 2.00 (1–2) 2.00 (1–3) 0.299 2.00 (1–2)
Violence
 Cumulative violenceb 0 (0–3) 0 (0–3) 0.003⁎⁎ 0 (0–4) 0 (0–4) 0.031⁎ 0.00 (0–4)
 Cumulative violence (report ≥1) 31 29 60 49 0.002⁎⁎ 43 33 48 48 0.022⁎ 91 40
 Child sexual abuse (ever) 21 20 35 28 0.120 30 23 26 26 0.609 56 24
 Child physical abuse (ever) 19 18 37 30 0.030⁎⁎ 29 22 27 27 0.411 56 24
 Adult sexual abuse (ever) 31 29 60 49 0.002⁎⁎ 43 33 48 48 0.022⁎ 91 40
 Adult physical abuse (ever) 25 23 51 41 0.004⁎⁎ 36 28 40 40 0.049⁎ 76 33
 Adult sexual abuse (past year) 18 17 27 22 0.328 24 18 21 21 0.630 45 20
 Adult physical abuse (past year) 17 16 26 21 0.308 21 16 22 22 0.260 43 19
STIs
 STIs (number ever)b 1 (0–1) 2 (1–3) 0.000⁎⁎⁎ 1 (1–2) 2 (1–3) 0.001⁎⁎⁎ 1 (1–2)
  Yes 67 62 102 83 0.001⁎⁎⁎ 87 67 82 82 0.010⁎⁎ 169 73
 STIs (number in past year)b 0 (0–1) 1 (0–2) 0.038⁎ 0 (0–1) 1 (0–2) 0.001⁎⁎⁎ 0 (0–1)
  Yes 41 38 65 53 0.027⁎ 47 36 59 59 0.001⁎⁎⁎ 106 46
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Source: The ESSENCE Project 2015–2018.

Note: Boldfaces indicate statistical significance.

⁎

p<0.05, **p<0.01, and ***p<0.001).

a

p-value for statistical difference between BV infection and no BV infection using chi-square for comparisons among categorical variables (unless there is a zero cell) and the F-statistic for comparison of means among continuous variables.

b

Median (IQR) reported for continuous variables; columns may add to >100% owing to rounding.

BV, bacterial vaginosis; STI, sexually transmitted infection.

Table 2.

Logistic Regression Models of Cumulative Violence and Violence Types as Predictors of BV Infection Among Black Women in Baltimore, Maryland (N=230)

Model Lifetime BV (yes/no)
 Model Past-year BV (yes/no)
Unadjusted model
 Adjusted model
 Unadjusted model
 Adjusted model
OR 95% CI p-value Adjusted p-value AOR 95% CI p-value Adjusted p-value OR 95% CI p-value Adjusted p-value AOR 95% CI p-value Adjusted p-value
1 Cumulative violence (continuous) 1.17 (1.03, 1.33) 0.015⁎ 0.030⁎ 1.12 (0.98, 1.28) 0.090 0.113 9 1.10 (0.97, 1.24) 0.129 0.258 —
2 Cumulative violence (categorical) 10
 0 ref ref ref ref
 1–6 2.33 (1.35,4.04) 0.002⁎⁎ 0.005⁎⁎ 1.98 (1.10, 3.54) 0.021⁎ 0.053 1.87 (1.09, 3.19) 0.022⁎ 0.088 1.61 (0.92, 2.81) 0.095 0.143
3 Child sexual abuse (ever) 1.63 (0.88, 3.02) 0.121 0.161 — 11 1.17 (0.64, 2.14) 0.609 0.631 —
4 Child physical abuse (ever) 2.00 (1.06, 3.73) 0.031⁎ 0.049⁎ 1.61 (0.82, 3.14) 0.167 0.167 12 1.29 (0.70, 2.36) 0.412 0.549 —
5 Adult sexual abuse (ever) 2.33 (1.35, 4.04) 0.002⁎⁎ 0.005⁎⁎ 1.98 (1.11, 3.54) 0.021⁎ 0.053 13 1.87 (1.09, 3.19) 0.022⁎ 0.088 1.61 (0.92, 2.82) 0.095 0.143
6 Adult physical abuse (ever) 2.32 (1.31, 4.12) 0.004⁎⁎ 0.005⁎⁎ 1.85 (1.01, 3.40) 0.048⁎ 0.080 14 1.74 (1.00, 3.03) 0.050⁎ 0.133 1.45 (0.81, 2.60) 0.214 0.214
7 Adult sexual abuse (past year) 1.39 (0.72, 2.70) 0.329 0.329 — 15 1.17 (0.61, 2.26) 0.631 0.631 —
8 Adult physical abuse (past year) 1.42 (0.72, 2.79) 0.310 0.329 — 16 1.46 (0.75, 2.85) 0.261 0.418 —
Open in a new tab

Source: The ESSENCE Project 2015–2018.

Notes: Boldfaces indicate statistical significance.

Adjusted models include the bivariate association and the confounders of age, high school education, and total number of lifetime sexual partners. A 0.05 false discovery rate level was applied to Models 1–16.

BV, bacterial vaginosis.

⁎

p<0.05, **p<0.01, and ***p<0.001).

Table 3.

Logistic Regression Models of Cumulative Violence and BV Infection as Predictors of STIs Among Black Women in Baltimore, Maryland (N=230)

Model Lifetime STI (yes/no)
 Model Past-year STI (yes/no)
Unadjusted model
 Adjusted model
 Unadjusted model
 Adjusted model
OR 95% CI p-value Adjusted p-value AOR 95% CI p-value Adjusted p-value OR 95% CI p-value Adjusted p-value AOR 95% CI p-value Adjusted p-value
1 Cumulative violence (continuous) 1.05 (0.91, 1.21) 0.514 0.514 — 6 0.95 (0.84, 1.07) 0.415 0.533
2 Cumulative violence (categorical) 7
 0 ref ref
 1–6 1.49 (0.80, 2.75) 0.208 0.277 — 0.87 (0.51, 1.48) 0.600 0.600 —
3 BV infection (ever) 2.90 (1.57, 5.34) 0.001⁎⁎⁎ 0.004⁎⁎ 2.76 (1.45, 5.22) 0.002⁎⁎ 0.004⁎⁎ 8 1.80 (1.07, 3.05) 0.028⁎ 0.056 2.10 (1.19, 3.70) 0.011⁎ 0.017⁎
4 BV infection (past year) 2.25 (1.20, 4.21) 0.011⁎ 0.022⁎ 2.16 (1.14, 4.10) 0.018⁎ 0.018⁎ 9 2.54 (1.49, 4.34) 0.001⁎⁎⁎ 0.004⁎⁎ 3.00 (1.70, 5.31) 0.000⁎⁎⁎ 0.003⁎⁎
5 Interaction model
Cumulative violence (continuous) 0.87 (0.72, 1.05) 0.148 0.86 (0.71, 1.05) 0.137 — —
BV infection (ever) 1.69 (0.81, 3.54) 0.164 1.63 (0.77, 3.48) 0.205 — —
Cumulative violence (continuous)×
 BV infection (ever)		 1.44 (1.05, 1.98) 0.022⁎ 1.45 (1.05, 1.99) 0.024⁎ — —
Open in a new tab

Source: The ESSENCE Project 2015–2017.

Notes: Boldfaces indicate statistical significance.

Adjusted models include the bivariate association and the confounders of age, high school education, and total number of lifetime sexual partners. A 0.05 false discovery rate level was applied to Models 1–4 and 6–9.

⁎

p<0.05, **p<0.01, and ***p<0.001).

BV, bacterial vaginosis; STI, sexually transmitted infection.

Finally, we estimated models to test whether BV infection moderated the association between cumulative lifetime violence and STIs (Table 3: Model 5). For the moderation model, we estimated an interaction between cumulative violence and BV diagnosis to test our hypothesis that the association between cumulative violence and STI diagnosis is stronger for women with a BV diagnosis than for women without a BV diagnosis.

RESULTS

Table 1 reports the sociodemographic, cumulative violence, and STI characteristics of the total and stratified samples (stratified by lifetime versus past-year BV diagnosis). The median age was 25 (IQR=21–30) years. Most women had at least a high school education (84%), were formally employed (61%), had an individual annual income <$10,000 (58%), identified as heterosexual (85%), and were single (69%). Women had a median of 2 sexual partners in their lifetime (IQR=1–2). Women had a median cumulative violence score of 0 (IQR=0–4), with 40% reporting at least 1 experience of violence, 24% reporting child sexual abuse, 24% reporting child physical abuse, 40% reporting adult sexual abuse, 33% reporting adult physical abuse, 20% reporting past-year adult sexual abuse, and 19% reporting past-year adult physical abuse. A large proportion (73%) of women reported lifetime STI diagnosis, whereas 46% reported past-year STI diagnosis.

Women with lifetime BV diagnosis were significantly older; reported more experiences of child physical abuse, adult sexual abuse, and adult physical abuse; had a higher cumulative violence score; and had more lifetime and past-year STIs than women with no prior BV infection. The same held for women with past-year BV diagnosis, except that frequency of child physical abuse and cumulative violence score did not significantly differ from those reported by women with no past-year BV diagnosis.

Table 2 reports findings from logistic regression models assessing the impacts of cumulative violence on BV diagnosis. Compared with women reporting no cumulative violence exposure, women with 1–6 cumulative violence exposures had increased odds of ever having a BV infection (AOR=1.98; 95% CI=1.10, 3.54), but these were marginally significant once adjusting for multiple comparisons using 0.5 FDR. Among the cumulative violence types, adult sexual abuse (AOR=1.98; 95% CI=1.11, 3.54) was significantly associated with increased adjusted odds of having a lifetime BV diagnosis, but this was marginally significant once adjusting for multiple comparisons using 0.5 FDR.

Table 3 reports findings from logistic regression models of the association of cumulative violence and BV infection on STIs. Lifetime BV diagnosis (AOR=2.76; 95% CI=1.45, 5.22) and past-year BV diagnosis (AOR=2.16; 95% CI=1.14, 4.10) were both associated with significantly increased odds of lifetime STI diagnosis. In addition, lifetime BV diagnosis (AOR=2.10; 95% CI=1.19, 3.70) and past-year BV diagnosis (AOR=3.00; 95% CI=1.70, 5.31) were significantly associated with past-year STI diagnosis.

We then examined whether lifetime BV moderates the association between cumulative violence and STIs (Table 3). Figure 1 shows the positive relationship between cumulative violence and lifetime STIs for women ever reporting BV diagnosis. Similarly, it demonstrates a negative relationship between cumulative violence and lifetime STI for women who did not ever experience BV. The directionality of the association between cumulative violence and lifetime STI differed significantly between women reporting lifetime BV and those not reporting BV.

Figure 1.

Figure 1

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Predictive margins with 95% CIs of the interaction of cumulative violence and lifetime bacterial vaginosis.

STI, sexually transmitted infection.

DISCUSSION

This study examined the associations between cumulative violence, BV, and STIs among Black women. From our analysis, we had 4 key findings: (1) women with cumulative violence exposure had greater odds of lifetime BV diagnosis, (2) sexual abuse during adulthood was associated with greater odds of lifetime BV diagnosis, (3) BV diagnosis was significantly associated with increased odds of STI diagnosis, and (4) the impact of cumulative violence on lifetime STIs is moderated by the presence of lifetime BV diagnosis.

Cumulative violence significantly increased the odds of reporting a lifetime BV diagnosis. According to MST, Black women may face more cumulative violence owing to their intersecting minority statuses (e.g., race, gender). Cumulative violence over their life course can be a significant, chronic stressor that may cause physiologic changes and altered inflammatory response, thereby increasing the risk for BV.25,34, 35, 36, 37 Existing literature also identified stressful life events, including violence, as significant predictors of BV. One study found that each additional stressful life event reported resulted in an estimated 13% increase in BV risk for Black women (95% CI=1.04, 1.19).38 In addition, cumulative violence may also significantly contribute to increased risk behaviors, such as condomless sex and multiple partners, associated with increased BV risk.5

Adult sexual abuse and reporting any cumulative violence were associated with greater odds of lifetime BV, controlling for other factors. Identifying specific violence types associated with BV is essential for developing targeted interventions to overcome these increased risks. This abuse may lead to toxic stress and physiologic changes that create an environment that increases the risk for BV.30,39, 40, 41 In addition, sexual abuse may increase the risk of BV owing to vaginal trauma.41,42 Our findings support the criticality of addressing violence and screening for BV among abused women, especially Black women who face additional minority stressors.

Our study found that BV was significantly associated with both increased odds of lifetime and past-year STI infection, an association also found in the Galvin and Cohen review.5 Our findings are similar to existing research that examined a cohort of women in India and found that current BV infection was significantly associated with incident STI infection.43 STI risk reduction interventions should also consider how to lower rates of BV.44,45

We found that BV infection moderates the association between cumulative violence and lifetime STI diagnosis. Specifically, we observed a positive association between cumulative violence and lifetime STI among women with a history of BV infection, whereas a negative association was found among women without a BV history. The interaction between cumulative violence and BV may partially explain the disproportionate STI and HIV rates in Black women. Although we cannot determine temporality between BV and STIs, our cross-sectional results provide support to prior studies in which BV led to inflammatory and physiologic changes that increased susceptibility to STIs.21 This identifies a potentially important mechanism by which we can attenuate cumulative violence's adverse sexual health effects. Our findings support recommendations to address BV in efforts to reduce rates of STIs for Black women.46

Limitations

This study has strengths but is also not without limitations. Strengths of this study include the comprehensiveness of our cumulative violence variable in which we identified different types of cumulative violence events. We gain better insight into how different types of violence and their timing over the life course are associated with BV and STIs, especially in cities such as Baltimore with a high concentration of STIs. In terms of limitations, there may have been reporting bias in self-reported measures, particularly with BV. The number of women with previous BV infection may be higher than reported because BV can go undiagnosed, and there can be issues with recall accuracy. Another limitation is that our measure of IPV centers on violence perpetrated by male sex partners. This does not fully encompass the experiences of nonheterosexual women. We also do not have a direct measure to evaluate stress, so we are unable to evaluate explicitly the role that chronic stress plays in the relationship between IPV and BV. In addition, this study's cross-sectional design does not allow a temporal examination of relationships, limiting our conclusions.

CONCLUSIONS

The MST highlights the toxic stress that Black women in the U.S. face at the confluence of race, gender, and violence. That stress conveys a risk for adverse mental and physical effects.25,27 Cumulative violence across the life course can add to these stressors and have deleterious physiologic effects on immune function,5,26 and can potentially increase the risk for BV infection. This study supports efforts to limit the disproportionately high rates of BV and STIs among Black women, especially survivors of violence. Our results support the need to further study whether leveraging positive coping responses, such as resilience and social support, reduces the negative impacts of BV and STIs among Black women who experience violence-induced stress across their lifetime.

CRediT authorship contribution statement

Yordanos Tesfai: Conceptualization, Writing – original draft. Marguerite B. Lucea: Writing – review & editing. Erica Chan: Writing – review & editing. Theresa Asuquo: Writing – original draft, Writing – review & editing. Helen Zhu: Writing – review & editing. Tommi L. Gaines: Formal analysis, Supervision. Jacquelyn C. Campbell: Conceptualization, Data curation, Funding acquisition, Writing – review & editing. Jamila K. Stockman: Conceptualization, Data curation, Funding acquisition, Writing – review & editing. Kiyomi Tsuyuki: Conceptualization, Formal analysis, Writing – original draft.

ACKNOWLEDGMENTS

IRB of Johns Hopkins University and the University of California, San Diego reviewed and approved ethical considerations. Informed consent was obtained from all individual participants included in the study.

The funders had no role in study design, data collection and analysis, publication decision, or preparation of the paper.

This research was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD077891 for JKS, JCC, TG, KT, and MBL), the National Institute on Minority Health and Health Disparities (L60MD003701for JKS and L60MD011184 for KT), and the National Institute of Alcohol Abuse and Alcoholism (K01AA025009 for KT). We also acknowledge support from the San Diego Center for AIDS Research (Grant Number P30AI036214).

Declaration of interest: none.

REFERENCES

  • 1.Oser CB, Pullen E, Stevens-Watkins D, et al. African American women and sexually transmitted infections: the contextual influence of unbalanced sex ratios and individual risk behaviors. J Drug Issues. 2017;47(4):543–561. doi: 10.1177/0022042616678610. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (U.S.) Centers for Disease Control and Prevention; Atlanta, GA: 2021. Division of STD Prevention. Sexually transmitted disease surveillance 2019: Sexually transmitted disease surveillance 2019 [Slides]https://stacks.cdc.gov/view/cdc/105136 Published April 13. Accessed March 17, 2023. [Google Scholar]
  • 3.HIV surveillance report. Centers for Disease Control and Prevention.http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Updated December 12, 2023. Accessed June 30, 2021.
  • 4.Kaiser Family Foundation . Kaiser Family Foundation; San Francisco, CA: 2020. Black Americans and HIV/AIDS: the basics.https://www.kff.org/hivaids/fact-sheet/black-americans-and-hivaids-the-basics/ Published February 7, 2020. Accessed July 2, 2021. [Google Scholar]
  • 5.Galvin SR, Cohen MS. The role of sexually transmitted diseases in HIV transmission. Nat Rev Microbiol. 2004;2(1):33–42. doi: 10.1038/nrmicro794. [DOI] [PubMed] [Google Scholar]
  • 6.Bacterial vaginosis-CDC fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm. Updated January 5, 2022. Accessed March 19, 2021.
  • 7.Zhang J, Hatch M, Zhang D, Shulman J, Harville E, Thomas AG. Frequency of douching and risk of bacterial vaginosis in African-American women. Obstet Gynecol. 2004;104(4):756–760. doi: 10.1097/01.AOG.0000139947.90826.98. [DOI] [PubMed] [Google Scholar]
  • 8.Bacterial vaginosis (BV) statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/std/bv/stats.htm. Updated February 10, 2020. Accessed March 19, 2021.
  • 9.Bilardi JE, Walker S, Temple-Smith M, et al. The burden of bacterial vaginosis: women's experience of the physical, emotional, sexual and social impact of living with recurrent bacterial vaginosis. PLoS One. 2013;8(9):e74378. doi: 10.1371/journal.pone.0074378. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Myer L, Denny L, Telerant R, de Souza M, Wright TC, Jr, Kuhn L. Bacterial vaginosis and susceptibility to HIV infection in South African women: a nested case-control study. J Infect Dis. 2005;192(8):1372–1380. doi: 10.1086/462427. [DOI] [PubMed] [Google Scholar]
  • 11.Martin HL, Jr, Richardson BA, Nyange PM, et al. Vaginal lactobacilli, microbial flora, and risk of human immunodeficiency virus type 1 and sexually transmitted disease acquisition. J Infect Dis. 1999;180(6):1863–1868. doi: 10.1086/315127. [DOI] [PubMed] [Google Scholar]
  • 12.Minkoff H, Grunebaum AN, Schwarz RH, et al. Risk factors for prematurity and premature rupture of membranes: a prospective study of the vaginal flora in pregnancy. Am J Obstet Gynecol. 1984;150(8):965–972. doi: 10.1016/0002-9378(84)90392-2. [DOI] [PubMed] [Google Scholar]
  • 13.Cu-Uvin S, Hogan JW, Caliendo AM, et al. Association between bacterial vaginosis and expression of human immunodeficiency virus type 1 RNA in the female genital tract. Clin Infect Dis. 2001;33(6):894–896. doi: 10.1086/322613. [DOI] [PubMed] [Google Scholar]
  • 14.Cohn JA, Hashemi FB, Camarca M, et al. HIV-inducing factor in cervicovaginal secretions is associated with bacterial vaginosis in HIV-1–infected women. J Acquir Immune Defic Syndr. 2005;39(3):340–346. doi: 10.1097/01.qai.0000146599.47925.e0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Cherpes TL, Meyn LA, Krohn MA, Lurie JG, Hillier SL. Association between acquisition of herpes simplex virus type 2 in women and bacterial vaginosis. Clin Infect Dis. 2003;37(3):319–325. doi: 10.1086/375819. [DOI] [PubMed] [Google Scholar]
  • 16.Esber A, Vicetti Miguel RD, Cherpes TL, Klebanoff MA, Gallo MF, Turner AN. Risk of bacterial vaginosis among women with herpes simplex virus type 2 infection: a systematic review and meta-analysis. J Infect Dis. 2015;212(1):8–17. doi: 10.1093/infdis/jiv017. [DOI] [PubMed] [Google Scholar]
  • 17.Alcendor DJ. Evaluation of health disparity in bacterial vaginosis and the implications for HIV-1 acquisition in African American women. Am J Reprod Immunol. 2016;76(2):99–107. doi: 10.1111/aji.12497. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Koumans EH, Sternberg M, Bruce C, et al. The prevalence of bacterial vaginosis in the United States, 2001–2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis. 2007;34(11):864–869. doi: 10.1097/OLQ.0b013e318074e565. [DOI] [PubMed] [Google Scholar]
  • 19.Nansel TR, Riggs MA, Yu KF, Andrews WW, Schwebke JR, Klebanoff MA. The association of psychosocial stress and bacterial vaginosis in a longitudinal cohort. Am J Obstet Gynecol. 2006;194(2):381–386. doi: 10.1016/j.ajog.2005.07.047. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Culhane JF, Rauh V, McCollum KF, Hogan VK, Agnew K, Wadhwa PD. Maternal stress is associated with bacterial vaginosis in human pregnancy. Matern Child Health J. 2001;5(2):127–134. doi: 10.1023/a:1011305300690. [DOI] [PubMed] [Google Scholar]
  • 21.Turpin R, Brotman RM, Miller RS, Klebanoff MA, He X, Slopen N. Perceived stress and incident sexually transmitted infections in a prospective cohort. Ann Epidemiol. 2019;32:20–27. doi: 10.1016/j.annepidem.2019.01.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Stockman JK, Hayashi H, Campbell JC. Intimate partner violence and its health impact on ethnic minority women [corrected] J Womens Health (Larchmt) 2015;24(1):62–79. doi: 10.1089/jwh.2014.4879. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Sundermann JM, Chu AT, DePrince AP. Cumulative violence exposure, emotional nonacceptance, and mental health symptoms in a community sample of women. J Trauma Dissociation. 2013;14(1):69–83. doi: 10.1080/15299732.2012.710186. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidemiol. 2002;31(2):285–293. doi: 10.1093/ije/31.2.285. [DOI] [PubMed] [Google Scholar]
  • 25.Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697. doi: 10.1037/0033-2909.129.5.674. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.R Glaser and J Kiecolt-Glaser, How stress damages immune system and health, Discov Med, 5 (26), 2005, 165–169. https://www.discoverymedicine.com/Ronald-Glaser/2009/07/18/stress-damages-immune-system-and-health/. Accessed June 30, 2021. [PubMed]
  • 27.Perry BL, Harp KLH, Oser CB. Racial and gender discrimination in the stress process: implications for African American women's health and well-being. Sociol Perspect. 2013;56(1):25–48. doi: 10.1525/sop.2012.56.1.25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Şimşek Ş, Kaplan İ, Uysal C, Yüksel T, Alaca R. The levels of cortisol, oxidative stress, and DNA damage in the victims of childhood sexual abuse: a preliminary study. J Child Sex Abus. 2016;25(2):175–184. doi: 10.1080/10538712.2016.1123790. [DOI] [PubMed] [Google Scholar]
  • 29.Aneshensel CS. Social stress: theory and research. Annu Rev Sociol. 1992;18(1):15–38. doi: 10.1146/annurev.so.18.080192.000311. [DOI] [Google Scholar]
  • 30.Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–e246. doi: 10.1542/peds.2011-2663. [DOI] [PubMed] [Google Scholar]
  • 31.Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2): development and preliminary psychometric data. J Fam Issues. 1996;17(3):283–316. doi: 10.1177/019251396017003001. [DOI] [Google Scholar]
  • 32.StataCorp, StataCorp LLC; 2017. https://www.stata.com/order/federal-supply-service/GS35F0108W-Rel15.pdf, accessed June 30, 2021.
  • 33.Glickman ME, Rao SR, Schultz MR. False discovery rate control is a recommended alternative to Bonferroni-type adjustments in health studies. J Clin Epidemiol. 2014;67(8):850–857. doi: 10.1016/j.jclinepi.2014.03.012. [DOI] [PubMed] [Google Scholar]
  • 34.James SA. John Henryism and the health of African-Americans. Cult Med Psychiatry. 1994;18(2):163–182. doi: 10.1007/BF01379448. [DOI] [PubMed] [Google Scholar]
  • 35.James SA, Hartnett SA, Kalsbeek WD. John Henryism and blood pressure differences among black men. J Behav Med. 1983;6(3):259–278. doi: 10.1007/BF01315113. [DOI] [PubMed] [Google Scholar]
  • 36.Stevens-Watkins D, Sharma S, Knighton JS, Oser CB, Leukefeld CG. Examining cultural correlates of active coping among African American female trauma survivors. Psychol Trauma. 2014;6(4):328–336. doi: 10.1037/a0034116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Tsuyuki K, Cimino AN, Holliday CN, Campbell JC, Al-Alusi NA, Stockman JK. Physiological changes from violence-induced stress and trauma enhance HIV susceptibility among women. Curr HIV/AIDS Rep. 2019;16(1):57–65. doi: 10.1007/s11904-019-00435-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Paul K, Boutain D, Manhart L, Hitti J. Racial disparity in bacterial vaginosis: the role of socioeconomic status, psychosocial stress, and neighborhood characteristics, and possible implications for preterm birth. Soc Sci Med. 2008;67(5):824–833. doi: 10.1016/j.socscimed.2008.05.017. [DOI] [PubMed] [Google Scholar]
  • 39.Bennett GG, Merritt MM, Sollers Iii JJ, et al. Stress, coping, and health outcomes among African-Americans: a review of the John Henryism hypothesis. Psychol Health. 2004;19(3):369–383. doi: 10.1080/0887044042000193505. [DOI] [Google Scholar]
  • 40.Campbell-Sills L, Stein MB. Psychometric analysis and refinement of the Connor–Davidson resilience scale (CD-RISC): validation of a 10-item measure of resilience. J Trauma. 2007;20(6):1019–1028. doi: 10.1002/jts.20271. [DOI] [PubMed] [Google Scholar]
  • 41.Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385–396. doi: 10.2307/2136404. [DOI] [PubMed] [Google Scholar]
  • 42.Catabay CJ, Stockman JK, Campbell JC, Tsuyuki K. Perceived stress and mental health: the mediating roles of social support and resilience among black women exposed to sexual violence. J Affect Disord. 2019;259:143–149. doi: 10.1016/j.jad.2019.08.037. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Weiss HA, Patel V, West B, Peeling RW, Kirkwood BR, Mabey D. Spousal sexual violence and poverty are risk factors for sexually transmitted infections in women: a longitudinal study of women in Goa, India. Sex Transm Infect. 2008;84(2):133–139. doi: 10.1136/sti.2007.026039. [DOI] [PubMed] [Google Scholar]
  • 44.Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies. AIDS. 2008;22(12):1493–1501. doi: 10.1097/QAD.0b013e3283021a37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Carmona-Gutierrez D, Kainz K, Madeo F. Sexually transmitted infections: old foes on the rise. Microb Cell. 2016;3(9):361–362. doi: 10.15698/mic2016.09.522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Steen R, Wi TE, Kamali A, Ndowa F. Control of sexually transmitted infections and prevention of HIV transmission: mending a fractured paradigm. Bull World Health Organ. 2009;87(11):858–865. doi: 10.2471/blt.08.059212. [DOI] [PMC free article] [PubMed] [Google Scholar]

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