Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Jan 3.
Published in final edited form as: Subst Use Misuse. 2015 Nov 19;50(12):1501–1509. doi: 10.3109/10826084.2015.1018546

Correlates of Trichomonas vaginalis Among Middle Age and Older Adults Who Use Drugs

Lauren E Hearn 1, Nicole Ennis Whitehead 1, Eugene M Dunne 1, William W Latimer 2
PMCID: PMC6941433  NIHMSID: NIHMS1064994  PMID: 26583203

Abstract

Background:

Recent studies have reported high rates of Trichomonas vaginalis among middle age and older adults. Though trichomoniasis risk factors in this age cohort remain largely unknown, illicit drug use has been associated with increased incidence of sexually transmitted infections (STIs). The number of mid-older adults using illicit drugs has increased significantly in recent years suggesting the need to understand the relationship between drug use and STIs in this age cohort.

Objectives:

This study examined the relationship between drug use, sexual-risk behaviors, and biologically confirmed T. vaginalis in a sample of mid-older and younger adults who reported recent drug use.

Methods:

The cross-sectional design examined the relationship between past 6-month drug use, sexual risk-behaviors, and PCR-confirmed T. vaginalis in 264 adults age 18–64 who were recruited from Baltimore, Maryland. These relationships were also explored in the age-stratified sample among those 18–44 years (“younger”) and individuals 45+ years (“mid-older”).

Results:

Trichomoniasis prevalence did not differ significantly between younger (18.8%) and mid-older (19.1%) adults. Mid-older adults that tested positive for T. vaginalis were more likely to have used marijuana and crack in the past 6 months. Among younger adults, there were no associations between trichomoniasis and past 6-month drug use and sexual-risk behavior.

Conclusions/Importance:

Age- and drug-related immune decline is hypothesized to contribute to increase susceptibility to T. vaginalis in mid-older adults. Broad screening for trichomoniasis, particularly among older adults who are often not regarded as at risk for STIs, is needed to control this often asymptomatic infection.

Keywords: trichomoniasis, older adults, drug use, crack cocaine, sexually transmitted infections, immunity

INTRODUCTION

Trichomonas vaginalis is a common sexually transmitted protozoal parasite affecting an estimated 3.7 million people in the United States (Sutton et al., 2007). The true prevalence of trichomoniasis is likely even higher. Owing to the asymptomatic nature of the infection, many infected individuals do not seek treatment (Hobbs et al., 2006). Further, most clinics do not routinely screen for trichomoniasis, and trichomoniasis currently is not a reportable infection in any state (Hoots et al., 2013; Krieger, 1995). The more sensitive nucleic amplification tests used in recent investigations have shown that T. vaginalis prevalence rates are higher than previously estimated through wet mount microscopy and culture (Andrea & Chapin, 2011; Caliendo et al., 2005).

For reasons not understood, susceptibility to infection upon exposure to T. vaginalis varies widely among individuals, as do the symptoms experienced by infected persons (Andrea & Chapin, 2011; Gaydos, Barnes, Quinn, Jett-Goheen, & Hsieh, 2013; Joyner, Douglas, Ragsdale, Foster, & Judson, 2000; Sutton et al., 2007). Women are biologically more susceptible to sexually transmitted infections (STIs) than men, yet T. vaginalis has been detected in up to 70% of male partners of infected women (Petrin, Delgaty, Bhatt, & Garber, 1998; Seña et al., 2007). Recently, a higher prevalence of trichomoniasis has been detected among older men and women compared to younger adults (Andrea & Chapin, 2011; Gaydos et al., 2013; Sutton et al., 2007). Biological changes associated with aging have been proposed to influence older adults’ susceptibility for STIs (Patel, Gillespie, & Foxman, 2003). Extant literature has shown that while the frequency of sexual activity may decrease in middle and older adulthood, a significant proportion of older adults engage in risky sex behaviors, such as inconsistent condom use and multiple sex partnerships (Foster, Clark, Holstad, & Burgess, 2012). Additionally, aging adults who use drugs may have heightened STI susceptibility. Prevalence of past-year illicit drug use has been increasing among individuals over age 50, driven in large part by the aging baby boomer cohort (Johnson & Gerstein, 1998). By 2020, the number of adults over age 50 with a substance use disorder is expected to reach 5.7 million, a twofold increase from reported rates in 2006 (Han, Gfroerer, Colliver, & Penne, 2009). Elevated STI rates have been observed among drug users due to risky sex behavior such as low condom use and multiple partners (Kwiatkowski & Booth, 2003).

Aging adults who use drugs have received attention as an understudied, high-risk group for HIV, and STI’s (Blazer & Wu, 2009; Gossop & Moos, 2008; Wu & Blazer, 2011). To expand on the recent findings of high trichomoniasis prevalence among older adults, this study aimed to identify and compare trichomoniasis prevalence among a sample of community-recruited older and younger adults. A second aim of this study was to characterize drug-use and sexual-risk-behavior patterns among older and younger adults to explore their potential associations with trichomoniasis. In light of recent findings, we hypothesized that higher trichomoniasis prevalence would be found among older adults than among younger adults. Additionally, we predicted that a higher prevalence of behavioral risk factors (i.e., drug use and sexual risk taking) would explain higher trichomoniasis prevalence among older adults.

METHODS

Data from this study were obtained from the baseline data of the NEURO-HIV Epidemiologic Study. The study was approved by the University of Florida’s Institutional Review Board and has received annual renewals. The NEURO-HIV Epidemiologic Study is a longitudinal epidemiological examination of neuropsychological, social and behavioral risk factors of HIV, hepatitis B, hepatitis C, and STIs among injection and noninjection drug users in Baltimore, MD. Study participants were recruited using a variety of community-based outreach strategies, including local newspaper advertisements, street recruitment, and referral; participants were enrolled if they were 18 years of age or older and reported injection or noninjection drug use in the past 6 months. Trained research staff provided detailed information about the study and obtained informed consent before giving the interviewer-administered risk behavior interview (Harrell, Mancha, Petras, Trenz, & Latimer, 2012; Latimer et al., 2007). Urine samples collected at the baseline assessment were screened for the presence of T. vaginalis. Participants who tested positive for T. vaginalis were notified of their results and received counseling; during the counseling conversation, participants received an informational packet on trichomoniasis and a list of community-based clinics that offer free STI testing and treatment. Participants were compensated $45 for completing the baseline assessment.

The present study examined data from the baseline assessment. This study used a subset of participants from the parent study who had a T. vaginalis test performed on their urine sample (n = 275). The final sample size (n = 264) was reached after excluding those with missing data on a variable of interest: age (n = 4) and condom use (n = 7).

Measurements

Demographics.

Participant demographic information including age, gender, race, education, employment, history of homelessness in the past 6 months, and history of incarceration in the past 6 months was obtained. Age was dichotomized as 18–44 years of age or 45+ years of age. Previous studies have denoted 45+ as mid-older age (Phongsavan et al., 2013). Race was dichotomized as Black versus non-Black, as a higher prevalence of trichomoniasis has been reported among individuals who identify as Black (Gaydos et al., 2013; Gollub et al., 2010; Sutton et al., 2007). Dichotomous variables were also created to distinguish participants with or without a high school diploma or General Education Development (GED) equivalent, income from regular employment in the past 6 months, and a positive history of homelessness or incarceration in the past 6 months.

Alcohol and Illicit Drug Use.

The baseline interview assessed for drug type, route of administration, and frequency of usage over the 6 months preceding the assessment. Past 6-month drug use is a common duration of time in substance use research and is often used to reflect patterns of drug use defined as “recent” (e.g., Parry, Petersen, Carney, Dewing, & Needle, 2008; Trenz et al., 2013). Dichotomous variables were created for self-reported past 6-month use of the following drugs: nasal heroin, injection heroin, marijuana, smoked crack, and problem drinking. These drugs were included because they had a past 6-month use prevalence of at least 20% in the sample (Trenz et al., 2013). Problem drinking was defined according to Center for Disease Control and Prevention (2014) guidelines as averaging more than one alcoholic beverage per day for females and more than two per day for males (2014). The baseline interview also acquired information on participants’ lifetime number of years of drug use and lifetime number of years of regular (i.e., daily) drug use.

Sex Risk Behaviors.

Sex risk behaviors that were assessed by the baseline interview include: condom use at last sex; receiving or giving drugs or money for sex in the past 6 months (transactional sex); using alcohol before or during sex in the past 6 months; using noninjection drugs before or during sex in the past 6 months; and using injection drugs before or during sex in the past 6 months. Condom use at last sex is considered a valid indicator of typical condom use behaviors over longer periods (Younge et al., 2008). Dichotomous variables were also created for the five sex risk behaviors to distinguish individuals who reported the behavior from those who did not.

T. Vaginalis Infection.

Participants provided a urine sample that was used to test for T. vaginalis by polymerase chain reaction (PCR). For women, trichomoniasis was assessed using a PCR-based enzyme-linked immunosorbent assay (ELISA) with a digoxigenin-labeled for the detection of amplified T. vaginalis DNA from urine with a sensitivity and specificity of the PCR of 90.8% and 93.4%, respectively (Kaydos et al., 2002.) For men, trichomoniasis was diagnosed from a positive urine test using the GEN-Probe transcription-mediated amplification T. vaginalis research assay with a sensitivity and specificity of 96.7% and 97.5%, respectively (Hardick, Hardick, Wood, & Gaydos, 2006).

Data Analysis

The sample was stratified by age 18–44 and 45+ years. Descriptive statistics for each variable of interest were obtained by frequencies, percentages, and means for the overall sample and for both age groups. Chi-square and two-tailed t-test analyses compared the two age groups on demographic variables, past 6-month drug use, sexual risk taking, and T. vaginalis. In addition, differences in T. vaginalis across gender and age were measured with a two [gender (female, male)] by two [age (18–44 years, 45+ years)] Analysis of Variance (ANOVA) test. The odds ratio (OR) and 95% confidence interval (CI) for the main effects of past 6-month drug use and sexual risk taking on trichomoniasis were calculated using binary logistic regression, stratifying by age to appreciate the relationship between health behaviors and T. vaginalis in older and younger adults. Adjusted models included gender, race, educational attainment, past 6-month incarceration, and past 6-month homelessness; these variables were included due to their previously reported association with trichomoniasis (Allsworth, Ratner, & Peipert, 2009; Nijhawan et al., 2011; Swygard, Sena, Hobbs, & Cohen, 2004). All statistical analyses were performed using IBM SPSS Statistics 21 (2013).

RESULTS

Sample Characteristics

The majority of the overall sample (N = 264) identified as Black (86.4%); 57.6% of participants were female, and 18.9% of the sample tested positive for T. vaginalis (Table 1). Past 6-month sexual risk behavior was high, 76.5% of the sample reported engaging in at least one sexual risk behavior. The sample was fairly evenly split between older and younger participants, with 52.3% of the sample between 18 and 44 years of age and 47.7% age 45 and older.

TABLE 1.

Demographic and drug use comparisons by age (N = 264)a

Variable Entire sample 18–44 years old 45+ years old Test statistics
M or N SD or % M or N SD or % M or N SD or % χ2 or t p-value
N 264 100 138 52.3 126 47.7
Age 41.8 9.5 34.7 7.3 49.6 3.6 −21.4 <0.001
Gender 6.6 0.007
Female 152 57.6 90 65.2 62 49.2
Race/ethnicity 0.6 0.452
Black 228 86.4 116 84.1 112 88.9
Non-Black 31 11.7 18 13.0 13 10.3
Education 3.6 0.056
<High school 106 40.2 63 45.7 43 34.1
High school or GED 158 59.9 75 54.3 83 65.9
Employed past 6 months 50 18.9 32 23.2 18 14.3 3.4 0.065
Homeless in last 6 months 40 15.2 21 15.2 19 15.1 0.001 0.916
Incarcerated in past 6 months 26 9.9 15 10.9 12 9.5 0.03 0.987
T. vaginalis (+) 50 18.9 26 18.8 24 19.1 0.002 0.966
Engaged in ≥1 sex risk behavior in past 6 months 202 76.5 110 79.7 92 73.0 2.7 0.099
Transactional sex 26 9.9 16 11.6 10 7.9 1.0 0.319
Used alcohol before/during sex 98 37.1 54 39.1 44 34.9 0.5 0.475
Used non-IVb drugs 97 36.7 61 44.2 36 28.6 6.9 0.009
Used IV drugs before/during sex 89 33.7 58 42.0 31 24.6 9.0 0.003
Condom used at last sex 78 29.6 32 23.2 46 36.5 5.6 0.018
Past 6 month drug use
Problem drinking 105 39.8 63 45.7 42 33.3 4.6 0.032
Nasal heroin 67 25.4 32 23.2 35 27.8 0.7 0.411
Marijuana 96 36.4 64 46.4 32 25.4 12.5 <0.001
Smoked crack 103 39.0 43 31.2 60 47.6 7.5 0.006
Injection heroin 36 13.6 16 11.6 20 15.9 1.0 0.312
Lifetime drug use history
Years smoked crack 14.3 7.9 13.0 7.2 15.6 8.3 2.1 0.034
Years daily crack smoking 4.9 7.4 4.6 6.8 5.3 8.0 0.8 0.428
Years marijuana use 15.1 13.1 12.1 9.9 18.4 15.3 3.8 <0.001
Years daily marijuana use 5.3 8.0 5.1 6.6 5.5 9.3 0.4 0.672
Open in a new tab
a

N may vary slightly according to missing data.

b

Injection.

The mean age of the 18–44 age group was 34.7 (SD = 7.3), and the average age of the 45+ age group was 49.6 (SD = 3.6). Females comprised a larger portion of the 18–44 age group (65.2%) than the 45+ group (49.2%), χ2(1, N = 264) = 6.6, p = 0.007. Individuals in the 45+ age group were more likely to have used a condom at last sex (χ2(1, N = 264) = 5.6, p = 0.018) and to have used crack in the past 6 months (χ2(1, N = 264) = 7.5, p = 0.006) than those ages 18–44. Individuals in the 18–44 age group were more likely to have engaged in past 6-month problem drinking (χ2(1, N = 264) = 4.6, p = 0.032) and more likely to have used marijuana in the past 6 months (χ2(1, N = 264) = 12.5, p < 0.001) than the older age group. The younger cohort was also more likely in the past 6 months to have used noninjection drugs before or during sex (χ2(1, N = 264) = 6.9, p = 0.009) and to have used injection drugs before or during sex (χ2(1, N = 264) = 9.0, p = 0.003). The older cohort reported greater lifetime number of years of crack smoking (t(262) = 2.1, p = 0.034) and marijuana use (t(262) = 3.8, p < 0.001), though the two groups did not differ in number of years of daily crack smoking or daily marijuana use. The two groups also did not differ on race, education, and biologically confirmed Trichomonas infection, or on past 6-month employment, homelessness, incarceration, transactional sex, alcohol use before or during sex, nasal heroin use, and injection heroin use.

Comparison of Trichomoniasis by Gender, Age

There was a significant main effect of gender on trichomoniasis, F (1,261) = 15.33, p < 0.001, η2 = 0.046, with a significantly higher prevalence of trichomoniasis among women compared with men. There was not a main effect of age on T. vaginalis prevalence, F (1,261) = 0.44, p = 0.506, η2 = 0.001. There was no interaction between age and gender, F (1,261) = 0.67, p = 0.413, η2 = 0.002 (Table 2).

TABLE 2.

Comparison of trichomoniasis by gender and age (N = 264)

df Mean Square F η2 p
Gender 1 2.253 15.33 0.046 <0.001
Age 1 0.065 0.44 0.001 0.506
Gender × age 1 0.099 0.67 0.002 0.413
Error 261 0.147
Open in a new tab

Group differences in positive T. vaginalis test, by gender (male, female) and age (18–44 years, 45+ years).

Associations Between Risk Behavior and Trichomoniasis, by Age Group

Younger Adults.

Among those ages 18–44, there were no associations between past 6-month drug use and trichomoniasis. There were also no associations between sexual-risk behavior and trichomoniasis. Adjusting for sociodemographic variables did not change the pattern of nonsignificance.

Middle Age and Older Adults.

Individuals that tested positive for T. vaginalis were more likely to have used crack in the past 6 months (OR = 3.8, 95% CI: 1.5–9.8) and to have used marijuana (OR = 2.6, 95% CI: 1.1–6.6). Those who reported that they used a condom at last sex were less likely to test positive for Trichomonas (OR = 0.3, 95% CI: 0.1–0.9) than those who reported using a condom. After adjusting for sociodemographic variables, the patterns of significance remained unchanged for marijuana and crack use, though condom use lost significance (AOR = 0.3, 95% CI: 0.1–1.1). Unadjusted and adjusted odds ratios are presented in Table 3.

TABLE 3.

Odds ratios and 95% CIs for association between risk behavior and trichomoniasis, by age

18–44 years 45+ years
Unadjusted ORa p Adjusted ORc p Unadjusted ORa p Adjusted ORc p
(CIb) p (CIb) p (CIb) p (CIb) p
Problem drinking
No Referent Referent Referent Referent
Yes 1.1 (0.5–2.6) 0.847 0.8 (0.3–2.1) 0.742 1.3 (0.5–3.2) 0.63 1.0 (0.4–2.7) 0.979
Nasal heroin
No Referent Referent Referent Referent
Yes 1.2 (0.5–3.2) 0.702 1.4 (0.5–3.8) 0.562 1.3 (0.5–3.3) 0.612 0.9 (0.3–2.4) 0.780
Injection heroin
No Referent Referent Referent Referent
Yes 0.3 (0.03–2.1) 0.215 0.4 (0.1–3.3) 0.398 0.7 (0.2–2.6) 0.591 1.1 (0.3–4.8) 0.907
Marijuana
No Referent Referent Referent Referent
Yes 0.89 (0.4–2.3) 0.797 1.0 (0.4–2.6) 0.941 2.6 (1.1–6.6) 0.046 3.1 (1.1–8.9) 0.036
Smoked crack
No Referent Referent Referent Referent
Yes 1.1 (0.4–3.0) 0.848 1.0 (0.3–2.7) 0.956 3.8 (1.5–9.8) 0.005 3.8 (1.4–10.3) 0.010
Condom used at last sex
No Referent Referent Referent Referent
Yes 1.0 (0.4–2.8) 0.988 0.8 (0.3–2.3) 0.653 0.3 (0.1–0.9) 0.035 0.3 (0.1–1.1) 0.073
Transactional sex past 6 months
No Referent Referent Referent Referent
Yes 0.6 (0.1–2.8) 0.530 0.4 (0.6–2.5) 0.308 1.0 (0.2–5.2) 0.959 1.0 (0.2–5.9) 0.986
Used alcohol before/during sex past 6
months
No Referent Referent Referent Referent
Yes 1.2 (0.5–3.0) 0.604 1.2 (0.5–3.1) 0.727 0.5 (0.2–1.4) 0.208 0.7 (0.2–1.9) 0.54
Used non–IVd drugs before/during sex past 6 months
No Referent Referent Referent Referent
Yes 1.0 (0.4–2.3) 0.953 1.1 (0.4–2.8) 0.880 1.2 (0.5–3.1) 0.683 1.4 (0.5–4.0) 0.495
Used IV drugs before/during sex past 6 months
No Referent Referent Referent Referent
Yes 1.3 (0.6–3.2) 0.527 1.6 (0.6–4.2) 0.357 1.6 (0.6–4.1) 0.356 2.0 (0.7–5.9) 0.208
Open in a new tab
a

Odds ratio.

b

95% confidence interval (CI).

c

Adjusted for age, gender, education, race, past 6-month homelessness and past 6-month incarceration.

d

Injection.

DISCUSSION

This study examined correlates of trichomoniasis among a cohort of older and younger drug-using adults. The overall prevalence of trichomoniasis in this sample fell within the range of previously reported values detected using PCR in high-risk populations (Freeman et al., 2010; Kaydos et al., 2002). Consistent with previous reports, the prevalence of infection among women was significantly higher than among men (Krieger, 1995; Petrin et al., 2008; Seña et al., 2007). The prevalence of trichomoniasis in this sample did not differ significantly between older and younger adults, in contrast to previous samples of community residing adults and patients presenting for STI-related complaints (Andrea & Chapin, 2011; Gaydos et al., 2013; Verteramo, Calzolari, Degener, Masciangelo, & Patella, 2008). It is possible that the high-reported rate of sexual risk behaviors in this drug-using sample contributed to similar rates of infection in both age groups. In addition, the sexual networks of these participants may have been characterized by high prevalence of STIs (Hallfors, Iritani, Miller, & Bauer, 2007; Laumann & Youm, 1999).

However, differences in the correlates of trichomoniasis were found between the two age cohorts. Among older adults, crack smoking and marijuana use predicted Trichomonas infection while no association was found between drug use and risk behaviors among the younger cohort.

Consistent with prior research, alcohol, crack, heroin, and marijuana were the most commonly used drugs among the older cohort (Wu & Blazer, 2011). Crack use was particularly prevalent among older participants in this sample, with nearly 50% reporting recent use. Extant literature has shown that women who recently smoked crack were significantly more likely to have trichomoniasis compared with noncrack smokers, highlighting its possible role in trichomoniasis acquisition (Cu-Uvin et al., 2002; Gollub et al., 2010). Crack’s contribution to trichomoniasis infection may be due to its association with risky sexual behavior. Prior research has associated crack use with increased number of drug-using partners, exchange of sex for drugs, and low rates of condom use (Gossop & Moos, 2008). In the overall sample, crack smokers were almost eight times more likely to have engaged in transactional sex. However, when these relationships were reexamined in the age-stratified sample, the association between crack smoking and transactional sex was only found in the younger cohort. Therefore, crack’s association with sexual risk behavior cannot fully account for the increased prevalence of T. vaginalis among older crack users, suggesting that other factors such as age- and drug-related biological factors may have conferred greater susceptibility to infection among older participants in this sample.

Of the few studies that have examined the effects of aging on trichomoniasis susceptibility, it appears that mid-life biological changes may confer increased risk of trichomoniasis. Among women, declining estrogen levels in menopause can cause drying and thinning of vaginal mucosa (Bachmann & Leiblum, 2004; Kauschic, Roth, Anipindi, & Xiu, 2011). Mucosal tears can result from sexual activity, enhancing transmission of STIs (Minkin, 2010; Senanayake, 2000). Additionally, low estrogen levels result in elevated vaginal pH (Caillouette, Sharp, Zimmerman, & Roy, 1997). Increased vaginal pH appears important for T. vaginalis pathogenesis and has been hypothesized to contribute to the increased risk of trichomoniasis observed among menopausal women compared with younger women (Garber, Lemchukfavel, & Bowie, 1989; Spinillo et al., 1997). Hormone levels also affect the female reproductive tract’s innate immune system, which mounts the primary response against T. vaginalis (Beagley & Gockel, 2003; Fichorova, 2009). However, it is currently unclear how hormonal changes may affect T. vaginalis susceptibility in older women (Hickey, Patel, Fahey, & Wira, 2011; Wira & Fahey, 2008; Wira, Patel, Ghosh, Mukura, & Fahey, 2011).

Extant literature suggests a link between illicit drug use and susceptibility to infections. Evidence suggests that crack use promotes susceptibility to infection, though inconsistent findings warrant further exploration (Baldwin, Roth, & Tashkin, 1998; Pellegrino & Bayer, 1998). Similarly, it appears that marijuana may decrease resistance to infection. However, marijuana’s effects on various immune cell types and the clinical significance of these effects remain poorly understood (Friedman, Newton, & Klein, 2003). In addition to studying the immune-altering affects of illicit drug use, longitudinal epidemiological studies are needed to explore associations between drug use, altered immune function, and infection (Cabral, 2006). Other risk factors associated with drug using lifestyles, such as poor nutritional status, may contribute to poor health and infection susceptibility (Rosen, Smith, & Reynolds, 2008). Because recent drug use showed association with trichomoniasis among older adults but not younger adults in this study, it appears likely that cumulative years of drug use, associated lifestyle factors and age-related biological factors contributed to trichomoniasis susceptibility among the older adults.

This study fills a critical gap in the literature toward understanding clinically relevant associations between recent and chronic substance use and STI among older adults. Additional epidemiological studies, in conjunction with improved understanding of the effects of drug use and drug-related lifestyle factors on infection susceptibility, are needed to better understand these relationships. This study also describes the substance use patterns of a sample of older adults who continue to use drugs into middle and later life. The number of older adult illicit drug users is expected to increase over the next decades, and this population’s substance use will likely exacerbate many problems associated with aging (Colliver, Compton, Gfroerer, & Condon, 2006; Gossop & Moos, 2008). Limitations of this study include lack of information on participants’ history of diagnosis and treatment for trichomoniasis. Past 6-month drug use and sexual behaviors were self-reported by participants, which may have been inaccurate due to recall bias or social desirability bias. However, self-reported sex behavior and drug use from drug users have been found to be valid and reliable (Anthony et al., 1991). Our study differs from previous reports in that we found no association between race and trichomoniasis. This may be related to the small sample of non-Black participants in this study, which may have resulted in insufficient power to detect an association between race and trichomoniasis. Additional limitations include the cross-sectional nature of the data, limiting the ability to draw a causal connection between drug use and trichomoniasis.

While acknowledging these limitations, the current study demonstrates the high prevalence of trichomoniasis among both younger and older adults who use drugs, reinforcing the position that broad screening for trichomoniasis is needed to make a substantial impact on controlling this infection. Clinicians often do not consider their older patients to be at risk for STIs, making trichomoniasis especially likely to remain undiagnosed among older adults (Kwiatkowski & Booth, 2003). Without the inclusion of trichomoniasis as a standard component of STI screenings, testing, and treating only symptomatic individuals is unlikely to reduce the high prevalence of trichomoniasis in the United States. Further, clinicians frequently miss or misdiagnose substance use disorders among older adults, even as the number of adults with substance use disorders is expected to rise as the baby-boomer generation ages (Wu & Blazer, 2011). Substance use among older adults may exacerbate physical and psychological conditions. Given the proportion of older adults who engage in sexual risk behaviors, substance use may also place older adults at higher risk of acquiring STIs (Foster, Clark, Holstad, & Burgess, 2012; Gossop & Moos, 2008). Within the past decade the Screening, Brief Intervention, and Referral to Treatment for substance use disorders, designed as a universal screening component of routine medical care, has been tailored to the needs of older adults (SAMHSA, 2014; Schonfeld et al., 2014). Pilot data of the Brief Intervention and Treatment of Elders (BRITE) model show significant decreases in substance use following brief intervention (Schonfeld et al., 2010). Adoption of brief, universal screening programs by medical and community service settings is a promising opportunity to identify and treat substance misuse among older adults, which may potentially impact drug-associated health conditions in this population.

GLOSSARY

Polymerase Chain Reaction (PCR)

A technique used to generate copies of a DNA sequence. This technique has several applications, including diagnosing infectious diseases.

Trichomoniasis

A sexually transmitted infection of the urogenital tract affecting both men and women.

Trichomonas vaginalis

The causative agent of trichomoniasis, a sexually transmitted infection.

Biographies

graphic file with name nihms-1064994-b0001.gif

Lauren E. Hearn, MS, is a doctoral student in Clinical and Health Psychology at the University of Florida. Her research interests include healthcare utilization and disease management among medically underserved populations.

graphic file with name nihms-1064994-b0002.gif

Nicole Ennis Whitehead, PhD, is an Assistant Professor in the Clinical and Health Psychology program at the University of Florida. Dr. Whitehead’s research aims to understand the unique factors that influence inequities in health outcomes among low income and minority populations and to apply this knowledge in the development and dissemination of effective interventions.

graphic file with name nihms-1064994-b0003.gif

Eugene M. Dunne, MA, is a doctoral student in Clinical and Health Psychology and a predoctoral fellow at University of Florida Substance Abuse Training Center in Public Health (NIDA-T32–035167; PI: Linda Cottler). His research interests are focused on prevention of substance abuse and infectious disease.

graphic file with name nihms-1064994-b0004.gif

William W. Latimer, PhD, MPH, is Dean of the School of Health Sciences, Human Services and Nursing at Lehman College of the City University of New York. He has published extensively on the epidemiology, prevention, and treatment of infectious disease and drug dependence, with a focus on neurobehavioral risk factors of disease, treatment engagement, and outcome.

Footnotes

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES

  1. Allsworth JE, Ratner JA, & Peipert JF (2009). Trichomoniasis and other sexually transmitted infections: results from the 2001–2004 National Health and Nutrition Examination Surveys. Sexually Transmitted Diseases, 36(12), 738–744. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Andrea SB, & Chapin KC (2011). Comparison of Aptima Trichomonas vaginalis transcription-mediated amplification assay and BD affirm VPIII for detection of T. vaginalis in symptomatic women: performance parameters and epidemiological implications. Journal of Clinical Microbiology, 49(3), 866–869. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Anthony JC, Vlahov D, Celentano DD, Menon AS, Margolick JB, Cohn S, … Polk BF (1991). Self-report interview data for a study of HIV-1 infection among intravaneous drug users: descrption of methods and preliminary evidence on validity. Journal of Drug Issues, 21(4), 739–757. [Google Scholar]
  4. Bachmann GA, & Leiblum SR (2004). The impact of hormones on menopausal sexuality: a literature review. Menopause, 11(1), 120–130. [DOI] [PubMed] [Google Scholar]
  5. Baldwin GC, Roth MD, & Tashkin DP (1998). Acute and chronic effects of cocaine on the immune system and the possible link to AIDS. Journal of Neuroimmunology, 83(1–2), 133–138. [DOI] [PubMed] [Google Scholar]
  6. Beagley KW, & Gockel CM (2003). Regulation of innate and adaptive immunity by the female sex hormones oestradiol and progesterone. FEMS Immunololgy & Medical Microbiology, 38(1), 13–22. [DOI] [PubMed] [Google Scholar]
  7. Blazer DG, & Wu LT (2009). The epidemiology of substance use and disorders among middle aged and elderly community adults: national survey on drug use and health. American Journal of Geriatric Psychiatry, 17(3), 237–245. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cabral GA (2006). Drugs of abuse, immune modulation, and AIDS. Journal of Neuroimmune Pharmacology, 1(3), 280–295. [DOI] [PubMed] [Google Scholar]
  9. Caillouette JC, Sharp CF Jr., Zimmerman GJ, & Roy S (1997). Vaginal pH as a marker for bacterial pathogens and menopausal status. American Journal of Obstetrics & Gynecology, 176(6), 1270–1275. [DOI] [PubMed] [Google Scholar]
  10. Caliendo AM, Jordan JA, Green AM, Ingersoll J, Diclemente RJ, & Wingood GM (2005). Real-time PCR improves detection of Trichomonas vaginalis infection compared with culture using self-collected vaginal swabs. Infectious Diseases in Obstetrics and Gynecology, 13(3), 145–150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Centers for Disease Control and Prevention. (2014). Fact sheets alcohol use and health. Retrieved from http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
  12. Colliver JD, Compton WM, Gfroerer JC, & Condon T (2006). Projecting drug use among aging baby boomers in 2020. Annals of Epidemiology, 16(4), 257–265. [DOI] [PubMed] [Google Scholar]
  13. Cu-Uvin S, Ko HJ, Jamieson DJ, Hogan JW, Schuman P, Anderson J, & Grp H (2002). Prevalence, incidence, and persistence or recurrence of trichomoniasis among human immunodeficiency virus (HIV)-positive women and among HIV-negative women at high risk for HIV infection. Clinical Infectious Diseases, 34(10), 1406–1411. [DOI] [PubMed] [Google Scholar]
  14. Fichorova RN (2009). Impact of T. vaginalis infection on innate immune responses and reproductive outcome. Journal of Reproductive Immunology, 83(1–2), 185–189. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Foster V, Clark PC, Holstad MM, & Burgess E (2012). Factors associated with risky sexual behaviors in older adults. Journal of the Association of Nurses in AIDS Care, 23(6), 487–499. [DOI] [PubMed] [Google Scholar]
  16. Freeman AH, Katz KA, Pandori MW, Rauch LM, Kohn RP, Liska S, & Klausner JD (2010). Prevalence and correlates of Trichomonas vaginalis among incarcerated persons assessed using a highly sensitive molecular assay. Sexually Transmitted Diseases, 37(3), 165–168. [DOI] [PubMed] [Google Scholar]
  17. Friedman H, Newton C, & Klein TW (2003). Microbial infections, immunomodulation, and drugs of abuse. Clinical Microbiology Review, 16(2), 209–219. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Garber GE, Lemchukfavel LT, & Bowie WR (1989). Isolation of a cell-detaching factor of Trichomonas-Vaginalis. Journal of Clinical Microbiology, 27(7), 1548–1553. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Gaydos CA, Barnes MR, Quinn N, Jett-Goheen M, & Hsieh YH (2013). Trichomonas vaginalis infection in men who submit self-collected penile swabs after internet recruitment. Sexually Transmitted Infections, 89(6), 504–508. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Gollub EL, Armstrong K, Boney T, Mercer D, Chhatre S, Fiore D, … Mackey K (2010). Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial. Substance Use & Misuse, 45(12), 2203–2220. [DOI] [PubMed] [Google Scholar]
  21. Gossop M, & Moos R (2008). Substance misuse among older adults: a neglected but treatable problem. Addiction, 103(3), 347–348. [DOI] [PubMed] [Google Scholar]
  22. Hallfors DD, Iritani BJ, Miller WC, & Bauer DJ (2007). Sexual and drug behavior patterns and HIV and STD racial disparities: the need for new directions. American Journal of Public Health, 97(1), 125–132. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Han B, Gfroerer JC, Colliver JD, & Penne MA (2009). Substance use disorder among older adults in the United States in 2020. Addiction, 104(1), 88–96. [DOI] [PubMed] [Google Scholar]
  24. Hardick A, Hardick J, Wood BJ, & Gaydos C (2006). Comparison between the Gen-Probe transcription-mediated amplification Trichomonas vaginalis research assay and real-time PCR for Trichomonas vaginalis detection using a Roche LightCycler instrument with female self-obtained vaginal swab samples and male urine samples. Journal of Clinical Microbiology, 44(11), 4197–4199. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Harrell PT, Mancha BE, Petras H, Trenz RC, & Latimer WW (2012). Latent classes of heroin and cocaine users predict unique HIV/HCV risk factors. Drug and Alcohol Dependence, 22(1), 220–227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hickey DK, Patel MV, Fahey JV, & Wira CR (2011). Innate and adaptive immunity at mucosal surfaces of the female reproductive tract: stratification and integration of immune protection against the transmission of sexually transmitted infections. Journal of Reproductive Immunology, 88(2), 185–194. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Hobbs MM, Lapple DM, Lawing LF, Schwebke JR, Cohen MS, Swygard H, & Sena AC (2006). Methods for detection of Trichomonas vaginalis in the male partners of infected women: implications for control of trichomoniasis. Journal of Clinical Microbiology, 44(11), 3994–3999. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Hoots BE, Peterman TA, Torrone EA, Weinstock H, Meites E, & Bolan GA (2013). A Trich-y question: should Trichomonas vaginalis infection be reportable? Sexually Transmitted Diseases, 40(2), 113–116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Johnson RA & Gerstein DR (1998). Initiation of use of alcohol, cigarettes, marijuana, cocaine, and other substances in US birth cohorts since 1919. American Journal of Public Health, 88(1), 27–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Joyner JL, Douglas JM, Ragsdale S, Foster M, & Judson FN (2000). Comparative prevalence of infection with Trichomonas vaginalis among men attending a sexually transmitted diseases clinic. Sexually Transmitted Diseases, 27(4), 236–240. [DOI] [PubMed] [Google Scholar]
  31. Kauschic C, Roth KL, Anipindi V, & Xiu F (2011). Increased prevalence of sexually transmitted viral infections in women: the role of female sex hormones in regulating susceptibility and immune responses. Journal of Reproductive Immunology, 88(2), 204–209. [DOI] [PubMed] [Google Scholar]
  32. Kaydos SC, Swygard H, Wise SL, Sena AC, Leone PA, Miller WC, & Hobbs MM (2002). Development and validation of a PCR-based enzyme-linked immunosorbent assay with urine for use in clinical research settings to detect Trichomonas vaginalis in women. Journal of Clinical Microbiology, 40(1), 89–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Krieger JN (1995). Trichomoniasis in men - old issues and new data. Sexually Transmitted Diseases, 22(2), 83–96. [PubMed] [Google Scholar]
  34. Kwiatkowski CF, & Booth RE (2003). HIV risk behaviors among older American drug users. Journal of Acquired Immune Deficiency Syndrome, 33(Suppl 2), S131–S173. [DOI] [PubMed] [Google Scholar]
  35. Latimer WW, Moleko AG, Melnikov A, Mitchell M, Severtson SG, & Floyd L (2007). Prevalence and correlates of hepatitis A among adult drug users: the significance of incarceration and race/ethnicity. Vaccine, 25(41), 7125–7131. [DOI] [PubMed] [Google Scholar]
  36. Laumann EO, & Youm Y (1999). Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases, 26(5), 250–261. [DOI] [PubMed] [Google Scholar]
  37. Minkin MJ (2010). Sexually transmitted infections and the aging female: placing risks in perspective. Maturitas, 67(2), 114–116. [DOI] [PubMed] [Google Scholar]
  38. Nijhawan AE, DeLong AK, Celentano DD, Klein RS, Sobel JD, & Cu-Uvin S (2011). The association between Trichomonas infection and incarceration in HIV-seropositive and at-risk HIV-seronegative women. Sexually Transmitted Diseases, 38(12), 1094–1100. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Parry C, Petersen P, Carney T, Dewing S, & Needle R (2008). Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using populations in Cape Town, Durban and Pretoria, South Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 5(3), 113–119. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Patel D, Gillespie B, & Foxman B (2003). Sexual behavior of older women: results of a random-digit-dialing survey of 2,000 women in the United States. Sexually Transmitted Diseases, 30(3), 216–220. [DOI] [PubMed] [Google Scholar]
  41. Pellegrino T, & Bayer BM (1998). In vivo effects of cocaine on immune cell function. Journal of Neuroimmunology, 83(1–2), 139–147. [DOI] [PubMed] [Google Scholar]
  42. Petrin D, Delgaty K, Bhatt R, & Garber G (1998). Clinical and microbiological aspects of Trichomonas vaginalis. Clinical Microbiology Reviews, 11(2), 300–317. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Phongsavan P, Grunseit AC, Bauman A, Broom D, Byles J, Clarke J, … Seef Project. (2013). Age, gender, social contacts, and psychological distress: findings from the 45 and up study. Journal of Aging and Health, 25(6), 921–943. [DOI] [PubMed] [Google Scholar]
  44. Rosen D, Smith ML, & Reynolds CF (2008). The prevalence of mental and physical health disorders among older methadone patients. American Journal of Geriatric Psychiatry, 16(6), 488–497. [DOI] [PubMed] [Google Scholar]
  45. Schonfeld L, Hazlett RW, Hedgecock DK, Duchene DM, Burns LV, & Gum AM (2015). Screening, brief intervention, and referral to treatment for older adults with substance misuse. American Journal of Public Health, 105, 205–211 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Schonfeld L, King-Kallimanis BL, Duchene DM, Etheridge RL, Herrera JR, Barry KL, & Lynn N (2010). Screening and brief intervention for substance misuse among older adults: The Florida BRITE project. American Journal ofPublic Health, 100(1), 108–114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Seña AC, Miller WC, Hobbs MM, Schwebke JR, Leone PA, Swygard H, & Cohen MS (2007). Trichomonas vaginalis infection in male sexual partners: implications for diagnosis, treatment, and prevention. Clinical Infectious Diseases, 44(1), 13–22. [DOI] [PubMed] [Google Scholar]
  48. Senanayake P (2000). Women and reproductive health in a graying world. International Journal of Gynecology & Obstetrics, 70(1), 59–67. [DOI] [PubMed] [Google Scholar]
  49. Spinillo A, Bernuzzi AM, Cevini C, Gulminetti R, Luzi S, & DeSantolo A (1997). The relationship of bacterial vaginosis, candida and trichomonas infection to symptomatic vaginitis in postmenopausal women attending a vaginitis clinic. Maturitas, 27(3), 253–260. [DOI] [PubMed] [Google Scholar]
  50. Substance Abuse and Mental Health Services Administration (SAMHSA) (24 April 2014). About Screening, Brief Intervention, and Referral to Treatment (SBIRT). Retrieved from http://beta.samhsa.gov/sbirt/about
  51. Sutton M, Sternberg M, Koumans EH, McQuillan G, Berman S, & Markowitz L (2007). The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clinical Infectious Diseases, 45(10), 1319–1326. [DOI] [PubMed] [Google Scholar]
  52. Swygard H, Sena AC, Hobbs MM, & Cohen MS (2004). Trichomoniasis: clinical manifestations, diagnosis and management. Sexually Transmitted Infections, 80, 91–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Trenz RC, Scherer M, Duncan A, Harrell PT, Moleko GA, & Latimer WW (2013). Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African drug users. Drug and Alcohol Dependence, 132(3), 441–448. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Verteramo R, Calzolari E, Degener AM, Masciangelo R, & Patella A (2008). Trichomonas vaginalis infection: risk indicators among women attending for routine gynecologic examination. Journal of Obstetrics and Gynaecology Research, 34(2), 233–237. [DOI] [PubMed] [Google Scholar]
  55. Wira CR, & Fahey JV (2008). A new strategy to understand how HIV infects women: identification of a window of vulnerability during the menstrual cycle. AIDS, 22(15), 1909–1917. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Wira CR, Patel MV, Ghosh M, Mukura L, & Fahey JV (2011). Innate immunity in the human female reproductive tract: endocrine regulation of endogenous antimicrobial protection against HIV and other sexually transmitted infections. American Journal of Reproductive Immunology, 65(3), 196–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Wu LT & Blazer DG (2011). Illicit and nonmedical drug use among older adults: a review. Journal of Aging and Health, 23(3), 481–504. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Younge SN, Salazar LF, Crosby RF, DiCLemente RJ, Wingood GM, & Rose E (2008). Condom use at last sex as a proxy for other measures of condom use: is it good enough? Adolescence, 43(172), 927–931. [PMC free article] [PubMed] [Google Scholar]

RESOURCES