An intervention to decrease intravaginal practices in hiv-infected women in Zambia: a pilot study

Assessing Intravaginal Practices in HIV Prevention Research: Development and Validation of an Intravaginal Practices Questionnaire

Intravaginal practices (IVPs) refer to placing items (e.g., water, soap, commercial douches, fingers, rags) inside the vagina. IVPs have been shown to contribute to the development of bacterial vaginosis (BV) and may increase sexually transmitted infections and HIV risk. We developed the Intravaginal Practices Questionnaire (IVQ). The purpose of this study was to validate the IVQ, with the goal of establishing a consistent method of assessing IVP across studies. Women enrolled in this study (n = 180) were on average 30 years of age (SD = 8.32). Half (54%) identified as non-Hispanic, and 45% identified as Black; 41% reported lifetime IVP. Past month IVP use included commercial douches (9%), water (35%), fingers (41%), soap (21%), cloths/rags/wipes (10%), and vinegar (3%), which were placed in the vagina. No women used yogurt or herbs. An exploratory factor analysis indicated that a single-factor structure best explained the underlying constructs in participant responses in six endorsed items assessing commercial douches, water, fingers, soap, clothes/rags/ wipes, and vinegar use, suggesting that a common factor underlies these behaviors. All factor loadings were > 0.496. Cronbach's α was 0.99, suggesting that the reliability of the scale was excellent. Lastly, a total IVQ score was related to BV diagnosis (p = .007) as well as self-reported symptoms of BV (p = .034). Results illustrate that the IVQ has adequate psychometric properties. This tool may be used by public health experts and clinicians to identify IVPs that may potentially increase HIV risk.

Vaginal practices among women at risk for HIV acquisition in Soweto, South Africa

BACKGROUND

Vaginal practices (VP) may adversely affect normal vaginal flora and mucosal integrity, and increase acquisition risk of HIV and other genital tract infections.

OBJECTIVE

The aim of this study was to describe self-reported VP, changes in the reported number of VP over time and factors associated with VP in a cohort of young Sowetan women enrolled in the HVTN 915 observational study.

METHOD

We longitudinally assessed self-reported VP in 50 young women at risk of HIV acquisition aged 18-25 years in a prospective study over 3 months in Soweto, South Africa. Interviewer-administered HIV behavioural risk questionnaires were completed. No intervention to reduce VP was specified per protocol, but clinicians provided education at their discretion. The generalised estimating equation with inverse probability weights assessed VP over time.

RESULTS

The mean age at screening was 22 years; women reported multiple sexual partnerships with a mean of one main and 2 casual partners in the last 30 days. Consistent condom use was 2% (n = 1), 25% (n = 12) and 43% (n = 3) with main, casual and new partners, respectively. Commonly reported VP included washing the vagina with water (44%) and using fingers (48%). VP decreased significantly over time (p < 0.001). Women who used condoms inconsistently or whose last sex was with a casual partner were 3 times more likely to report VP (p = 0.001).

CONCLUSION

Despite the high incidence of HIV in our setting, VP are still common and are associated with other behavioural risks for HIV. Further study is needed to assess whether clinician education may reduce VP and therefore should be included in HIV risk reduction counselling.

Adolescent and young adult couples' views of intravaginal practices: a qualitative analysis of a pilot study

Purpose

In this study, we evaluated the risk behaviors that are drivers of the HIV epidemic among adolescent girls and young women in Zambia using a focus group research technique.

Subjects and methods

Eighteen adolescent couples (n=18 females and 18 males) aged 16–24 participated in six focus groups discussions (3 per gender) convened at three health facilities in Lusaka, Zambia. Focus group moderators utilized a set of open-ended questions to guide the 60-minute sessions. The focus group audio recordings were transcribed, coded, and analyzed using qualitative content analysis in Nvivo 11.

Results

Three themes and four subthemes were identified relating to adolescent and young adult couples’ knowledge, views, and male partner attitudes toward intravaginal practices (IVPs). The first theme, knowledge and rationale for IVPs, consisted of the subthemes relating to why adolescents and young adult couples engage in IVPs and assessed their knowledge of health risks associated with IVPs. The second theme, attitudes toward IVPs, consisted of the subtheme willingness to stop or support partner to discontinue IVP and practices toward IVP and strategies for changing. The third theme, strategies for changing IVPs, consisted of the subtheme raise awareness.

Conclusion

IVPs used for cleaning purposes were perceived as essential to enhancing hygiene, health, and sexual satisfaction for both girls and boys. However, couples expressed concern about the health effects of IVPs used for tightening and a desire for learning more about this practice as well as stopping it.

Influencing the importance of health, partners, and hygiene among Zambian women

Intravaginal practices (IVPs) are common in Zambia and are usually practiced for hygiene, partner pleasure, and health. IVPs are associated with HIV acquisition, changes in the vaginal flora, and bacterial vaginosis (BV), making it important to understand the decision-making process behind IVP engagement. The Women's and Sexual Health (WASH) intervention decreased IVP engagement among HIV-infected Zambian women, though change in reasons for engagement has not been assessed. We used conjoint analysis (CA) to quantify the decision-making process of IVP engagement and evaluated how the WASH intervention impacted these factors. Participants were N = 84 women (37 ± 8 years old) randomized to WASH (n = 46) or standard of care plus (SOC+; n = 38) who completed demographic measures and a CA questionnaire at baseline, six months, and 12 months to quantify the importance placed on hygiene, partner pleasure, and health. The importance placed on health increased from baseline to six months (15.5 versus 25.1; p < 0.001) and from baseline to 12 months (15.5 versus 50.5; p < 0.001), and was higher in SOC+ at six months (19.9 versus 30.3; p = 0.003). Hygiene importance decreased from baseline (63.6) to six months (50.3), and from baseline to 12 months (26.1), and was higher in the experimental arm at six months (56.1) compared to SOC+ (44.6; p = 0.029). Importance placed on partner pleasure did not change over time in either group. Findings suggest that both groups exhibited an increase in the importance placed on health and a decrease on hygiene importance for IVP engagement, suggesting that SOC+ may be sufficient to promote attitude changes that may facilitate IVP discontinuation and may prove to be more cost effective by using fewer monetary resources. Findings highlight the potential of interventions to influence attitudes toward IVPs and provide novel avenues for research to improve the design and conduct of interventions aimed at reducing IVPs among Zambian women and contribute to HIV prevention efforts.

A bio-behavioral intervention to decrease intravaginal practices and bacterial vaginosis among HIV infected Zambian women, a randomized pilot study

BACKGROUND

Intravaginal practices (IVP) (cleansing or introducing products inside the vagina for hygiene, health or to please sexual partners) are common among women with HIV. IVP increase the risk of developing bacterial Vaginosis (BV), the most common genital infection associated with transmission of sexually transmitted infections and HIV. This study tested a pilot intervention to reduce IVP and BV in HIV infected women in Zambia.

METHODS

One hundred twenty-eight HIV infected women engaging in IVP were randomized to two conditions: enhanced standard of care (n = 70) and experimental (n = 58) from May 1, 2013 to February 28, 2014. All participants received a brief educational counseling session on discontinuation of IVP, and those with BV, were provided with medical treatment for BV. Women in the experimental condition received an additional group-based, culturally tailored intervention. Participants completed questionnaires assessing sexual risk factors and IVP and were assessed for BV using Nugent criteria at baseline, 6 months and 12 months.

RESULTS

At 12-month, the proportion of self-reported use of IVPs decreased in the experimental condition: soap (28% vs. 47%); cloth or a rag (19% vs. 38%); and traditional medicines (22% vs. 42%) (all p < 0.05)) compared with the enhanced standard of care condition. The prevalence of BV at 6 and 12 months did not differ by study condition but averaging over study condition, prevalence of BV decreased from 64.2% at baseline to 15.6% at 6 months (p < 0.01) and to 23.6% at 12 months (p = 0.15). Using an enhanced standard of care approach and an enhanced standard of care + a group intervention, IVP and BV decreased over time, but the experimental condition had greater reduction in self-reported use of IVP.

CONCLUSIONS

Future studies should address interventions in communities with high burden of IVP, BV and HIV. Interventions that could be administered during routine medical care and decrease IVP and BV are needed, and should be considered part of women's health programs.

TRIAL REGISTRATION NUMBER

NCT03134924 (retrospectively registered 21st April 2017).

Motivations for Intravaginal Product Use among a Cohort of Women in Los Angeles

OBJECTIVE

Intravaginal practices-including behaviors such as intravaginal cleansing and insertion of products-have been linked to a number of adverse reproductive health outcomes, including increased risk for bacterial vaginosis, sexually transmitted infections, and HIV. Currently, little is known about the motivations for intravaginal practices among women in the United States. The objective of this study was to identify and describe motivations for intravaginal washing and intravaginal insertion of products among women of differing ages and racial/ethnic groups.

METHODS

Between 2008 and 2010, we enrolled a convenience sample of sexually active women aged 18-65 years living in Los Angeles recruited through community education and outreach activities in HIV/AIDS service organizations, women's health clinics, community-based organizations, and HIV testing sites. At the enrollment visit, women completed a self-administered, computer-assisted questionnaire covering demographics, sexual behaviors, intravaginal practices, and motivations for intravaginal practices over the past month and past year.

RESULTS

We enrolled 141 women; 34% of participants were Caucasian, 40% African American, and 26% Latina. Peri-sexual intravaginal washing was common in all groups, whether to clean up after sex (70%) or to prepare for sex (54%). African American women were more likely to report learning to wash intravaginally from their mothers compared to Latina or Caucasian women (70% vs. 49%, P = 0.04). Sixty-one percent of African American women reported using a douching device over the past year compared to 41% of Latina and 40% of Caucasian women (p = 0.02). Younger women were more likely to report that their male partners wanted them to wash intravaginally than older women (77% vs. 24%, P<0.01), and more likely to report the removal of odors as a motive than older women (65% vs. 40%, P = 0.04). The most commonly used intravaginal products included sexual lubricants, petroleum jelly, body lotions, oils, and wet wipes. Use of these products varied by race, and motives given included increasing lubrication, preparing for sex, smelling good, and preventing sexually transmitted infections.

CONCLUSION

Women's intravaginal practices and motivations for these practices differ across race and age. Motivations for use also vary by type of intravaginal product used. Given that some intravaginal practices have been shown to be harmful, interventions, programs and counseling messages to encourage less harmful practices are needed, and should consider underlying motivations that influence women's vaginal practices. Practitioners may use these results to better support women in achieving vaginal health.

Cessation of intravaginal practices to prevent bacterial vaginosis: a pilot intervention in Zimbabwean women

OBJECTIVES

Intravaginal practices--including behaviours such as washing with soap or other materials, using fingers or cloth, or insertion of herbs, powders or other products to dry, cleanse or 'tighten' the vagina--may increase women's risk of bacterial vaginosis by disrupting the vaginal microbiota. In Zimbabwe, intravaginal practices are common. The objective of this study was to assess the feasibility of an intervention based on the transtheoretical model of behaviour change (also called the 'stages of change' model) to encourage cessation of vaginal practices among a sample of Zimbabwean women.

METHODS

We conducted a 12-week behaviour change intervention to encourage cessation of intravaginal practices (other than cleansing with water) among 85 Zimbabwean women who reported these practices.

RESULTS

Self-reported intravaginal practices declined significantly over follow-up, with 100% of women reporting at least one intravaginal practice at enrolment compared with 8% at the final visit. However, we found no significant effect of this reduction on bacterial vaginosis prevalence in unadjusted or adjusted multivariable models (adjusted prevalence ratio for any practice vs none: 0.94, 95% CI 0.61 to 1.43).

CONCLUSIONS

While the intervention was successful in reducing women's self-reported engagement in intravaginal practices, we observed no corresponding benefit to vaginal health.