Examining targets for HIV prevention: intravaginal practices in Urban Lusaka, Zambia

Pharmacogenomics of drug transporters for antiretroviral long-acting pre-exposure prophylaxis for HIV

The use of antiretrovirals (ARVs) as oral, topical, or long-acting pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for HIV prevention. Clinical trials testing Truvada® [tenofovir disoproxil fumarate (TDF)/tenofovir (TFV) and emtricitabine (FTC)] as oral or topical PrEP in African women showed mixed results in preventing HIV infections. Since oral and topical PrEP effectiveness is dependent on adequate drug delivery and availability to sites of HIV infection such as the blood and female genital tract (FGT); host biological factors such as drug transporters have been implicated as key regulators of PrEP. Drug transporter expression levels and function have been identified as critical determinants of PrEP efficacy by regulating PrEP pharmacokinetics across various cells and tissues of the blood, renal tissues, FGT mucosal tissues and other immune cells targeted by HIV. In addition, biological factors such as genetic polymorphisms and genital inflammation also influence drug transporter expression levels and functionality. In this review, drug transporters and biological factors modulating drug transporter disposition are used to explain discrepancies observed in PrEP clinical trials. This review also provides insight at a pharmacological level of how these factors further increase the susceptibility of the FGT to HIV infections, subsequently contributing to ineffective PrEP interventions in African women.

A qualitative exploration on accounts of condom-use negotiation with clients: challenges and predicaments related to sex work among street-based female sex workers in Ekurhuleni District, South Africa

INTRODUCTION

female sex workers (FSWs) are the key vulnerable populations since they carry the high burden of HIV and sexually transmitted infections (STIs). However, the vulnerability of street-based FSWs to HIV/STIs is much higher than that of the establishment-based FSWs. The study aimed to explore street-based FSWs' condom negotiation skills, barriers to condom use as well as the challenges and predicaments they face on a daily basis.

METHODS

an exploratory qualitative approach using focus group discussions was conducted among FSWs working in a major provincial road in a district of Gauteng Province. Thematic content analysis using NVivo version 10 software was conducted.

RESULTS

the age range of the FSWs was 19 to 44 years. The themes that emerged from the data on challenges to negotiation and condom use among FSWs revealed the ways condoms are used in early sex work and over time, ways of enforcing condom used, preferred types of condoms and the predicaments to working in the sex trade. FSWs gained experience of negotiating condom use over time in their work. Both female and male condoms were available and accurate insertion of condoms was reported. Male condom was preferred. Condom use strategies included direct request; using health-information messages; charging more for condomless sex; and refusing condomless sex. The FSW reported the risks of violent attacks of unregulated street-based environment.

CONCLUSION

condom negotiation strategies illustrated that peer-education and sharing experiences among themselves were beneficial for protective sexual behaviours. Peer-education benefits and peer-interactions yielded assertive attitudes and behaviours of demanding and/or enforcing condom use.

Preferences and Acceptability of Vaginal Delivery Forms for HIV Prevention Among Women, Male Partners and Key Informants in South Africa and Zimbabwe: Qualitative Findings

The attributes of an HIV microbicide may affect its acceptability, uptake and use. Quatro, a clinical study with a qualitative component, was conducted to elicit input from end-users and key informants (KIs) on four different placebo vaginal microbicide delivery forms; fast dissolving insert, ring, film and gel. In-depth interviews and focus group discussions were conducted with young women, their male partners and KIs, to explore acceptability and preferences of the four placebo products, with the intention of improving product attributes, adherence, and consequently, long term effectiveness. None of the four microbicide delivery forms stood well above others as the most preferred. Product attributes; long-action, ease of use, invisibility, female initiated and non-interference during sex were favourable in both countries. Despite preference for the long-action, on-demand products were the most liked by women. Qualitative data from the Quatro study provided rich feedback on specific attributes important to the acceptability of four HIV prevention product platforms currently in development, enabling more informed and guided product development efforts moving forward.

Consideration of Cultural Practices When Characterizing the Vaginal Microbiota Among African and African American Women

This manuscript considers intravaginal practices prevalent among African and African-American women, with the aim of providing a framework for how these practices may affect vaginal health and the vaginal microbiota, and consequently, impact pregnancy outcomes. Intravaginal practices are influenced by traditional socio-cultural beliefs and gender norms, with prominent practices including intravaginal insertion of substances (herbs and traditional medicines), intravaginal cleansing (douching), and anatomical modification of the female organs (labia elongation and female genital mutilation). Common motivations for such practices included hygiene, prevention of infection, enhancement of sexual pleasure, and compliance with societal or cultural norms. The use of soaps and other chemicals for vaginal douching has been reported to reduce diversity of the vaginal microbiota and lower pH, thus increasing the chances of bacterial vaginosis, but the evidence is minimal. The practice of vaginal insertion of natural or other substances is associated with physical abrasions, disruption of the vaginal flora, bacterial vaginosis, and HIV and other infections, but effects on pregnancy outcomes and the vaginal microbiota are unclear. Finally, female genital mutation has been reported to have immediate and prolonged physiological and psychological effects, including frequent infections and chronic inflammation, but similar to most other practices, consequences for preterm birth remain understudied and for the vaginal microbiota, unknown. Overall, findings identify the need for additional research, focusing on how these common practices influence both birth outcomes and the vaginal microbiota, so that nurses, midwives, physicians, and other providers worldwide are better equipped to assess and care for pregnant women.

Douching practices among women in the Bolgatanga municipality of the upper east region of Ghana

BACKGROUND

Vaginal douching is a common practice among women all over the world. Women douche for various reasons, despite evidence indicating the harmful health effects of the practice. There is lack of data on the practice in Ghana but health behaviors like vaginal douching may be influenced by differences in culture and geography. Therefore, this study sought to assess prevalence and predictors of vaginal douching practices among women of the Bolgatanga Municipality of Ghana.

METHODS

This cross-sectional study was conducted among 200 women from January to March 2016.

RESULTS

Sixty-seven percent of the women practiced vaginal douching, from which a similar proportion did it daily. Over two-thirds (67.7%) of the women used water for douching. The reasons for douching were cleansing the vagina (67.7%), therapeutic effects (12.8%) and tightening of the vaginal muscles (19.5%). The majority (87.2%) of women who douched were unaware of the harmful health effects associated with the practice. The educational level of the women (p = 0.025) and having knowledge of the dangers associated with douching (p <  0.001) were then significantly associated with douching practices.

CONCLUSION

Vaginal douching is commonly practiced by women in the Bolgatanga Municipality. Most of these women douche because they did not know that there are health problems associated with the practice. Health education on the issues of women health is very vital for the improvement of women's health.

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.

Risk of heterosexual HIV transmission attributable to sexually transmitted infections and non-specific genital inflammation in Zambian discordant couples, 1994-2012

Background

Studies have demonstrated the role of ulcerative and non-ulcerative sexually transmitted infections (STI) in HIV transmission/acquisition risk; less is understood about the role of non-specific inflammatory genital abnormalities.

Methods

HIV-discordant heterosexual Zambian couples were enrolled into longitudinal follow-up (1994-2012). Multivariable models estimated the effect of genital ulcers and inflammation in both partners on time-to-HIV transmission within the couple. Population-attributable fractions (PAFs) were calculated.

Results

A total of 207 linked infections in women occurred over 2756 couple-years (7.5/100 CY) and 171 in men over 3216 CY (5.3/100 CY). Incident HIV among women was associated with a woman's non-STI genital inflammation (adjusted hazard ratio (aHR) = 1.55; PAF = 8%), bilateral inguinal adenopathy (BIA; aHR = 2.33; PAF = 8%), genital ulceration (aHR = 2.08; PAF = 7%) and the man's STI genital inflammation (aHR = 3.33; PAF = 5%), BIA (aHR = 3.35; PAF = 33%) and genital ulceration (aHR = 1.49; PAF = 9%). Infection among men was associated with a man's BIA (aHR = 4.11; PAF = 22%) and genital ulceration (aHR = 3.44; PAF = 15%) as well as with the woman's non-STI genital inflammation (aHR = 1.92; PAF = 13%) and BIA (aHR = 2.76; PAF = 14%). In HIV-M+F- couples, the man being uncircumcised. with foreskin smegma. was associated with the woman's seroconversion (aHR = 3.16) relative to being circumcised. In F+M- couples, uncircumcised men with BIA had an increased hazard of seroconversion (aHR = 13.03 with smegma and 4.95 without) relative to being circumcised. Self-reporting of symptoms was low for ulcerative and non-ulcerative STIs.

Conclusions

Our findings confirm the role of STIs and highlight the contribution of non-specific genital inflammation to both male-to-female and female-to-male HIV transmission/acquisition risk. Studies are needed to characterize pathogenesis of non-specific inflammation including inguinal adenopathy. A better understanding of genital practices could inform interventions.

Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review

INTRODUCTION

Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.

HIV Knowledge and Risk among Zambian Adolescent and Younger Adolescent Girls: Challenges and Solutions

In sub-Saharan Africa, young women are at the highest risk of HIV infection. Comprehensive sexuality education (CSE) and open parent-child communication about sex have been shown mitigate risky sexual practices associated with HIV. This study aimed to identify sources of HIV prevention knowledge among young women aged 10-14 years and community-based strategies to enhance HIV prevention in Zambia. Focus group discussions were conducted with 114 young women in Zambian provinces with the highest rates (~20%) of HIV. Discussions were recorded, transcribed and coded, and addressed perceived HIV risk, knowledge and access to information. Participants reported that limited school-based sexuality education reduced the potential to gain HIV prevention knowledge, and that cultural and traditional practices promoted negative attitudes regarding condom use. Parent-child communication about sex was perceived to be limited; parents were described as feeling it improper to discuss sex with their children. Initiatives to increase comprehensive sexuality education and stimulate parental communication about sexual behavior were suggested by participants. Culturally tailored programmes aiming to increase parent-child communication appear warranted. Community-based strategies aimed at enhancing protective sexual behaviour among those most at risk are essential.

Intravaginal practices among young HIV-infected women in Lusaka, Zambia

Intravaginal practices (IVP) are linked to bacterial vaginosis (BV), obstetric/gynecological complications, and HIV. Late adolescent and young adult (LAYA) women in Zambia have high rates of HIV. Adult and mature (AM) HIV-infected women in Zambia engage in IVP for hygiene, health, and sexuality reasons; however, to our knowledge, IVP use among LAYA women has not been examined. This study compares IVP use between LAYA and AM women to identify age-specific factors to target when developing IVP reduction interventions for LAYA women. LAYA (≤25 years; n = 24) and AM (>25 years; n=124) HIV-infected women completed self-administered demographic, HIV history, sexual risk factor, and IVP measures. LAYA and AM women were then compared. Number of sexual partners, sexual activity, or condom use did not differ between groups. Rates of IVP in the prior month with different products were similar, though LAYA women used soap more frequently (96% versus 74.2%, p = 0.034). LAYA women were more likely to use products for hygiene reasons (soap 83% versus 43%; cloth, paper, or wipes 50% versus 17%, p < 0.05); and AM women to use products to please sexual partners (cloth 20% versus 56%, p = 0.074). Interventions tailored to LAYA women may be needed to reduce IVP and subsequent BV as LAYA women may have different reasons for engaging in IVP, in comparison with AM women. Reduced IVP among LAYA women may decrease the risk for HIV transmission to sexual partners and newborns and is urgently needed in settings with high prevalence of IVP, BV, and HIV infections, such as Zambia.

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).

Addressing intravaginal practices in women with HIV and at-risk for HIV infection, a mixed methods pilot study

Intravaginal practices (IVPs), include intravaginal cleansing (cleansing the inside of the vagina) or intravaginal insertion of products for hygiene, health or sexuality reasons. IVPs are associated with adverse female health outcomes, development of bacterial vaginosis, HIV acquisition and transmission. A mixed methods approach was used in this study to examine the prevalence of IVP, assess reasons for engagement, and perceptions of IVP among a sample of minority (African-American and Hispanic) women infected, or at-risk, for HIV in Miami, USA, a city with increasing numbers of sexually transmitted infections (STIs) and HIV. Three focus groups (total n=20) and quantitative assessments (n=72) were conducted with women infected or uninfected with HIV. In the qualitative assessments, most women reported engaging in both intravaginal cleansing and intravaginal insertion, and stated the main motivation for IVP was hygiene. The quantitative assessments confirmed that cleansing with water alone, soap with water or using commercial douches was common, as well as intravaginal insertion using a cloth or a rag in both HIV-infected and uninfected women. Women with HIV infection reported less use of water and water and soap for IVPs, and reported learning about the potential harm of IVP from their HIV health care providers. Despite their health risks, IVP appeared common in both HIV-infected and at-risk minority women, and interventions to decrease IVP could have important health implications among populations with high rates of IVP, STIs and HIV.

Intravaginal practices among HIV-negative female sex workers along the US-Mexico border and their implications for emerging HIV prevention interventions

OBJECTIVE

To describe intravaginal practices (IVPs) among female sex workers (FSWs) who inject drugs in two cities-Tijuana and Ciudad Juarez-on the border between the USA and Mexico.

METHODS

Data for a secondary analysis were obtained from interviews conducted as part of a randomized controlled trial in FSWs who injected drugs between October 28, 2008, and May 31, 2010. Eligible individuals were aged at least 18years and reported sharing injection equipment and having unprotected sex with clients in the previous month. Descriptive statistics were used to assess frequency and type of IVPs. Logistic regression was used to assess correlates of IVPs.

RESULTS

Among 529 FSWs who completed both surveys, 229 (43.3%) had performed IVPs in the previous 6months. Factors independently associated with IVPs were reporting any sexually transmitted infection in the previous 6months (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1-3.1; P=0.03), three or more pregnancies (aOR 1.9, 95% CI 1.1-3.2; P=0.02), and having clients who became violent when proposing condom use (aOR 5.8, 95% CI 1.0-34.3; P=0.05), which are all factors related to inconsistent condom use.

CONCLUSION

Screening for IVPs could help to identify FSW at increased risk of HIV, and facilitate conversations about specific risk-reduction methods.

A cross-sectional study of bacterial vaginosis, intravaginal practices and HIV genital shedding; implications for HIV transmission and women's health

OBJECTIVES

Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP) are an important risk factor for developing BV. The relationship between IVP, BV and HIV lower genital shedding, responsible for HIV transmission, has not been examined in women receiving antiretrovirals in Zambia.

DESIGN

Cross-sectional study.

SETTING

Community Health Center in Lusaka, Zambia.

PARTICIPANTS AND METHODS

Participants were HIV-infected women receiving antiretroviral therapy and engaging in IVP (n=128). Participants completed audio computer-administered self-interviews to assess IVP and underwent a vaginal examination. BV was diagnosed using Nugent criteria. HIV-1 lower genital shedding was assessed by measuring HIV-1 RNA in cervicovaginal lavages.

RESULTS

Most women engaged in IVP daily (114, 89.0%) and 81 (63.3%) of the participants had BV. HIV-1 genital shedding was detected in 18 (14.2%) participants. BV was associated with daily use of IVP (prevalence ratio, PR=4.58, CI 1.26 to 16.64, p=0.02) and weekly use of traditional medicines for IVP (PR=1.33, CI 1.05 to 1.68, p=0.02). The only factor associated with HIV-1 lower genital shedding was plasma viraemia (PR=4.61, CI 2.02 to 10.54, p<0.001). Neither IVP nor BV were associated with HIV shedding.

CONCLUSIONS

Despite the frequency of IVP and high prevalence of BV, plasma viraemia was the primary factor associated with HIV lower genital shedding. These findings support early initiation of antiretrovirals as an HIV prevention tool. Given adverse health outcomes associated with BV, the association between frequent IVP and BV, and the powerful local norms and traditions encouraging IVP, there is a need for studies assessing culturally tailored interventions to decrease BV in high-prevalence settings.

Determinants of intravaginal practices among HIV-infected women in Zambia using conjoint analysis

Intravaginal practices (IVPs) are associated with an increased risk of bacterial vaginosis and may play a role in HIV transmission. The objective of this study was to identify the importance of factors underlying the decision to engage in IVP using conjoint analysis; a novel statistical technique used to quantify health-related decisions. This study was a cross-sectional study. HIV-infected women in Zambia completed audio computer-administered self-interview questionnaires assessing demographic, risk factors and IVPs. Reasons for engaging in IVPs were explored using conjoint questionnaires. Conjoint analysis was used to identify the relative importance of factors for engaging in IVPs. Results of the conjoint analysis demonstrated that hygiene was the most important reason for engaging in IVPs (mean importance score = 61, SD = 24.3) followed by partner's preference (mean importance score = 20, SD = 14.4) and health (mean importance score = 17, SD = 13.5). When making the decision to engage in IVPs, women rank the importance of hygiene, partner preference and health differently, according to their personal characteristics. The use of conjoint analysis to define the characteristics of women more likely to engage in specific practices should be used to develop tailored rather than standardised IVP interventions, and such interventions should be incorporated into clinical practice and women's health programmes.

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.