Intravaginal Practices, HIV and Other Sexually Transmitted Diseases Among South African Women

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.

Intravaginal practices and genital human papillomavirus infection among female sex workers in Cambodia

OBJECTIVES

Intravaginal practices (IVPs) include washing, wiping, or inserting something inside the vagina. This study investigates the associations between IVPs and genital human papillomavirus (HPV) infection.

METHODS

We conducted a cross-sectional study of 200 female sex workers aged 18 to 35 years in Phnom Penh, Cambodia. From August to September 2014. Data on sociodemographic characteristics, IVPs, and other behaviors were collected through face-to-face interviews. Self-collected cervicovaginal specimens were tested for 37 HPV genotypes.

RESULTS

Multivariable Poisson regression models showed that a lower number of infecting HPV genotypes were associated with intravaginal washing in the past 3 months (incident rate ratios [IRR] = 0.65, 95% confidence interval [CI]: 0.46-0.94) and often performing intravaginal washing shortly after sex (IRR = 0.89, 95% CI: 0.81-0.99). Intravaginal washing before vaginal sex, intravaginal wiping, and intravaginal insertion were not associated with HPV infection.

CONCLUSION

These findings challenge the existing view that all types of vaginal cleansing are harmful. Specifically, intravaginal washing shortly after sex (mainly with water) may help prevent HPV infection in female sex workers, who have several partners and thus frequently expose to sources of HPV infection with different genotypes.

Acceptability of a Tenofovir Disoproxil Fumarate Vaginal Ring for HIV Prevention Among Women in New York City

Vaginal rings for pre-exposure prophylaxis are a female-initiated HIV prevention method that does not require daily or coitally-dependent dosing. As part of a randomized placebo-controlled trial of a tenofovir disoproxil fumarate intravaginal ring, we assessed product acceptability through in-depth interviews with 18 women during and after 14 days of continuous use. Women reported that the ring was comfortable with few side effects, regardless of experimental arm. However, interest in future use by this cohort was modest for several reasons including: low self-perceived HIV risk; concern that use implied promiscuity; potential for interference with relationship formation and trust; concern for interference with menstruation and cleanliness; and worries about partners' acceptability and sexual pleasure. Potential issues were raised with duration of use prior to ring exchange. Future studies should continue to identify and address individual and relationship factors that influence acceptability, early in the product development process.

Sexual Behavior and Vaginal Practices During Pregnancy and Postpartum: Implications for HIV Prevention Strategies

BACKGROUND

Understanding sexual behaviors and vaginal practices of pregnant and breastfeeding women in sub-Saharan Africa is critical to inform HIV prevention strategies during these periods.

METHODS

HIV-uninfected women presenting for antenatal care in western Kenya were enrolled and followed through 36 weeks postpartum. Sexual behavior and vaginal practices were ascertained by structured questionnaires. Logistic regression was used to assess correlates of unprotected sex, vaginal washing, and vaginal drying.

RESULTS

Among 1252 women enrolled, 78.4% were married (of whom 15.1% were in polygamous unions), 1.4% had a known HIV-infected partner, and 33.6% had a partner of unknown HIV status. At enrollment, 58.5% reported sex in the past month (94.3% unprotected) and 4.5% reported forced sex. Odds of unprotected sex at enrollment was >11-fold higher in married than in unmarried women (P < 0.001) and lower among women who reported partners of unknown HIV status or HIV-infected compared with HIV-uninfected partners. Median time to postpartum resumption of sex was 7 weeks (interquartile range 4-12). Prevalence of unprotected sex in the past week increased from 6.6% to 60.0% between 2 and 36 weeks postpartum (P < 0.001). Vaginal washing was reported by 60.1% of women at enrollment and prevalence remained stable postpartum; vaginal drying was reported by 17.9% at enrollment and decreased to 6.1% at 36 weeks postpartum (P < 0.001). Vaginal washing and drying were associated with forced sex.

CONCLUSIONS

High rates of unknown partner HIV status, polygamy, and less frequent condom use among pregnant/postpartum women underscore the need for female-controlled HIV prevention interventions. Vaginal washing and drying may present challenges to microbicide use.

Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique

Intra-vaginal drying and tightening and labia minora elongation are commonly practised in some parts of southern Africa. We sought to capture data on these practices among women living in Zambézia province, Mozambique. Information was gathered from 3543 female heads of household on > 500 variables, including vaginal practices, in 2014. Women who planned to use intra-vaginal tightening substances had 1.84 times higher odds of ever receiving an HIV test (p < 0.001) and 1.40 times higher odds of at least one antenatal care visit attended during last pregnancy (p = 0.015). Women who had or planned to undergo labia minora elongation had 2.61 times higher odds of receiving an HIV test in the past (p < 0.001) and 1.60 times higher odds of attending at least one antenatal care visit during their last pregnancy (p < 0.001). There was little evidence for a relationship between self-reported HIV status and anticipated use of intra-vaginal tightening substances (p = 0.21). Current or anticipated participation in labia elongation showed a protective effect on HIV infection (p = 0.028). Given documented associations between intra-vaginal substance use, vaginal infections and HIV acquisition, understanding the prevalence of vaginal practices is an essential component to addressing the epidemic.

High Burden of Human Papillomavirus (HPV) Infection among Young Women in KwaZulu-Natal, South Africa

OBJECTIVES

HPV infection causes cervical cancer, yet information on prevalence and risk factors for HPV in Africa remain sparse. This study describes the prevalence of HPV genotypes and risk factors associated with HPV among young women ≤ 30 years of age in KwaZulu-Natal (KZN), South Africa.

METHODS

Cervicovaginal lavage samples were tested for HPV genotypes in 224 women enrolled in a prospective cohort study. Clinical, behavioural and demographic data were collected. We measured prevalence of HPV genotypes and using logistic regression, examined for factors associated with HPV.

RESULTS

Median age of participants was 21 years [interquartile range (IQR):18-23]. The overall prevalence of HPV was 76.3% (171/224) with multiple and single genotypes prevalent in 56.3% and 20.1% of women respectively. Proportion of women with high-risk genotypes (16, 18, 31, 33, 35, 39, 45, 51, 52, 56 and 58) was 54.5%. Women not living with their partner [adjusted odds ratio (aOR)] = 3.42 95% CI1.22-9.60; p = 0.019), was significantly associated with HPV infection and high-risk HPV genotype infection.

CONCLUSION

The high burden of HPV and associated risk behaviours highlight the need to intensify behavioural interventions to prevent HPV acquisition in young women. The large scale delivery of HPV vaccine should be prioritised to prevent HPV acquisition and reduce HPV-related morbidity.

Intravaginal practices and lactobacilli colonization among women in Accra, Ghana

Background

Intravaginal practices may affect the colonization of vaginal flora and lead to vaginal infections due to the potential effects on the vaginal environment. This study investigated the vaginal practices and their possible effects on vaginal lactobacilli flora colonization in women in Accra.

Methods

A cross-sectional, descriptive single-site study was carried out on 141 women assessing medical care at the Obstetrics and Gynaecology Department of the Korle-Bu Teaching Hospital (KBTH) in Accra. Study-relevant information on participants was obtained by means of questionnaire. Vaginal swab samples were collected and processed for laboratory analyses.

Results

All the participants (141/141, 100.0 %) indicated they performed intravaginal practices using various methods. Almost half (46.1 %) of these women were between the ages of 25–34 years and 65.0 % were married. Internal douching (82.3 %; p > 0.05) was the commonest practice reported. Other practices such as insertion and wiping with hands and objects, as well as use of locally prepared concoctions and certain commercial products were also reported. The reason most commonly given was for hygienic purpose (83.0 %); a few (10.6 %) did it for sexual satisfaction, while others indicated vaginal tightness (5.7 %) and wound healing (0.7 %) as reasons for their practice. No Lactobacillus sp. was detected in as many as 78.7 % of the sample. Association tests by the Pearson correlation analysis showed strong significant negative correlation (r = −0.954, p < 0.05) between use of traditional herbs/concoction and vaginal lactobacilli colonization; and douching being the least negatively (r = −0.601, p > 0.05) correlated practice.

Conclusions

Vaginal practices were common among the women studied. A more elaborate prospective, case–control study into intravaginal practices and their impact on the health of women in Ghana should be explored.

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-015-0205-2) contains supplementary material, which is available to authorized users.

The implications of post-coital intravaginal cleansing for the introduction of vaginal microbicides in South Africa

Post-coital intravaginal cleansing (IVC) could counteract the protective effect of a vaginal microbicide. IVC less than 1 h after sex is discouraged in most microbicide trials. During a microbicide trial in KwaZulu-Natal, we collected quantitative data on post-coital IVC. We discussed IVC during in-depth-interviews (IDIs) and focus-group discussions (FGDs) with women enrolled in the trial, and during FGDs with community members. Nearly one-third (336/1,143) of women reported IVC less than an hour after sex. In multivariate analysis, post-coital IVC was associated with younger age, larger household size, greater sexual activity, consistent gel use, and clinic of enrolment. During IDIs and FGDs, respondents described post-coital IVC as a common hygiene practice motivated by the need to remove semen, vaginal fluids and sweat, although this practice may be amenable to change in the context of microbicide use. We need to consider strategies for influencing post-coital IVC practices in future microbicide trials and delivery programmes.

Understanding motives for intravaginal practices amongst Tanzanian and Ugandan women at high risk of HIV infection: the embodiment of social and cultural norms and well-being

Some types of intravaginal practices (IVP) may increase the risk for HIV acquisition. This is particularly worrisome for populations with dual high prevalence of HIV and IVP. Women involved in transactional sex are at increased risk for HIV infection in sub-Saharan Africa. Social, cultural and economic influences are strong drivers of IVP in this population. To explore this, we carried out a qualitative research study to investigate the drivers and motivations for using IVP within a large observational study of women at high risk of HIV in Tanzania and Uganda from September 2008 to September 2009. Of the 201 women selected, 176 women took part in a semi-structured in-depth interview. Additionally, in Tanzania, eight focus group discussions among study participants and community members were carried out to obtain information on community norms and expectations. IVP were motivated by overlapping concerns with hygiene, morality, sexual pleasure, fertility, relationship security, and economic security. These motives were driven by the need to meet cultural and social expectations of womanhood, and at the same time attend to personal well-being. Among women involved in transactional sex in East Africa, interventions aimed at modifying or eliminating IVP should attend to local cultural and social norms as well as the individual as an agent of change.

•

Previous research has shown that some types of intravaginal practice (IVP) may increase HIV risk.

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The motives of women at high risk of HIV to carry out IVP fulfil sociocultural norms of womanhood and well-being.

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Economic factors for women involved in transactional sex are an important motive.

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Interventions aimed at reducing or eliminating IVP should address these issues.

Intravaginal practices and microbicide acceptability in Papua New Guinea: implications for HIV prevention in a moderate-prevalence setting

BACKGROUND

The acceptability of female-controlled biomedical prevention technologies has not been established in Papua New Guinea, the only country in the Pacific region experiencing a generalised, moderate-prevalence HIV epidemic. Socio-cultural factors likely to impact on future product uptake and effectiveness, such as women's ability to negotiate safer sexual choices, and intravaginal hygiene and menstrual practices (IVP), remain unclear in this setting.

METHODS

A mixed-method qualitative study was conducted among women and men attending a sexual health clinic in Port Moresby. During in-depth interviews, participants used copies of a hand-drawn template to indicate how they wash/clean the vulva and/or vagina. Interviewers pre-filled commercially available vaginal applicators with 2-3mL KY Jelly® to create a surrogate vaginal microbicide product, which was demonstrated to study participants.

RESULTS

A total of 28 IDIs were conducted (women=16; men=12). A diverse range of IVP were reported. The majority of women described washing the vulva only with soap and water as part of their daily routine; in preparation for sex; and following sexual intercourse. Several women described cleaning inside the vagina using fingers and soap at these same times. Others reported cleaning inside the vagina using a hose connected to a tap; using vaginal inserts, such as crushed garlic; customary menstrual 'steaming' practices; and the use of material fragments, cloth and newspaper to absorb menstrual blood. Unprotected sex during menstruation was common. The majority of both women and men said that they would use a vaginal microbicide gel for HIV/STI protection, should a safe and effective product become available. Microbicide use was considered most appropriate in 'high-risk' situations, such as sex with non-regular, transactional or commercial partners. Most women felt confident that they would be able to negotiate vaginal microbicide use with male sexual partners but if necessary would be prepared to use product covertly.

CONCLUSIONS

Notional acceptability of a vaginal microbicide gel for HIV/STI prevention was high among both women and men. IVP were diverse in nature, socio-cultural dimensions and motivators. These factors are likely to impact on the future acceptability and uptake of vaginal microbicides and other biomedical HIV prevention technologies in this setting.

HIV incidence rates and risk factors for urban women in Zambia: preparing for a microbicide clinical trial

OBJECTIVES

A preparedness study was conducted to evaluate the suitability of sites and populations following the same study procedures intended for a larger scale microbicide efficacy trial. In the process the study evaluated human immunodeficiency virus (HIV) incidence, prevalence, and risk profiles for HIV-acquisition among young women in urban Zambia.

METHODS

Women aged 16 to 49 years were screened for participation in the study that involved HIV/sexually transmitted infection testing and the assessment of sexual behavioral characteristics. Two hundred thirty-nine eligible women were enrolled and followed up for 12 months.

RESULTS

Baseline HIV prevalence at screening was 38.7% (95% CI: 34.2%-43.3%). The highest age-specific prevalence of HIV was 54.1% (95% CI: 46.3%-61.8%) seen in women aged 26 to 34 years. HIV incidence was 2.6% per 100 woman years. Pregnancy rates were high at 17.4 per 100 woman years (95% CI: 12.2-24.1).

CONCLUSION

It was concluded that our general population sample, characterized by high HIV prevalence and ongoing incidence rates despite receiving regular risk reduction counseling and free condoms qualifies for future microbicide studies.A microbicide preparedness study conducted in Lusaka, Zambia found high HIV prevalence and appreciable HIV incidence in a population of women in an urban setting.

Use of modern and traditional products to self-treat symptoms of sexually transmitted infections in South African women

The objective of the study is to investigate products used by women self-treating symptoms of reproductive tract infections (RTIs), including sexually transmitted infections (STIs), and their methods of administration. A household survey using a multi-stage cluster sample design was undertaken in KwaZulu-Natal, South Africa. Women aged 18-60 years were interviewed (n = 867) and information was collected on demographics, reproductive health and sexual behaviours. A fifth of women reported having RTI/STI symptoms (20.5%), of whom 41.9% were treating these symptoms (mostly discharge [79.1%], ulcers [6.8%] and itching [7.7%]). Only three women were using medication prescribed by a health provider, while the remainder were self-treating using traditional medicines and modern products, including antiseptics, soaps, petroleum jelly, menthol creams and alum. Products were administered in various ways. Although RTI/STI treatment is widely available and free in public health facilities, many women are still self-treating. Potential harm of products for self-treatment requires further investigation and efforts should be made to improve STI service uptake.

Intravaginal and menstrual practices among women working in food and recreational facilities in Mwanza, Tanzania: implications for microbicide trials

Intravaginal and menstrual practices may potentially influence results of trials of microbicides for HIV prevention through effects on the vaginal environment and on adherence to microbicide and placebo products. As part of the feasibility study for the Microbicides Development Programme Phase 3 trial of a vaginal microbicide in Mwanza, a variety of quantitative and qualitative methods were used to describe these practices, associations with behaviour and underlying social norms among women working in food and recreational facilities. Intravaginal cleansing by inserting fingers and either water alone or soap and water was thought necessary to remove “uchafu” (dirt), referring to vaginal secretions, including menstrual blood and post-coital discharge. Vaginal cleansing was carried out within 2 hours after 45% of sex acts. Sexual enhancement practices were less common. Intravaginal and menstrual practices and associated behaviours and demographic factors should be measured and monitored throughout microbicide trials to enable analyses of their impacts on microbicide effectiveness.

Human papillomavirus-based cervical cancer prevention: long-term results of a randomized screening trial

BACKGROUND

Screen-and-treat approaches to cervical cancer prevention are an attractive option for low-resource settings, but data on their long-term efficacy are lacking. We evaluated the efficacy of two screen-and-treat approaches through 36 months of follow-up in a randomized trial.

METHODS

A total of 6637 unscreened South African women aged 35-65 years who were tested for the presence of high-risk human papillomavirus (HPV) DNA in cervical samples underwent visual inspection of the cervix using acetic acid staining and HIV serotesting. Of these, 6555 were randomly assigned to three study arms: 1) HPV-and-treat, in which all women with a positive HPV DNA test result underwent cryotherapy; 2) visual inspection-and-treat, in which all women with a positive visual inspection test result underwent cryotherapy; or 3) control, in which further evaluation or treatment was delayed for 6 months. All women underwent colposcopy with biopsy at 6 months. All women who were HPV DNA- or visual inspection-positive at enrollment, and a subset of all other women had extended follow-up to 36 months (n = 3639) with yearly colposcopy. The endpoint-cervical intraepithelial neoplasia grade 2 or worse (CIN2+)-was analyzed using actuarial life-table methods. All statistical tests were two-sided.

RESULTS

After 36 months, there was a sustained statistically significant decrease in the cumulative detection of CIN2+ in the HPV-and-treat arm compared with the control arm (1.5% vs 5.6%, difference = 4.1%, 95% confidence interval [CI] = 2.8% to 5.3%, P < .001). The difference in the cumulative detection of CIN2+ in the visual inspection-and-treat arm compared with the control was less (3.8% vs 5.6%, difference = 1.8%, 95% CI = 0.4% to 3.2%, P = .002). Incident cases of CIN2+ (identified more than 12 months after enrollment) were less common in the HPV-and-treat arm (0.3%, 95% CI = 0.05% to 1.02%) than in the control (1.0%, 95% CI = 0.5% to 1.7%) or visual inspection-and-treat (1.3%, 95% CI = 0.8% to 2.1%) arms.

CONCLUSIONS

In this trial, a screen-and-treat approach using HPV DNA testing identified and treated prevalent cases of CIN2+ and appeared to reduce the number of incident cases of CIN2+ that developed more than 12 months after cryotherapy.

Vaginal practices of HIV-negative Zimbabwean women

Background. Vaginal practices (VPs) may increase HIV risk by injuring vaginal epithelium or by increasing risk of bacterial vaginosis, an established risk factor for HIV. Methods. HIV-negative Zimbabwean women (n = 2,185) participating in a prospective study on hormonal contraception and HIV risk completed an ancillary questionnaire capturing detailed VP data at quarterly followup visits for two years. Results. Most participants (84%) reported ever cleansing inside the vagina, and at 40% of visits women reported drying the vagina using cloth or paper. Vaginal tightening using cloth/cotton wool, lemon juice, traditional herbs/powders, or other products was reported at 4% of visits. Women with ≥15 unprotected sex acts monthly had higher odds of cleansing (adjusted odds ratio (aOR): 1.17, 95% CI: 1.04–1.32). Women with sexually transmitted infections had higher odds of tightening (aOR: 1.42, 95% CI: 1.08–1.86). Conclusion. Because certain vaginal practices were associated with other HIV risk factors, synergism between VPs and other risk factors should be explored.

Vaginal practices and associations with barrier methods and gel use among Sub-Saharan African women enrolled in an HIV prevention trial

Vaginal practices may interfere with the use and/or the effectiveness of female-initiated prevention methods. We investigated whether vaginal practices differed by randomization group in a phase III trial of the diaphragm with lubricant gel (MIRA) in Sub-Saharan Africa (n = 4925), and if they were associated with consistent use of study methods. At baseline, vaginal practices were commonly reported: vaginal washing (82.77%), wiping (56.47%) and insertion of dry or absorbent materials (20.58%). All three practices decreased during the trial. However, women in the intervention group were significantly more likely to report washing or wiping during follow-up compared to those in the control group. Additionally, washing, wiping, and insertion, were all independently and inversely associated with consistent diaphragm and gel use and with condom use as well, regardless of study arm. A better understanding of the socio-cultural context in which these practices are embedded could improve educational strategies to address these potentially modifiable behaviors, and may benefit future HIV prevention interventions of vaginal methods.

Personal hygienic behaviors and bacterial vaginosis

BACKGROUND

Vaginal douching is consistently associated with bacterial vaginosis (BV), but whether it is a cause or result of BV remains unknown. The association between BV and other feminine hygienic behaviors is less studied; if BV symptoms caused behavior change then all hygiene behaviors might be more common among women with BV. Lack of association between nondouching hygiene behavior and BV would argue against reverse causation.

METHODS

In the Longitudinal Study of Vaginal Flora 3620 women had 13,517 visits where BV (Nugent score) was assessed. Associations between hygienic behavior and BV were assessed by Poisson regression.

RESULTS

After adjusting for demographic and sexual behavior factors, neither type of underwear (nylon vs. cotton prevalence ratio (PR) 1.05, 95% CI: 0.97-1.13), menstrual protection (tampons vs. pads; PR: 1.04, 95% CI: 0.95-1.12; pads and tampons vs. pads 1.00, 95% CI: 0.92-1.07), use of pads or panty liners when not menstruating (PR: 0.99, 95% CI: 0.95-1.05), nor weekly or greater use of hygiene spray (PR: 1.01, 95% CI: 0.94-1.09), powder (PR: 1.02, 95% CI: 0.96-1.07) or towlettes (PR: 1.03, 95% CI: 0.94-1.13) were strongly associated with BV. PR for daily versus less than daily bathing and showering were 1.06 (95% CI: 1.02-1.12) and 1.04 (95% CI: 1.00-1.09). Douching remained associated with BV (PR for weekly or greater vs. never 1.17, 95% CI: 1.09-1.26) and was not substantially impacted by adjustment for other hygienic behavior.

CONCLUSIONS

Douching, but not other feminine hygiene behaviors, is significantly associated with BV, providing additional evidence that douching may be causally associated with BV and is not simply a response to BV symptoms.

Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis

BACKGROUND

Intravaginal practices are commonly used by women to manage their vaginal health and sexual life. These practices could, however, affect intravaginal mucosal integrity. The objectives of this study were to examine evidence for associations between: intravaginal practices and acquisition of HIV infection; intravaginal practices and vaginal infections; and vaginal infections and HIV acquisition.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a systematic review of prospective longitudinal studies, searching 15 electronic databases of journals and abstracts from two international conferences to 31(st) January 2008. Relevant articles were selected and data extracted in duplicate. Results were examined visually in forest plots and combined using random effects meta-analysis where appropriate. Of 2120 unique references we included 22 publications from 15 different studies in sub-Saharan Africa and the USA. Seven publications from five studies examined a range of intravaginal practices and HIV infection. No specific vaginal practices showed a protective effect against HIV or vaginal infections. Insertion of products for sex was associated with HIV in unadjusted analyses; only one study gave an adjusted estimate, which showed no association (hazard ratio 1.09, 95% confidence interval, CI 0.71, 1.67). HIV incidence was higher in women reporting intravaginal cleansing but confidence intervals were wide and heterogeneity high (adjusted hazard ratio 1.88, 95%CI 0.53, 6.69, I(2) 83.2%). HIV incidence was higher in women with bacterial vaginosis (adjusted effect 1.57, 95%CI 1.26, 1.94, I(2) 19.0%) and Trichomonas vaginalis (adjusted effect 1.64, 95%CI 1.28, 2.09, I(2) 0.0%).

CONCLUSIONS/SIGNIFICANCE

A pathway linking intravaginal cleaning practices with vaginal infections that increase susceptibility to HIV infection is plausible but conclusive evidence is lacking. Intravaginal practices do not appear to protect women from vaginal infections or HIV and some might be harmful.

A cross cultural study of vaginal practices and sexuality: implications for sexual health

Between 2005 and 2006, we investigated vaginal practices in Yogyakarta, Indonesia; Tete, Mozambique; KwaZulu-Natal, South Africa; and Bangkok and Chonburi, Thailand. We sought to understand women's practices, their motivations for use and the role vaginal practices play in women's health, sexuality and sense of wellbeing. The study was carried out among adult women and men who were identified as using, having knowledge or being involved in trade in products. Further contacts were made using snowball sampling. Across the sites, individual interviews were conducted with 229 people and 265 others participated in focus group discussions. We found that women in all four countries have a variety of reasons for carrying out vaginal practices whose aim is to not simply 'dry' the vagina but rather decrease moisture that may have other associated meanings, and that they are exclusively "intravaginal" in operation. Practices, products and frequency vary. Motivations generally relate to personal hygiene, genital health or sexuality. Hygiene practices involve external washing and intravaginal cleansing or douching and ingestion of substances. Health practices include intravaginal cleansing, traditional cutting, insertion of herbal preparations, and application of substances to soothe irritated vaginal tissue. Practices related to sexuality can involve any of these practices with specific products that warm, dry, and/or tighten the vagina to increase pleasure for the man and sometimes for the woman. Hygiene and health are expressions of femininity connected to sexuality even if not always explicitly expressed as such. We found their effects may have unexpected and even undesired consequences. This study demonstrates that women in the four countries actively use a variety of practices to achieve a desired vaginal state. The results provide the basis for a classification framework that can be used for future study of this complex topic.

General hygiene, sexual risk behaviour and HIV prevalence in truck drivers from Andhra Pradesh, South India: implications for prevention interventions

The relationships between hygiene, sexual behaviour and HIV infection are poorly understood. We examine these relationships in Indian truck drivers, a group at high risk for HIV infection. Truck drivers (n = 189) were recruited into an integrated HIV and hygiene Information Motivation (IM) programme. Sociodemographic characteristics, sexual and hygiene behaviour and HIV prevalence were determined. Multivariate logistic regression and linear generalized estimating equation models were utilized. At baseline, 2.1% of drivers were HIV infected and 34% who reported having contact with female sex workers (FSWs) had contact within the previous six months. Those who washed their hands postdefecation were less likely to report genital symptoms (OR 0.02; P = 0.01) and have sex with an FSW (OR [odds ratio] 0.21; P = 0.05). After an IM intervention, there were no changes in sexual risk-taking behaviour (coefficient -0.15 to -0.02; P = 0.13-0.75); however, hygiene behaviour improved from baseline (coefficient 0.09-0.31; P < 0.01 to P = 0.03). Personal hygiene habits, like handwashing, seem to be a modifiable behaviour after a modest intervention, whereas HIV risk-taking behaviour was not. The association between hygiene and HIV risk-taking suggests the need for further evaluation of the relationship and that of other hygiene practices in high-risk men in India.

Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents

OBJECTIVE

The objective of the study was to examine the association between douching and 4 sexually transmitted infections (STIs).

STUDY DESIGN

We followed up 411 high-risk human immunodeficiency virus-infected and uninfected female adolescents aged 12-19 years over a median 3-year period, both by time from study entry/first STI-free visit until an incident STI for participants who never, intermittently, and always douched and also by reported douching at a given STI-free visit and incidence of STI at the next visit, using adjusted Cox proportional hazards models to calculate hazard ratios (HR).

RESULTS

The time to STI was shorter for adolescents who always (HR, 2.1; 95% confidence interval [CI], 1.2-3.4) and intermittently (HR, 1.5; 95% CI, 1.0-2.2) douched, compared with never-douchers. An adjusted hazard for STI was 1.8 times larger for always-douchers (95% CI, 1.1-3.1) and 1.4 times larger for intermittent douchers (95% CI, 0.9-2.0), compared with never-douchers. When classifying by follow-up after an STI-free visit, always-douchers had a shorter STI-free time than never-douchers (HR(adj), 2.1; 95% CI, 1.5-3.1).

CONCLUSION

Counseling to discourage douching may reduce STI risk in adolescents.

Lime Juice as a Candidate Microbicide? An Open-Label Safety Trial of 10% and 20% Lime Juice Used Vaginally

OBJECTIVE

Lime has a long history as a contraceptive and vaginal hygiene douche, and ongoing use in Africa is documented. We report on the first safety study on diluted lime juice to assess its potential as a candidate microbicide.

METHODS

Twenty-five sexually abstinent women were randomly assigned to apply a 10% or 20% concentration of lime juice or 0% (water-only) through a soaked tampon once daily for 14 consecutive days. Tests for genital infections, measurement of inflammatory biomarkers, and a colposcopy were performed before and after treatment.

RESULTS

No participant showed severe vaginal irritation. Two women developed a yeast infection after using lime juice. More than 70% of women in all groups reported side effects, most being singular, mild, and transient events. The users of 20% diluted lime juice experienced a significantly higher frequency of burning and dryness. Vaginal inflammatory biomarkers showed no significant change between preexposure and postexposure levels. The naturally low vaginal pH showed little change, and lactobacilli colonization did not decrease.

CONCLUSIONS

Lime juice up to 20% concentration has an acceptable safety profile for vaginal use. However, as new in vitro research shows that the effectiveness of lime juice to prevent HIV transmission in concentrations lower than >or=50% is unlikely and concentrations of 50% have been shown to be toxic, women should be discouraged from commencing or continuing the vaginal use of lime juice.

Associations between intravaginal practices and bacterial vaginosis in Kenyan female sex workers without symptoms of vaginal infections

BACKGROUND

Bacterial vaginosis (BV) is highly prevalent among African women and has been associated with adverse pregnancy outcomes, sexually transmitted diseases, and HIV-1.

GOAL

The goal of this study was to analyze the relationship among intravaginal practices, bathing, and BV.

STUDY DESIGN

The authors conducted a cross-sectional study of HIV-1-seronegative Kenyan female sex workers without symptoms of vaginal infections.

RESULTS

Of 237 women enrolled, 206 (87%) reported vaginal washing using either a finger or cloth. Increasing frequency of vaginal washing was associated with a higher likelihood of BV (chi(2) test for trend, P = 0.05). In multivariate analysis, vaginal lubrication with petroleum jelly (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.4-5.6), lubrication with saliva (OR = 2.3, 95% CI = 1.1-4.8), and bathing less than the median for the cohort (14 times/week; OR = 4.6, 95% CI = 1.2-17.5) were associated with a significantly higher likelihood of BV.

CONCLUSIONS

Modification of intravaginal and general hygiene practices should be evaluated as potential strategies for reducing the risk of BV.

Preparing for microbicide trials in Rwanda: focus group discussions with Rwandan women and men

The acceptability and feasibility of microbicide studies and future microbicide use are influenced by existing norms and values regarding sexual and contraceptive behaviour. In preparation for microbicide research in Rwanda, focus group discussions were conducted to assess sexual and contraceptive behaviour, preferences for vaginal lubrication, and hypothetical acceptability of microbicides among Rwandan women and men. Seven focus group discussions were conducted among sexually active married women, unmarried women, sex workers, female students, older women and men living in Kigali, Rwanda, and an additional group of women living in a rural area. The results indicate that condom use is low among Rwandan men and women and that condoms are mainly used by men during commercial sex. Women have limited power to negotiate condom or family planning use. Vaginal hygiene practices are very common and consist primarily of washing with water. Lubrication during sex is highly preferred by both men and women. Hypothetical microbicide acceptability after an explanation of what microbicides are and a demonstration with lubricant jelly was high.

Is HIV drug resistance a limiting factor in the development of anti-HIV NNRTI and NRTI-based vaginal microbicide strategies?

Antiviral drugs that act at specific sites within the HIV life cycle have important rationale for development as anti-HIV microbicides. However, to be effective, such drugs must act by directly interfering with viral enzymatic function and eliminate the ability of HIV to mediate infection. Compounds that are developed as microbicides must have high potency, and should ideally not be well absorbed from the vaginal cavity in order to minimize any potential problems of drug resistance. Such compounds should also be active over long periods of time and should be able to be combined with other active agents, in order to promote the concept of synergy, such as that which has been demonstrated in HIV therapeutic studies.

Challenges to microbicide introduction in South Africa

Qualitative research was conducted in South Africa to determine perceptions about intra-vaginal microbicides in order to better understand the socioeconomic, cultural and structural contexts for the support of future introduction of this new HIV prevention method. Focus group discussions and in-depth interviews were conducted at community, health service, and policy levels of inquiry. The main study site was a black working class urban area close to Cape Town. "Desperation" in response to the HIV/AIDS epidemic, rape, sexual coercion and unplanned consensual sex emerged as major reasons to support microbicides, while concerns about the partial effectiveness of microbicide protection and its hypothetical nature elicited a more cautious approach. Other key findings included the likelihood that microbicides would be "mainstream", the possible impact on sexual practices and gender norms, issues of condom substitution/migration and potential avenues for education and distribution. We found that microbicides have the potential to meet diverse needs beyond that suggested by prior research. This included a desire for products that could protect against HIV infection following rape, sexual coercion and unplanned sex, and the finding that a wider range of people than previously suggested would potentially use microbicides. The challenge for microbicide introduction will be to develop products that can meet diverse needs not only in South Africa, but also in the broader global context.

"We have our protector": misperceptions of protection against HIV among participants in a microbicide efficacy trial

OBJECTIVES

We examined perceptions of the effectiveness and acceptability of a candidate microbicide among 94 South African female sex workers who had participated in a phase 3 microbicide trial for HIV prevention.

METHODS

Sixteen focus groups were conducted in 2001, 12 to 15 months after participants were informed that the candidate microbicide had been determined to be ineffective in preventing HIV and other sexually transmitted infections (STIs).

RESULTS

Participants clearly indicated that they understood the experimental nature of the candidate microbicide, and they recognized that they had been informed after the trial that the product was ineffective. Nevertheless, most continued to believe that the candidate microbicide helped prevent HIV and other STIs, alleviated reproductive tract pain and STI symptoms, and helped to clean the vagina.

CONCLUSIONS

These findings underscore the importance of understanding women's perceptions of the efficacy of candidate microbicides and the rationale for these beliefs. These issues need to be addressed in counseling throughout microbicide trials for HIV prevention. These results also demonstrate how desperate many women at high risk of HIV infection may be for new HIV prevention technologies.

Distinguishing the temporal association between women's intravaginal practices and risk of human immunodeficiency virus infection: a prospective study of South African women

Cross-sectional studies have suggested that intravaginal practices, such as douching or "dry sex," may increase women's susceptibility to infection with human immunodeficiency virus (HIV). The authors examined the temporal nature of this association in a cohort of South African women. At enrollment (2001-2002), 4,089 women were tested for HIV infection. Participants reported their intravaginal practices at a 6-month follow-up visit and were followed with repeat HIV testing for up to 24 months. Among the 3,570 women who were HIV-negative at enrollment, 26% reported some type of intravaginal practice, mostly washing inside the vagina with water and/or cloth as part of daily hygiene. During follow-up, 85 incident HIV infections were observed. Intravaginal practices were associated with prevalent HIV at enrollment (adjusted odds ratio = 1.50, 95% confidence interval: 1.22, 1.85), but during follow-up there was no association between intravaginal practices and incident HIV (adjusted hazard ratio = 1.04, 95% confidence interval: 0.65, 1.68). These findings may be explained by a reversal of the causal sequence assumed for this association, since intravaginal practices may be undertaken in response to vaginal infections that occur more commonly among HIV-infected women. Intravaginal practices appear unlikely to be a cofactor in the male-to-female transmission of HIV in this setting.

Vaginal washing and increased risk of HIV-1 acquisition among African women: a 10-year prospective study

BACKGROUND

No prospective study has examined the risk of HIV-1 acquisition associated with vaginal washing, although intravaginal practices have been identified as potentially important contributors to HIV-1 susceptibility.

OBJECTIVE

To evaluate the contribution of vaginal washing to incident HIV-1 infection.

DESIGN

Prospective cohort study.

METHODS

Data were derived from a 10-year study of risk factors for HIV-1 acquisition among 1270 Kenyan female sex workers. Intravaginal practices were ascertained at study enrollment. At monthly follow-up visits, women completed a standardized interview and specimens were collected for diagnosis of HIV-1 and genital tract infections.

RESULTS

: Compared with women who did not perform vaginal washing, there was an increased risk for acquiring HIV-1 among women who used water [adjusted hazard ratio (HR), 2.64; 95% confidence interval (CI), 1.00-6.97] or soap (adjusted HR 3.84; 95% CI, 1.51-9.77) to clean inside the vagina, after adjustment for demographic factors, sexual behavior, and sexually transmitted infections. Furthermore, women who performed vaginal washing with soap or other substances were at higher risk for HIV-1 compared with those who used water alone (adjusted HR, 1.47; 95% CI, 1.02-2.13).

CONCLUSIONS

In populations where vaginal washing is common, this practice may be an important factor promoting the spread of HIV-1. Intervention strategies aimed at modifying intravaginal practices should be evaluated as a possible female-controlled HIV-1 prevention strategy.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

Microbicide acceptability research: current approaches and future directions

With growing recognition of the potential value of microbicides for HIV/STI prevention, the importance of the acceptability of this brand-new technology has been widely acknowledged. We review the current body of microbicide acceptability research, characterize the limitations in assessment approaches, and suggest strategies for improvement. Electronic databases and abstracts of recent meetings were searched for acceptability data regarding vaginal and rectal products that may be used for HIV prevention. Of the 61 studies reviewed, more than half assessed acceptability based primarily on the description of a hypothetical microbicide, or with the demonstration of a spermicide or lubricant. Physical characteristics of microbicidal products, their effects after insertion, and their effects on sensation during intercourse (for both partners) were the dimensions most frequently assessed (measured in 77%, 49% and 49% of studies, respectively). Attention to the social context of use was inadequate. As acceptability is likely to be a key determinant in the use-effectiveness of microbicides, in-depth understanding of the social processes that shape microbicide acceptability across diverse populations will become increasingly valuable. This includes exploring the effects that sexual partners, health care providers, and key opinion leaders have on the acceptability of microbicides among women and men, including youth and people living with HIV. Future research will benefit from studies of the acceptability of other contraceptive-barrier methods (especially the female condom), use of an agreed-upon operationalization of acceptability, use of acceptability assessments within clinical trials, expansion of measurement domains, and assessment of changes in perceptions of acceptability and use over time. Failure to understand the key factors associated with microbicide acceptability is likely to hinder the adoption and continued use of products that are effective in preventing HIV infection.