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Sabo MC, Balkus JE, Richardson BA, Srinivasan S, Kimani J, Anzala O, Schwebke J, Fiedler TL, Fredricks DN, McClelland RS. Next generation sequencing to examine associations between vaginal washing and vaginal microbiota: A cohort study. Int J STD AIDS 2023; 34:557-566. [PMID: 36945124 PMCID: PMC11075686 DOI: 10.1177/09564624231160806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND The association between vaginal washing and HIV risk may be mediated by vaginal washing-associated changes in vaginal microbiota. METHODS Data from a cohort of HIV-negative US and Kenyan women enrolled in the Preventing Vaginal Infections trial were analyzed. Vaginal fluid samples and vaginal washing data were collected every 2 months for 12 months. Bacterial relative abundances were measured by broad-range 16S rRNA gene polymerase chain reaction with next generation sequencing. Generalized estimating equations were used to evaluate the association between vaginal washing and i) the Shannon Diversity Index (SDI); and ii) mean change in percent bacterial relative abundances, with application of a 10% false discovery rate (FDR). RESULTS Participants (N = 111) contributed 93/630 (14.8%) vaginal washing visits. Mean SDI was 0.74 points higher (95% CI 0.35, 1.14; p < 0.001) at washing visits among US participants (N = 26). Vaginal washing was not associated with SDI in Kenyan participants (N = 85). There were no associations between vaginal washing and vaginal bacterial relative abundances after applying the FDR. CONCLUSIONS The discordant results in Kenyan versus US women suggests the link between vaginal washing and sub-optimal vaginal microbiota may be context specific. Vaginal microbial shifts may not fully explain the association between vaginal washing and HIV acquisition.
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Affiliation(s)
- Michelle C. Sabo
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer E. Balkus
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joshua Kimani
- Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Omu Anzala
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Jane Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tina L. Fiedler
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David N. Fredricks
- Department of Medicine, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - R. Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
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Brown SE, He X, Shardell MD, Ravel J, Ghanem KG, Zenilman JM, Brotman RM. Douching cessation and molecular bacterial vaginosis: a reanalysis of archived specimens. Sex Transm Infect 2023; 99:156-161. [PMID: 35636931 PMCID: PMC9708945 DOI: 10.1136/sextrans-2022-055459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/01/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Observational studies demonstrate an association between vaginal douching and bacterial vaginosis (BV) characterised by Gram stain. We sought to describe the effect of a douching cessation intervention on the composition and structure of the vaginal microbiota and molecular-BV, a state defined by low levels of Lactobacillus spp evaluated by molecular tools. METHODS 33 women self-collected mid-vaginal swabs twice weekly (982 samples) during a douching observation phase (4 weeks) followed by a douching cessation phase (12 weeks) in a 2005 single crossover pilot study conducted in Baltimore, Maryland. Vaginal microbiota were characterised by 16S rRNA gene amplicon sequencing (V3-V4) and clustered into community state types (CSTs). Conditional logistic regression modelling allowed each participant to serve as their own control. Wilcoxon signed-rank tests were used to evaluate changes in microbiota between phases. Broad-range qPCR assays provided estimates of bacterial absolute abundance per swab in a subsample of seven participants before and after douching. A piecewise linear mixed effects model was used to assess rates of change in bacterial absolute abundance before and after douching. RESULTS There was no statistically significant change in the odds of molecular-BV versus Lactobacillus-dominated CSTs comparing the douching cessation interval to douching observation (adjusted OR 1.77, 95% CI 0.89 to 3.55). Removal of L. iners-dominated CST III from the outcome did not affect the results. There were no significant changes in the relative abundance of four Lactobacillus spp and no meaningful changes in other taxa investigated. There was no significant change in bacterial absolute abundance between a participant's sample collected 3 days prior to and following douching (p=0.46). CONCLUSIONS In this pilot study, douching cessation was not associated with major changes in vaginal microbiota. Douching cessation alone may not durably shift the vaginal microbiota and additional interventions may be needed to restore optimal vaginal microbiota among those who douche.
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Affiliation(s)
- Sarah Elizabeth Brown
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Xin He
- Department of Epidemiology and Biostatistics, University of Maryland at College Park, College Park, Maryland, USA
| | - Michelle D Shardell
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Microbiology & Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Khalil G Ghanem
- Division of Infectious Diseases, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA
| | - Jonathan M Zenilman
- Division of Infectious Diseases, Johns Hopkins Medicine School of Medicine, Baltimore, Maryland, USA
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Wilkinson EM, Łaniewski P, Herbst-Kralovetz MM, Brotman RM. Personal and Clinical Vaginal Lubricants: Impact on Local Vaginal Microenvironment and Implications for Epithelial Cell Host Response and Barrier Function. J Infect Dis 2020; 220:2009-2018. [PMID: 31539059 DOI: 10.1093/infdis/jiz412] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/08/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND A majority of US women report past use of vaginal lubricants to enhance the ease and comfort of intimate sexual activities. Lubricants are also administered frequently in clinical practice. We sought to investigate if hyperosmolar lubricants are toxic to the vaginal mucosal epithelia. METHODS We tested a panel of commercially available lubricants across a range of osmolalities in human monolayer vaginal epithelial cell (VEC) culture and a robust 3-dimensional (3-D) VEC model. The impact of each lubricant on cellular morphology, cytotoxicity, barrier targets, and the induction of inflammatory mediators was examined. Conceptrol, containing nonoxynol-9, was used as a cytotoxicity control. RESULTS We observed a loss of intercellular connections, and condensation of chromatin, with increasing lubricant osmolality. EZ Jelly, K-Y Jelly, Astroglide, and Conceptrol induced cytotoxicity in both models at 24 hours. There was a strong positive correlation (r = 0.7326) between lubricant osmolality and cytotoxicity in monolayer VECs, and cell viability was reduced in VECs exposed to all the lubricants tested for 24 hours, except McKesson. Notably, select lubricants altered cell viability, barrier targets, and inflammatory mediators in 3-D VECs. CONCLUSIONS These findings indicate that hyperosmolar lubricants alter VEC morphology and are selectively cytotoxic, inflammatory, and barrier disrupting in the 3-D VEC model.
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Affiliation(s)
- Ellen M Wilkinson
- Department of Obstetrics and Gynecology, College of Medicine-Phoenix, University of Arizona.,Department of Biology and Biochemistry, University of Bath, United Kingdom
| | - Paweł Łaniewski
- Department of Basic Medical Sciences, College of Medicine-Phoenix, University of Arizona, Baltimore
| | - Melissa M Herbst-Kralovetz
- Department of Obstetrics and Gynecology, College of Medicine-Phoenix, University of Arizona.,Department of Basic Medical Sciences, College of Medicine-Phoenix, University of Arizona, Baltimore
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore
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Shivakoti R, Tuddenham S, Caulfield LE, Murphy C, Robinson C, Ravel J, Ghanem KG, Brotman RM. Dietary macronutrient intake and molecular-bacterial vaginosis: Role of fiber. Clin Nutr 2020; 39:3066-3071. [PMID: 32033845 DOI: 10.1016/j.clnu.2020.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Women with bacterial vaginosis (BV) have increased risk of sexually transmitted infections and other adverse health outcomes. Based on the composition of their vaginal microbiota, women can broadly be classified into low-Lactobacillus (termed molecular-BV) and Lactobacillus-dominated profiles. Our objective was to determine the association between dietary macronutrient intake and molecular-BV. METHODS In a cross-sectional study of 104 reproductive-age women, dietary intake data were obtained using the Block Brief 2000 food frequency questionnaire. Vaginal microbiota composition was characterized by sequencing amplicons of the 16S rRNA gene V3-V4 regions and clustering into community state types (CST). Logistic regression was used to determine the association of macronutrient intake with molecular-BV (low-Lactobacillus vs. Lactobacillus-dominated CSTs combined). RESULTS Participants had a median age of 25.9 (interquartile range: 21.9-29.6), 58% were white (30% black), 51% overweight/obese and 52% on hormonal contraception. In multivariable models, diets richer in fiber were inversely associated with molecular-BV (adjusted odds ratio: 0.49 per standard deviation increase in energy-adjusted fiber intake, 95% confidence interval: 0.24-0.99; p = 0.049). CONCLUSIONS Our results indicate that diets richer in fiber were associated with lower odds of molecular-BV. Further studies are needed to confirm these findings and to test whether increasing fiber intake can modulate the microbiota towards a more optimal Lactobacillus-dominant profile.
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Affiliation(s)
- Rupak Shivakoti
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, 10032, USA.
| | - Susan Tuddenham
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA.
| | - Laura E Caulfield
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Catherine Murphy
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA.
| | - Courtney Robinson
- Institute for Genome Science, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Jacques Ravel
- Institute for Genome Science, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - Khalil G Ghanem
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA.
| | - Rebecca M Brotman
- Institute for Genome Science, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
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5
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Lazarus E, Otwombe K, Dietrich J, Andrasik MP, Morgan CA, Kublin JG, Gray GE, Isaacs AJ, Laher F. Vaginal practices among women at risk for HIV acquisition in Soweto, South Africa. South Afr J HIV Med 2019; 20:866. [PMID: 31308962 PMCID: PMC6620501 DOI: 10.4102/sajhivmed.v20i1.866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 02/14/2019] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Erica Lazarus
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michele P. Andrasik
- HIV Vaccine Trials Network, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Cecilia A. Morgan
- HIV Vaccine Trials Network, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - James G. Kublin
- HIV Vaccine Trials Network, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Glenda E. Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- HIV Vaccine Trials Network, Fred Hutchinson Cancer Research Center, Seattle, United States
- South African Medical Research Council, Cape Town, South Africa
| | - Abby J. Isaacs
- Statistical Center for HIV/AIDS Research and Prevention, Seattle, United States
| | - Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sabo MC, Balkus JE, Richardson BA, Srinivasan S, Kimani J, Anzala O, Schwebke J, Feidler TL, Fredricks DN, McClelland RS. Association between vaginal washing and vaginal bacterial concentrations. PLoS One 2019; 14:e0210825. [PMID: 30677048 PMCID: PMC6345501 DOI: 10.1371/journal.pone.0210825] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/25/2018] [Indexed: 12/22/2022] Open
Abstract
Vaginal washing is a common practice associated with adverse outcomes including bacterial vaginosis (BV) and HIV infection. Prior studies have not examined the associations between vaginal washing and individual vaginal bacteria, or whether these associations are independent of the effect of vaginal washing on BV. The purpose of this study was to characterize the association between vaginal washing and the presence and concentrations of vaginal bacteria associated with optimal and sub-optimal vaginal states. The analysis utilized data from participants in the placebo arm of the Preventing Vaginal Infections trial, which enrolled HIV-uninfected women from the United States and Kenya. Detection of bacterial taxa associated with BV was compared between visits with versus without reported vaginal washing. The effect of vaginal washing on a number of vaginal bacteria differed substantially (p<0.05) between the US and Kenya, so results were stratified by country. In US women, vaginal washing was associated with a significantly higher likelihood of detection of BV associated bacterium 1 (BVAB1) (relative risk [RR] 1.55, 95% confidence interval [CI] 1.15-2.09, p = 0.004), BVAB2 (RR 1.99, 95%CI 1.46-2.71, p<0.001), Mageeibacillus indolicus (RR 2.08, 95%CI 1.46-2.96, p<0.001), Atopobium vaginae (RR 1.34, 95%CI 1.13-1.59, p = 0.001), Leptotrichia/Sneathia species (RR 1.66, 95% CI 1.33-2.09, p<0.001), Megasphaera species (RR 1.78, 95%CI 1.34-2.37, p<0.001) and Gardnerella vaginalis (RR 1.08, 95%CI 1.01-1.16, p = 0.02). No significant association between vaginal washing and bacterial detection was found in Kenyan women. Adjustment for bacterial vaginosis diagnosed by Gram stain did not alter these results. This study provides evidence that the association between vaginal washing and detection of individual bacterial taxa can vary regionally. For some vaginal bacteria, the association with vaginal washing may be independent of the effect on Gram stain detection of BV. Larger prospective studies in diverse geographic settings should explore whether eliminating vaginal washing impacts the presence and concentrations of key vaginal bacteria.
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Affiliation(s)
- Michelle C. Sabo
- Department of Medicine, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Jennifer E. Balkus
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Joshua Kimani
- Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Omu Anzala
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Jane Schwebke
- Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Tina L. Feidler
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - David N. Fredricks
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - R. Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Epidemiology, University of Washington, Seattle, WA, United States of America
- Institute for Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
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7
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Pines HA, Strathdee SA, Hendrix CW, Bristow CC, Harvey-Vera A, Magis-Rodríguez C, Martinez G, Semple SJ, Patterson TL. Oral and vaginal HIV pre-exposure prophylaxis product attribute preferences among female sex workers in the Mexico-US border region. Int J STD AIDS 2018; 30:45-55. [PMID: 30170533 DOI: 10.1177/0956462418793038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
To assess the potential uptake of HIV pre-exposure prophylaxis (PrEP) products among female sex workers (FSWs) vulnerable to HIV infection, we examined the influence of product attributes on willingness to use products among 271 HIV-negative FSWs in Tijuana and Ciudad Juarez, Mexico (2016-2017). Via five-point Likert scale ratings, participants indicated their willingness to use hypothetical products with six attributes: formulation (pill, gel, liquid, or ring), frequency of use (daily, on-demand, or monthly), cost per use (10 or 200 pesos), effectiveness (40% or 80%), side effects (none or mild), and access point (healthcare clinic or non-governmental organization). Conjoint analysis was used to determine the impact of attributes on product ratings and identify preferred product attributes. Multinomial logistic regression was used to identify factors associated with formulation preferences. In both cities, formulation and frequency of use had the greatest impact on ratings. Participants in Ciudad Juarez indicated a strong preference for oral pills, whereas participants in Tijuana indicated roughly equal preferences for oral pills and vaginal gels. Monthly product use was preferred in both cities. Compared to preferring oral pills (38%), preferring vaginal gels (28%) was associated with practicing vaginal lubrication (adjusted odds ratio = 2.08; 95% confidence interval: 1.07-4.04). Oral PrEP may be acceptable to many FSWs in Tijuana and Ciudad Juarez; however, continued development of behaviorally-congruent vaginal PrEP products may also facilitate uptake and ensure sufficient coverage.
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Affiliation(s)
- H A Pines
- 1 Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - S A Strathdee
- 1 Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - C W Hendrix
- 2 Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - C C Bristow
- 1 Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - A Harvey-Vera
- 1 Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - C Magis-Rodríguez
- 3 Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA; National Center for HIV/AIDS Prevention and Control), Ministry of Health, Mexico City, Mexico
| | - G Martinez
- 4 Federacion Mexicana de Asociaciones Privadas, Ciudad Juarez, Chihuahua, Mexico
| | - S J Semple
- 5 Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - T L Patterson
- 5 Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
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8
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Pines HA, Semple SJ, Strathdee SA, Hendrix CW, Harvey-Vera A, Gorbach PM, Magis-Rodríguez C, Martinez G, Patterson TL. Vaginal washing and lubrication among female sex workers in the Mexico-US border region: implications for the development of vaginal PrEP for HIV prevention. BMC Public Health 2018; 18:1009. [PMID: 30107833 PMCID: PMC6092873 DOI: 10.1186/s12889-018-5946-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 08/09/2018] [Indexed: 11/11/2022] Open
Abstract
Background To assess the potential acceptability and inform the development of behaviorally-congruent vaginal douche- or gel-based HIV pre-exposure prophylaxis (PrEP) products, we examined vaginal washing and lubrication practices among female sex workers (FSWs) in Tijuana and Ciudad Juarez, two northern Mexico cities bordering the United States (US). Methods Two hundred and ninety-five HIV-negative FSWs (145 Tijuana; 150 Ciudad Juarez) enrolled in a behavioral HIV prevention intervention trial completed surveys assessing vaginal washing and lubrication practices, as well as motivators and barriers to performing each practice. Logistic regression was used to identify potential predictors of each practice in the past month. Results In the past month, vaginal washing was performed by 56 and 22% of FSWs in Tijuana and Ciudad Juarez (p < 0.0001), respectively, while vaginal lubrication was performed by 64 and 45% of FSWs in Tijuana and Ciudad Juarez (p = 0.001), respectively. Vaginal washing was positively associated with living in Tijuana (adjusted odds ratio [AOR] = 4.35, 95% confidence interval [CI]: 2.60–7.30), older age (AOR = 1.04 per year, 95% CI: 1.01–1.06), and vaginal lubrication (AOR = 2.99, 95% CI: 1.67–5.35), while it was negatively associated with being born in the same state as the study site (AOR = 0.50, 95% CI: 0.31–0.82), earning a monthly income ≥3500 pesos (AOR = 0.53, 95% CI: 0.28–1.00), and hazardous alcohol consumption (AOR = 0.56, 95% CI: 0.33–0.95). Vaginal lubrication was positively associated with living in Tijuana (AOR = 2.21, 95% CI: 1.37–3.54) and vaginal washing (AOR = 2.91, 95% CI: 1.64–5.18), while it was negatively associated with being born in the same state as the study site (AOR = 0.47, 95% CI: 0.29–0.75). Conclusions The moderate and high prevalence of vaginal washing and lubrication, respectively, suggest behaviorally-congruent, multi-purpose, vaginal douche- and gel-based PrEP products that simultaneously address FSWs’ needs and prevent HIV infection may be acceptable to many FSWs along the Mexico-US border. Future product development and implementation should also consider the link between vaginal washing and lubrication to ensure existing practices do not undermine vaginal PrEP product effectiveness. Trial registration ClincialTrials.gov (NCT02447484). Electronic supplementary material The online version of this article (10.1186/s12889-018-5946-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Heather A Pines
- Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA.
| | - Shirley J Semple
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, MC 0680, La Jolla, CA, 92093, USA
| | - Steffanie A Strathdee
- Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Alicia Harvey-Vera
- Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093, USA
| | - Pamina M Gorbach
- Department of Epidemiology, University of California, Los Angeles, 650 Charles E Young Drive S, BOX 951772, Los Angeles, CA, 90095, USA
| | - Carlos Magis-Rodríguez
- Centro Nacional para la Prevención y Control del VIH/SIDA (CENSIDA) Ministry of Health, Mexico City, Mexico
| | - Gustavo Martinez
- Federacion Mexicana de Asociaciones Privadas, Ciudad Juarez, Chihuahua, Mexico
| | - Thomas L Patterson
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, MC 0680, La Jolla, CA, 92093, USA
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Intravaginal Practices and Prevalence of Sexual and Reproductive Tract Infections Among Women in Rural Malawi. Sex Transm Dis 2018; 43:750-755. [PMID: 27835627 DOI: 10.1097/olq.0000000000000531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many women engage in intravaginal practices (IVP) with a goal of improving genital hygiene and increasing sexual pleasure. Intravaginal practices can disrupt the genital mucosa, and some studies have found that IVP increases risk of acquisition of HIV and bacterial vaginosis (BV). Limited prior research also suggests significant associations between IVP, herpes simplex virus type 2 (HSV-2), and high-risk types of human papillomavirus (HPV). METHODS We examined associations between IVP and HPV, BV, and HSV-2 among 200 women in rural Malawi participating in a clinic-based study on sexual and reproductive tract infections. We calculated prevalence ratios for the associations between frequency and type of IVP and outcomes of HPV, BV, and HSV-2. RESULTS Intravaginal practices were commonly performed, with 95% of women reporting current use of at least 1 practice. Infections were also frequently detected: Twenty-two percent of the sample had at least 1 high-risk HPV type, 51% had BV, and 50% were HSV-2 seropositive. We observed no significant associations between type of IVP, frequency of IVP, or a combined measure capturing type and frequency of IVP-and any of the infection outcomes. CONCLUSIONS Although both IVP and our outcomes of interest (BV, HPV, and HSV-2) were common in the study population, we did not detect associations between IVP type or frequency and any of the 3 infections. However, the high prevalence and frequency of IVP may have limited our ability to detect significant associations.
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Ayehunie S, Wang YY, Landry T, Bogojevic S, Cone RA. Hyperosmolal vaginal lubricants markedly reduce epithelial barrier properties in a three-dimensional vaginal epithelium model. Toxicol Rep 2017; 5:134-140. [PMID: 29854584 PMCID: PMC5977164 DOI: 10.1016/j.toxrep.2017.12.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 09/03/2017] [Accepted: 12/08/2017] [Indexed: 12/24/2022] Open
Abstract
Most of the widely used vaginal lubricants in the U.S. and Europe are strongly hyperosmolal, formulated with high concentrations of glycerol, propylene glycol, polyquaternary compounds or other ingredients that make these lubricants 4 to 30 times the osmolality of healthy vaginal fluid. Hyperosmolal formulations have been shown to cause marked toxicity to human colorectal epithelia in vivo, and significantly increase vaginal transmission of genital herpes infections in the mouse/HSV model. They also cause toxicity to explants of vaginal epithelia, to cultured vaginal epithelial cells, and increase susceptibility to HIV in target cells in cell cultures. Here, we report that the osmolality of healthy vaginal fluid is 370 ± 40 mOsm/Kg in women with Nugent scores 0–3, and that a well-characterized three-dimensional human vaginal epithelium tissue model demonstrated that vaginal lubricants with osmolality greater than 4 times that of vaginal fluid (>1500 mOsm/Kg) markedly reduce epithelial barrier properties and showed damage in tissue structure. Four out of four such lubricants caused disruption in the parabasal and basal layers of cells as observed by histological analysis and reduced barrier integrity as measured by trans-epithelial electrical resistance (TEER). No epithelial damage to these layers was observed for hypo- and iso-osmolal lubricants with osmolality of <400 mOsm/Kg. The results confirm extensive reports of safety concerns of hyperosmolal lubricants and suggest the usefulness of reconstructed in vitro vaginal tissue models for assessing safety of lubricants in the absence of direct clinical tests in humans.
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Affiliation(s)
- Seyoum Ayehunie
- MatTek Corporation, 200 Homer Avenue, Ashland, MA 01721, United States
| | - Ying-Ying Wang
- T.C. Jenkins Department of Biophysics, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
| | - Timothy Landry
- MatTek Corporation, 200 Homer Avenue, Ashland, MA 01721, United States
| | | | - Richard A Cone
- T.C. Jenkins Department of Biophysics, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, United States
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From menarche to menopause: A population-based assessment of water, sanitation, and hygiene risk factors for reproductive tract infection symptoms over life stages in rural girls and women in India. PLoS One 2017; 12:e0188234. [PMID: 29206842 PMCID: PMC5716553 DOI: 10.1371/journal.pone.0188234] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/31/2017] [Indexed: 11/20/2022] Open
Abstract
Women face greater challenges than men in accessing water, sanitation, and hygiene (WASH) resources to address their daily needs, and may respond to these challenges by adopting unsafe practices that increase the risk of reproductive tract infections (RTIs). WASH practices may change as women transition through socially-defined life stage experiences, like marriage and pregnancy. Thus, the relationship between WASH practices and RTIs might vary across female reproductive life stages. This cross-sectional study assessed the relationship between WASH exposures and self-reported RTI symptoms in 3,952 girls and women from two rural districts in India, and tested whether social exposures represented by reproductive life stage was an effect modifier of associations. In fully adjusted models, RTI symptoms were less common in women using a latrine without water for defecation versus open defecation (Odds Ratio (OR) = 0.69; Confidence Interval (CI) = 0.48, 0.98) and those walking shorter distances to a bathing location (OR = 0.79, CI = 0.63, 0.99), but there was no association between using a latrine with a water source and RTIs versus open defecation (OR = 1.09; CI = 0.69, 1.72). Unexpectedly, RTI symptoms were more common for women bathing daily with soap (OR = 6.55, CI = 3.60, 11.94) and for women washing their hands after defecation with soap (OR = 10.27; CI = 5.53, 19.08) or ash/soil/mud (OR = 6.02; CI = 3.07, 11.77) versus water only or no hand washing. WASH practices of girls and women varied across reproductive life stages, but the associations between WASH practices and RTI symptoms were not moderated by or confounded by life stage status. This study provides new evidence that WASH access and practices are associated with self-reported reproductive tract infection symptoms in rural Indian girls and women from different reproductive life stages. However, the counterintuitive directions of effect for soap use highlights that causality and mechanisms of effect cannot be inferred from this study design. Future research is needed to understand whether improvements in water and sanitation access could improve the practice of safe hygiene behaviors and reduce the global burden of RTIs in women.
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Chisembele M, Rodriguez VJ, Brown MR, Jones DL, Alcaide ML. Intravaginal practices among young HIV-infected women in Lusaka, Zambia. Int J STD AIDS 2017; 29:164-171. [PMID: 28699385 DOI: 10.1177/0956462417721438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Maureen Chisembele
- 1 Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Violeta J Rodriguez
- 2 Department of Psychiatry and Behavioral Sciences, 5452 University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Megan R Brown
- 2 Department of Psychiatry and Behavioral Sciences, 5452 University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Deborah L Jones
- 2 Department of Psychiatry and Behavioral Sciences, 5452 University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Maria L Alcaide
- 3 Department of Medicine, Division of Infectious Diseases, 5452 University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Alcaide ML, Rodriguez VJ, Fischl MA, Jones DL, Weiss SM. Addressing intravaginal practices in women with HIV and at-risk for HIV infection, a mixed methods pilot study. Int J Womens Health 2017; 9:123-132. [PMID: 28280394 PMCID: PMC5339018 DOI: 10.2147/ijwh.s125883] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Maria L Alcaide
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Margaret A Fischl
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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14
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Kasaro MP, Husnik MJ, Chi BH, Reid C, Magure T, Makanani B, Tembo T, Ramjee G, Maslankowski L, Rabe L, Brad Guffey M. Impact of targeted counseling on reported vaginal hygiene practices and bacterial vaginosis: the HIV Prevention Trials Network 035 study. Int J STD AIDS 2016; 28:467-475. [PMID: 27277555 DOI: 10.1177/0956462416653001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to describe the impact of intense counseling to reduce vaginal hygiene practices and its effect on bacterial vaginosis. A secondary data analysis of the HIV Prevention Trials Network 035 study was undertaken, focusing on HIV-negative, nonpregnant women who were at least 18 years old, in seven African sites and one US site. At enrollment and during follow-up quarterly visits, vaginal hygiene practices were determined by face-to-face administration of a behavioral assessment questionnaire. Vaginal hygiene practices were categorized as insertion into the vagina of (1) nothing, (2) water only, and (3) other substances with or without water. Each practice was quantified by frequency and type/combination of inserted substances. At quarterly visits, diagnosis of bacterial vaginosis was made using the Nugent score. Trends for vaginal hygiene practices and bacterial vaginosis were evaluated using generalized estimating equation models. A total of 3087 participants from the HIV Prevention Trials Network 035 study were eligible for this analysis. At enrollment, 1859 (60%) reported recent vaginal hygiene practices. By one year, this figure had decreased to 1019 (33%) with counseling. However, bacterial vaginosis prevalence remained consistent across the study observation period, with 36%-38% of women testing positive for the condition ( p for trend = 0.27). Overall, those who reported douching with water only (AOR = 1.03, 95%CI: 0.94-1.13) and those who reported inserting other substances (AOR= 0.98, 95%CI: 0.88-1.09) in the past quarter were not more likely to have bacterial vaginosis compared to those who reported no insertions. However, in South Africa, an increase in bacterial vaginosis was seen among those who reported inserting other substances (AOR: 1.48, 95%CI: 1.17, 1.88). In conclusion, targeted counseling against vaginal hygiene practices resulted in change in self-reported behavior but did not have an impact on bacterial vaginosis diagnosis in all but one site.
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Affiliation(s)
- Margaret P Kasaro
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,2 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Marla J Husnik
- 3 Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research & Prevention, Seattle, WA, USA
| | - Benjamin H Chi
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cheri Reid
- 2 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Tsitsi Magure
- 4 Department of Obstetrics and Gynecology, College of Health Science, University of Zimbabwe, Harare, Zimbabwe
| | - Bonus Makanani
- 5 College of Medicine-John Hopkins University Research Project, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Tchangani Tembo
- 6 UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Gita Ramjee
- 7 HIV Prevention Research Unit 1, South African Medical Research Council, Durban, South Africa
| | | | - Lorna Rabe
- 9 Magee-Women's Research Institute, Pittsburgh, PA, USA
| | - M Brad Guffey
- 2 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,1 0Family Legacy, Lusaka, Zambia
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Wang B, Xiao BB, Shang CG, Wang K, Na RS, Nu XX, Liao Q. Molecular analysis of the relationship between specific vaginal bacteria and bacterial vaginosis metronidazole therapy failure. Eur J Clin Microbiol Infect Dis 2014; 33:1749-56. [PMID: 24816815 DOI: 10.1007/s10096-014-2128-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
Abstract
Bacterial vaginosis frequently persists, even after treatment. The role of some strains of bacteria associated with bacterial vaginosis treatment failure remains poorly defined. The aim of our study was to define the risk of bacterial vaginosis treatment failure, including pre-treatment detection of specific vaginal bacteria. Bacterial vaginosis is present when the Nugent score is ≥7 and the modified Amsel criteria is positive. Women with bacterial vaginosis were treated with intravaginal metronidazole gel nightly for 5 nights. The 454 pyrosequencing method was used to detect bacteria in vaginal fluid. By univariate analysis, a history of bacterial vaginosis, intrauterine device use and the presence of Facklamia, Corynebacterium and Veillonella were significantly associated with bacterial vaginosis treatment failure. Lactobacillus crispatus, Lactobacillus pentosus and Megasphaera were significantly associated with curing bacterial vaginosis. After logistic regression analysis and detection of these bacteria for test-of-cure, we found that women who had a history of bacterial vaginosis had a higher incidence of bacterial vaginosis treatment failure, whereas women with L. crispatus had a lower incidence of treatment failure. Post-treatment sexual activity was not associated with the treatment effect. Our data suggested that treatment failure may be not caused by drug resistance. Rather, it has a closer relationship with the failed restoration of lactobacilli.
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Affiliation(s)
- B Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, 100034, China
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16
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Bui TC, Tran LTH, Ross MW, Markham CM. Douching practices among female sex workers in Phnom Penh, Cambodia. Int J STD AIDS 2014; 26:238-42. [PMID: 24810219 DOI: 10.1177/0956462414533098] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several studies indicate that douching has few benefits but numerous adverse health outcomes, including increased risk for sexually transmitted infections and HIV. No published study explores douching practices among Cambodian female sex workers. This report provides preliminary data about the prevalence and frequency of douching among female sex workers in Phnom Penh, Cambodia. Survey data were obtained from 81 female sex workers who were taken into custody due to engagement in commercial sex from March to June 2011. Results showed that 91% of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD = 3.87) and 4.63 (SD = 3.94), respectively. Half of the participants thought that douching could help to prevent sexually transmitted infections including HIV; 24% were unsure about this. Usually, douching after sex was associated with ever obtaining an HIV test (p = .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p =. 063) and consistent condom use with clients (p = .053). This suggests that these practices may be related to individual perceptions of sexually transmitted infections/HIV risk or susceptibility. Given the commonness of douching and related misperceptions among Cambodian female sex workers, future studies and interventions are needed to prevent adverse health problems.
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Affiliation(s)
- Thanh Cong Bui
- Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA
| | - Ly T H Tran
- Division of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA
| | - Michael W Ross
- Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA
| | - Christine M Markham
- Division of Health Promotion and Behavioral Sciences, School of Public Health, The University of Texas - Health Science Center at Houston, Houston, TX, USA
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McCormick DF, Rahman M, Zadrozny S, Alam A, Ashraf L, Neilsen GA, Kelly R, Menezes P, Miller WC, Hoffman IF. Prevention and control of sexually transmissible infections among hotel-based female sex workers in Dhaka, Bangladesh. Sex Health 2014; 10:478-86. [PMID: 24262217 DOI: 10.1071/sh12165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 07/16/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hotel-based sex workers in Bangladesh have high rates of sexually transmissible infections (STIs), high client turnover and low condom use. Two monthly clinic-based strategies were compared: periodic presumptive treatment (PPT) and enhanced syndromic management (ESM) - one round of presumptive treatment followed by treatment based on assessment and laboratory tests. METHODS A randomised controlled trial compared PPT and ESM by prevalence and incidence, behaviour, retention, cost and STI incidence and prevalence. Demographic, behavioural and clinical data were collected from women at two clinics in Dhaka. All women received presumptive treatment and were randomised to receive PPT or ESM at nine monthly visits. RESULTS In total, 549 women (median age: <20 years) were enrolled. At baseline, the prevalence of chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) was 41% (ESM: 41%; PPT: 42%). After 9 months, chlamydia and gonorrhoea decreased to 7% overall, (ESM: 7.4%; PPT: 6.8%). At each visit, 98% of women receiving ESM met the therapy criteria and were treated. Retention was low (50%). Total costs were 50% lower per visit for each woman for PPT (ESM: $11.62 v. PPT: $5.80). The number of sex work sessions was reduced from 3.3 to 2.5 (P<0.001), but income did not change. Coercion was reduced but condom use at last sex did not change significantly. CONCLUSIONS Monthly PPT and ESM were effective approaches for STI control. PPT offered a feasible, low-cost alternative to ESM. Educational aspects led to a reduction in coercion and fewer sessions. Implementation studies are needed to improve condom use and retention.
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Affiliation(s)
- Duncan F McCormick
- University of North Carolina, Department of Medicine, Chapel Hill, NC 27517, USA
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18
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The implications of post-coital intravaginal cleansing for the introduction of vaginal microbicides in South Africa. AIDS Behav 2014; 18:297-310. [PMID: 24337726 PMCID: PMC3905171 DOI: 10.1007/s10461-013-0676-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
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.
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Lourenço AG, Komesu MC, Machado AA, Bourlet T, Pozzetto B, Delézay O. Potential contribution of saliva to the sexual transmission of HIV through the secretion of CCL20 by genital epithelial cells. J Med Virol 2013; 86:58-63. [PMID: 24122904 DOI: 10.1002/jmv.23776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2013] [Indexed: 12/29/2022]
Abstract
Saliva can be considered as an important actor during sexual intercourse. However, there is no data concerning its influence on HIV sexual transmission. The aim of this study was to evaluate the role of whole saliva on the in vitro secretion of CCL20 by monolayered HEC-1A endocervical epithelium cells. HEC-1A cells were cultivated in 96-well microplates and incubated with specimens of whole saliva collected from 57 subjects tested seropositive (n = 34) or seronegative (n = 23) for HIV and presenting different oral conditions (healthy periodontally, n = 22, and gingivitis/periodontitis, n = 35). The production of CCL20 in the supernatants of HEC-1A cells after overnight incubation at 37°C was quantified using ELISA. The salivary concentration of lactoferrin (Lf) and IL-1β was tested by ELISA. Saliva samples were found able to stimulate dramatically the production of CCL20 by epithelial cells, increasing this synthesis by a mean factor of 38.1 with reference to untreated cells. This stimulation was equivalent to that observed with IL-1β used as positive control. Although no difference was observed according to oral condition, HIV status or salivary concentration of Lf and IL-1β, the high salivary concentration of the latter protein could acknowledge in large part for the overproduction of CCL20 by HEC-1A cells when stimulated by saliva. Saliva was shown to significantly increase CCL20 secretion and may be responsible for an enhanced recruitment of dendritic/Langerhans cells at the genital level. These results suggest that saliva could facilitate HIV entry and possibly other pathogens through the genital mucosa during heterosexual intercourse.
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Affiliation(s)
- Alan Grupioni Lourenço
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil; Department of Morphology, Stomatology and Physiology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil; EA3064, Groupe Immunité des Muqueuses et Agents Pathogènes (GIMAP), Faculté de Médecine de Saint-Etienne, Université de Lyon, Saint-Etienne, France
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20
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Hormonal contraception is associated with a reduced risk of bacterial vaginosis: a systematic review and meta-analysis. PLoS One 2013; 8:e73055. [PMID: 24023807 PMCID: PMC3762860 DOI: 10.1371/journal.pone.0073055] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/16/2013] [Indexed: 11/19/2022] Open
Abstract
Objective To examine the association between hormonal contraception (HC) and bacterial vaginosis (BV) by systematic review and meta-analysis. Methods Medline, Web of Science and Embase databases were searched to 24/1/13 and duplicate references removed. Inclusion criteria 1) >20 BV cases; 2) accepted BV diagnostic method; 3) measure of HC-use either as combined oestrogen-progesterone HC (combined), progesterone-only contraception (POC) or unspecified HC (u-HC); 4) ≥10% of women using HC; 5) analysis of the association between BV and HC-use presented; 6) appropriate control group. Data extracted included: type of HC, BV diagnostic method and outcome (prevalent, incident, recurrent), and geographical and clinic-setting. Meta-analyses were conducted to calculate pooled effect sizes (ES), stratified by HC-type and BV outcome. This systematic review is registered with PROSPERO (CRD42013003699). Results Of 1713 unique references identified, 502 full-text articles were assessed for eligibility and 55 studies met inclusion criteria. Hormonal contraceptive use was associated with a significant reduction in the odds of prevalent BV (pooled effect size by random-effects [reES] = 0.68, 95%CI0.63–0.73), and in the relative risk (RR) of incident (reES = 0.82, 95%CI:0.72–0.92), and recurrent (reES = 0.69, 95%CI:0.59–0.91) BV. When stratified by HC-type, combined-HC and POC were both associated with decreased prevalence of BV and risk of incident BV. In the pooled analysis of the effect of HC-use on the composite outcome of prevalent/incident/recurrent BV, HC-use was associated with a reduced risk of any BV (reES = 0.78, 95%CI:0.74–0.82). Conclusion HC-use was associated with a significantly reduced risk of BV. This negative association was robust and present regardless of HC-type and evident across all three BV outcome measures. When stratified by HC-type, combined-HC and POC were both individually associated with a reduction in the prevalence and incidence of BV. This meta-analysis provides compelling evidence that HC-use influences a woman’s risk of BV, with important implications for clinicians and researchers in the field.
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Aubyn GB, Tagoe DNA. Prevalence of vaginal infections and associated lifestyles of students in the university of Cape Coast, Ghana. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2013. [DOI: 10.1016/s2222-1808(13)60068-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Intravaginal Practices and Risk of Bacterial Vaginosis and Candidiasis Infection Among a Cohort of Women in the United States. Obstet Gynecol 2013; 121:773-780. [DOI: 10.1097/aog.0b013e31828786f8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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23
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The posttrial effect of oral periodic presumptive treatment for vaginal infections on the incidence of bacterial vaginosis and Lactobacillus colonization. Sex Transm Dis 2012; 39:361-5. [PMID: 22504600 DOI: 10.1097/olq.0b013e31824790d7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We previously demonstrated a decrease in bacterial vaginosis (BV) and an increase in Lactobacillus colonization among randomized controlled trial (RCT) participants who received monthly oral periodic presumptive treatment (PPT; 2 g metronidazole + 150 mg fluconazole). Posttrial data were analyzed to test the hypothesis that the treatment effect would persist after completion of 1 year of PPT. METHODS Data were obtained from women who completed all 12 RCT visits and attended ≥ 1 posttrial visit within 120 days after completion of the RCT. We used Andersen-Gill proportional hazards models to estimate the posttrial effect of the intervention on the incidence of BV by Gram stain and detection of Lactobacillus species by culture. RESULTS The analysis included 165 subjects (83 active and 82 placebo). The posttrial incidence of BV was 260 per 100 person-years in the intervention arm versus 358 per 100 person-years in the placebo arm (hazard ratio = 0.76; 95% confidence interval, 0.51-1.12). The posttrial incidence of Lactobacillus colonization was 180 per 100 person-years in the intervention arm versus 127 per 100 person-years in the placebo arm (hazard ratio = 1.42; 95% confidence interval, 0.85-2.71). CONCLUSIONS Despite a decrease in BV and an increase in Lactobacillus colonization during the RCT, the effect of PPT was not sustained at the same level after cessation of the intervention. New interventions that reduce BV recurrence and promote Lactobacillus colonization without the need for ongoing treatment are needed.
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Marrazzo JM, Cates W. Interventions to prevent sexually transmitted infections, including HIV infection. Clin Infect Dis 2011; 53 Suppl 3:S64-78. [PMID: 22080271 PMCID: PMC3213401 DOI: 10.1093/cid/cir695] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) Treatment Guidelines were last updated in 2006. To update the "Clinical Guide to Prevention Services" section of the 2010 CDC STD Treatment Guidelines, we reviewed the recent science with reference to interventions designed to prevent acquisition of STDs, including human immunodeficiency virus (HIV) infection. Major interval developments include (1) licensure and uptake of immunization against genital human papillomavirus, (2) validation of male circumcision as a potent prevention tool against acquisition of HIV and some other sexually transmitted infections (STIs), (3) failure of a promising HIV vaccine candidate to afford protection against HIV acquisition, (4) encouragement about the use of antiretroviral agents as preexposure prophylaxis to reduce risk of HIV and herpes simplex virus acquisition, (5) enhanced emphasis on expedited partner management and rescreening for persons infected with Chlamydia trachomatis and Neisseria gonorrhoeae, (6) recognition that behavioral interventions will be needed to address a new trend of sexually transmitted hepatitis C among men who have sex with men, and (7) the availability of a modified female condom. A range of preventive interventions is needed to reduce the risks of acquiring STI, including HIV infection, among sexually active people, and a flexible approach targeted to specific populations should integrate combinations of biomedical, behavioral, and structural interventions. These would ideally involve an array of prevention contexts, including (1) communications and practices among sexual partners, (2) transactions between individual clients and their healthcare providers, and (3) comprehensive population-level strategies for prioritizing prevention research, ensuring accurate outcome assessment, and formulating health policy.
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Affiliation(s)
- Jeanne M Marrazzo
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Seattle, WA 98104, USA.
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Vaginal practices of HIV-negative Zimbabwean women. Infect Dis Obstet Gynecol 2010; 2010. [PMID: 20871844 PMCID: PMC2943083 DOI: 10.1155/2010/387671] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 07/23/2010] [Indexed: 11/27/2022] Open
Abstract
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.
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Abstract
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.
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Denney JM, Culhane JF. Bacterial vaginosis: a problematic infection from both a perinatal and neonatal perspective. Semin Fetal Neonatal Med 2009; 14:200-3. [PMID: 19362525 DOI: 10.1016/j.siny.2009.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Bacterial vaginosis (BV) infections are common in women of reproductive age and are easily diagnosed and treatable. Aside from being an annoyance when symptoms of discharge, odor, and pruritus occur in the gravid female, BV infections increase risk of late miscarriage, preterm labor, preterm premature rupture of membranes, and, consequently, preterm delivery. Antepartum and puerperal issues such as chorioamnionitis and endometritis are increased in the context of maternal BV. Moreover, the morbidities and mortality of preterm delivery are consequently increased as a result of BV during pregnancy. Although the pathology associated with BV appears to result from inflammation, more investigation is needed in terms of designing guidelines for appropriate screening and treatment for the prevention of adverse outcomes.
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Affiliation(s)
- Jeff M Denney
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, University of Utah, Salt Lake City, UT, USA
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Baisley K, Changalucha J, Weiss HA, Mugeye K, Everett D, Hambleton I, Hay P, Ross D, Tanton C, Chirwa T, Hayes R, Watson-Jones D. Bacterial vaginosis in female facility workers in north-western Tanzania: prevalence and risk factors. Sex Transm Infect 2009; 85:370-5. [PMID: 19473997 PMCID: PMC2709714 DOI: 10.1136/sti.2008.035543] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine prevalence of, and risk factors for, bacterial vaginosis (BV) among herpes simplex virus (HSV) 2 seropositive Tanzanian women at enrollment into a randomised, placebo-controlled trial of HSV suppressive treatment. METHODS 1305 HSV-2 seropositive women aged 16-35 years working in bars, guesthouses and similar facilities were interviewed, examined and tested for HIV, syphilis, Neisseria gonorrhoeae, Chlamydia trachomatis, BV, candidiasis and trichomoniasis. Factors associated with BV were analysed using logistic regression to estimate odds ratios and 95% confidence intervals. RESULTS BV prevalence was 62.9%; prevalence of Nugent score 9-10 was 16.1%. Independent risk factors for BV were work facility type, fewer dependents, increasing alcohol consumption, sex in the last week (adjusted OR 2.03; 95% CI 1.57 to 2.62), using cloths or cotton wool for menstrual hygiene, HIV (adjusted OR 1.41; 95% CI 1.09 to 1.83) and Trichomonas vaginalis infection. There was no association between BV and the frequency or method of vaginal cleansing. However, BV was less prevalent among women who reported inserting substances to dry the vagina for sex (adjusted OR 0.44; 95% CI 0.25 to 0.75). CONCLUSION BV was extremely prevalent among our study population of HSV-2 positive female facility workers in North-western Tanzania. Although recent sex was associated with increased BV prevalence, vaginal drying was associated with lower BV prevalence. Further studies of the effects of specific practices on vaginal flora are warranted.
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Affiliation(s)
- K Baisley
- London School of Hygiene & Tropical Medicine, London, UK.
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Schneider JA, Dude A, Dinaker M, Kumar V, Laumann EO, Holloway-Beth A, Oruganti G, Saluja GS, Chundi V, Yeldandi V, Mayer KH. General hygiene, sexual risk behaviour and HIV prevalence in truck drivers from Andhra Pradesh, South India: implications for prevention interventions. Int J STD AIDS 2009; 20:39-45. [PMID: 19103892 DOI: 10.1258/ijsa.2008.008163] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- J A Schneider
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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Vulnerability of women in southern Africa to infection with HIV: biological determinants and priority health sector interventions. AIDS 2008; 22 Suppl 4:S27-40. [PMID: 19033753 DOI: 10.1097/01.aids.0000341775.94123.75] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review biomedical determinants of women's vulnerability to infection with HIV and interventions to counter this, within the southern African context. RESULTS Apart from number of exposures, if any, several factors influence the efficiency of HIV transmission during sex. Acute HIV infection, with extraordinarily high semen viral load, in conjunction with concurrent partnerships maximizes this efficiency. Delaying sexual debut and avoiding HIV exposure among biologically and socially vulnerable youth is critical. Reducing unintended pregnancies keeps girls in school and prevents vertical (also possibly horizontal) transmission. Female condoms, especially newer versions, are an under-exploited prevention technology. Control of sexually transmitted infections (STI), which facilitate HIV acquisition and transmission, remains important, especially among the most at-risk populations. Pathogens, such as herpes simplex virus type 2, which contribute most to HIV transmission in southern Africa must be targeted, although the importance of bacterial vaginosis and Trichomonas vaginalis is under-recognized. Also, heavy episodic alcohol use affects sexual decision-making and condom skills. Moreover, prevailing social contexts, partly a consequence of poor leadership, constrain the behavioural 'choices' available for girls and women. CONCLUSIONS Priority health sector interventions for preventing HIV are: male and female condom programming; prevention and control of STI; outreach to most vulnerable populations; HIV testing in all patient-provider encounters; male circumcision; and the integration of HIV prevention within sexual and reproductive health services. Future interventions during acute HIV infection and microbicides will reduce women's biological vulnerability. Far-reaching measures, such as sexual equity and alcohol control, create conditions necessary for achieving sustained prevention results. These are, however, contingent on stronger, more informed cultural and political leadership.
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Brotman RM, Klebanoff MA, Nansel TR, Andrews WW, Schwebke JR, Zhang J, Yu KF, Zenilman JM, Scharfstein DO. A longitudinal study of vaginal douching and bacterial vaginosis--a marginal structural modeling analysis. Am J Epidemiol 2008; 168:188-96. [PMID: 18503038 DOI: 10.1093/aje/kwn103] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The etiology of bacterial vaginosis is unknown, and there are no long-term therapies for preventing this frequently recurring condition. Vaginal douching has been reported to be associated with bacterial vaginosis in observational studies. However, this association may be due to confounding by indication--that is, confounding by women douching in response to vaginal symptoms associated with bacterial vaginosis. The authors used marginal structural modeling to estimate the causal effect of douching on bacterial vaginosis risk while controlling for this confounding effect. In 1999-2002, nonpregnant women (n = 3,620) were recruited into a prospective study when they visited one of 12 public health clinics in Birmingham, Alabama, for routine care. Participants were assessed quarterly for 1 year. Bacterial vaginosis was based on a Nugent's Gram stain score of 7 or higher. Thirty-two percent of participants douched in every study interval, and 43.0% never douched. Of the 12,349 study visits, 40.2% were classified as involving bacterial vaginosis. The relative risk for regular douching as compared with no douching was 1.21 (95% confidence interval: 1.08, 1.38). These findings indicate that douching confers increased risk of disruption of vaginal flora. In the absence of a large randomized trial, these findings provide the best evidence to date for a risk of bacterial vaginosis associated with douching.
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Affiliation(s)
- Rebecca M Brotman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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Brotman RM, Ghanem KG, Klebanoff MA, Taha TE, Scharfstein DO, Zenilman JM. The effect of vaginal douching cessation on bacterial vaginosis: a pilot study. Am J Obstet Gynecol 2008; 198:628.e1-7. [PMID: 18295180 DOI: 10.1016/j.ajog.2007.11.043] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 10/17/2007] [Accepted: 11/19/2007] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate the risk for bacterial vaginosis (BV) in a douching cessation trial. STUDY DESIGN Thirty-nine reproductive-age women who reported use of douche products were enrolled into a 20-week study consisting of a 4 week douching observation (phase I) followed by 12-weeks of douching cessation (phase II). In phase III, participants then chose to resume douching or continue cessation for the remaining 4 weeks. Self-collected vaginal samples were obtained twice weekly in the first 16 weeks, and 1 sample was collected during week 20 (1107 samples total). BV was diagnosed by Nugent score of 7 or greater. Conditional logistic regression was used to evaluate douching cessation on the risk of BV. RESULTS The adjusted odds ratio (aOR) for BV in the douching cessation phase, as compared with the douching-observation phase was 0.76 (95% confidence interval [CI], 0.33 to 1.76). Among women who reported their primary reason for douching was to cleanse after menstruation, BV was significantly reduced in douching cessation (aOR:0.23; 95% CI, 0.12 to 0.44). CONCLUSION Vaginal douching cessation may reduce the risk for BV in a subset of women.
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McClelland RS, Richardson BA, Graham SM, Masese LN, Gitau R, Lavreys L, Mandaliya K, Jaoko W, Baeten JM, Ndinya-Achola JO. A prospective study of risk factors for bacterial vaginosis in HIV-1-seronegative African women. Sex Transm Dis 2008; 35:617-23. [PMID: 18418290 PMCID: PMC3902781 DOI: 10.1097/olq.0b013e31816907fa] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1. METHODS We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV. RESULTS Participants completed a median of 378 (interquartile range 350-412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73). CONCLUSIONS Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women.
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Affiliation(s)
- R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA 98104, USA.
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Brotman RM, Klebanoff MA, Nansel T, Zhang J, Schwebke JR, Yu KF, Zenilman JM, Andrews WW. Why do women douche? A longitudinal study with two analytic approaches. Ann Epidemiol 2008; 18:65-73. [PMID: 18063240 DOI: 10.1016/j.annepidem.2007.05.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 05/10/2007] [Accepted: 05/30/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Although vaginal douching is associated with several adverse outcomes, the reasons why women douche have not been studied prospectively. METHODS Non-pregnant (N = 3620) women aged 15 to 44 years presenting for routine care at 12 clinics in Birmingham, Alabama, participated in a longitudinal study of vaginal flora (1999-2003). Participants were assessed quarterly for 1 year. The authors applied conditional logistic regression in a case-crossover analysis to determine the individual-level factors that vary between a woman's douching and non-douching intervals. Findings were compared to a population-level analysis utilizing generalized estimating equations. RESULTS Thirty percent of participants douched in every interval; 28% douched in some but not all intervals. The case-crossover analysis indicated a woman was more likely to douche when reporting "fishy" vaginal odor (odds ratio [OR]:2.74; 95% confidence interval [CI]: 1.55, 1.84), vaginal irritation (OR: 1.52; 95% CI: 1.10, 2.11), summer month (OR: 1.37, 95% CI: 1.13, 1.67), or increase in number of sex partners (> or = 3, OR: 2.42, 95% CI: 1.11, 5.26). Bacterial vaginosis/trichomoniasis treatment (OR: 0.72, 95% CL: 0.59, 0.89) and absent menses (OR: 0.37, 95% CI: 0.28, 0.50) were negatively associated with douching. These ORs were farther from the null than comparable population-level estimates. CONCLUSIONS Programs targeting these predictors may decrease the untoward sequelae associated with douching. Furthermore, a case-crossover analysis applied to prospective studies can provide insights into time-varying factors.
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Affiliation(s)
- Rebecca M Brotman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21224.
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Hilber AM, Chersich MF, van de Wijgert JHHM, Rees H, Temmerman M. Vaginal practices, microbicides and HIV: what do we need to know? Sex Transm Infect 2008; 83:505-8. [PMID: 18024709 DOI: 10.1136/sti.2007.028597] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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