'You'll always stay right': understanding vaginal products and the motivations for use among adolescent and young women in rural KZN

Smokeless tobacco (snuff) and site-specific cancer risks in adult Black South African women: Findings from the Johannesburg Cancer Study

Smokeless tobacco (SLT) use is an established carcinogen to the nasal cavity, lip, and oropharynx, however, few studies have examined cancer risks in older African women among whom SLT use is common. We investigated snuff use and the risk of site-specific cancers among 15,336 newly diagnosed female cancer patients in the Johannesburg Cancer Study, South Africa. We designed case-control comparisons across multiple cancer outcomes: (a) known SLT-associated cancers; (b) other tobacco-related cancers and (c) genital cancers owing to intravaginal snuff use. Controls (n = 2961) comprised all other cancer patients. We also investigated (d) each control cancer type versus the remaining controls to explore possible associations with other cancers. Logistic models were fitted to estimate odds ratios adjusted for age, education, tobacco smoking, alcohol, HIV, and language. Overall, ever use of snuff was 22% among control cancers. Ever snuff use was associated with cervical (OR 1.14 [95%CI 1.00-1.30]) and eye and adnexa cancer (OR 1.95 [95%CI 1.03-3.70]). Associations with vulva cancer were less clear, 95% CI's for the main effects included 1 but a subgroup analysis restricted to never-smokers of current-versus-never users was positive (OR 2.10 [95%CI 1.25-3.50]). Surprisingly SLT users have lower risks of stomach cancer (OR 0.60 [95%CI 0.37-0.99]) and Hodgkin Lymphoma (OR 0.48 [95%CI 0.23-0.97]). Snuff use may increase the risk for cervical and vulva cancer in women, which is plausible via intravaginal use. Further research on the impact of SLT on female genital cancers with more detailed exposure data, including timing, intensity, and routes of use are required.

Differences in HIV risk factors between South African adolescents and adult women and their association with sexually transmitted infections

OBJECTIVES

In sub-Saharan Africa, approximately 86% of HIV infections in adolescents aged 15-19 years occur among girls. Their heightened susceptibility is likely influenced by converging sociobehavioural and biological factors, although the relative contributions remain unclear. To address this, we compared known and hypothesised risk factors for HIV between cisgender adolescent girls and adult women in South Africa and evaluated the relationships between these factors and sexually transmitted infection (STI) status.

METHODS

This cross-sectional observational study included adolescent (n=305; 14-19 years) and adult females (n=114; 25-35 years) in two South African provinces (Western Cape (WC), KwaZulu-Natal (KZN)). Demographic and sociobehavioural data were collected by questionnaire. Colposcopy was conducted to identify cervicovaginal abnormalities, and tests for bacterial vaginosis (BV), Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis were performed.

RESULTS

Adults reported higher risk sexual behaviour than adolescents across multiple variables, although adolescents were more likely to have STIs than adults (62.8% vs 34.0%, respectively, p=0.0010 for WC; 42.5% vs 16.4%, respectively, p=0.0002 for KZN). Adolescents did, however, report earlier sexual debut (16 years old vs 17 years old, p<0.0001 for both sites) and KZN adolescents were more likely to use intravaginal sexual enhancers than adults (34.6% vs 20.6%, respectively, p=0.0417). Numbers of sexual partners (β-coefficient: 0.34, SE: 0.12, p=0.0054) and sex acts within the previous 3 months (β-coefficient: 0.25, SE: 0.09, p=0.0062) were associated with STIs in adolescents and trended to significance for adults. Intravaginal sexual enhancer use (KZN only; β-coefficient: 0.95, SE: 0.38, p=0.0118) and biological risk factors, including BV Nugent score (β-coefficient: 0.09, SE: 0.04, p=0.0257) and signs of cervicovaginal injury/inflammation (β-coefficient: 1.07, SE: 0.45, p=0.0171), were associated with STIs in adolescents but not adults.

CONCLUSIONS

Risk factors for STIs including HIV may differ between age groups of girls and women, and mitigation interventions may need to be tailored accordingly.

Exploring the female genital tract mycobiome in young South African women using metaproteomics

BACKGROUND

Female genital tract (FGT) diseases such as bacterial vaginosis (BV) and sexually transmitted infections are prevalent in South Africa, with young women being at an increased risk. Since imbalances in the FGT microbiome are associated with FGT diseases, it is vital to investigate the factors that influence FGT health. The mycobiome plays an important role in regulating mucosal health, especially when the bacterial component is disturbed. However, we have a limited understanding of the FGT mycobiome since many studies have focused on bacterial communities and have neglected low-abundance taxonomic groups, such as fungi. To reduce this knowledge deficit, we present the first large-scale metaproteomic study to define the taxonomic composition and potential functional processes of the FGT mycobiome in South African reproductive-age women.

RESULTS

We examined FGT fungal communities present in 123 women by collecting lateral vaginal wall swabs for liquid chromatography-tandem mass spectrometry. From this, 39 different fungal genera were identified, with Candida dominating the mycobiome (53.2% relative abundance). We observed changes in relative abundance at the protein, genus, and functional (gene ontology biological processes) level between BV states. In women with BV, Malassezia and Conidiobolus proteins were more abundant, while Candida proteins were less abundant compared to BV-negative women. Correspondingly, Nugent scores were negatively associated with total fungal protein abundance. The clinical variables, Nugent score, pro-inflammatory cytokines, chemokines, vaginal pH, Chlamydia trachomatis, and the presence of clue cells were associated with fungal community composition.

CONCLUSIONS

The results of this study revealed the diversity of FGT fungal communities, setting the groundwork for understanding the FGT mycobiome. Video Abstract.

Ecology meets reproductive medicine in HIV prevention: the case for geography-informed approaches for bacterial vaginosis in Africa

Purpose of review

Women in Africa bear the burden of the HIV epidemic, which has been associated with the high prevalence of bacterial vaginosis (BV) in the region. However, little progress has been made in finding an effective cure for BV. Drawing on advances in microbiome-directed therapies for gastrointestinal disorders, similar live-biotherapeutic based approaches for BV treatment are being evaluated. Here, we summarize current knowledge regarding vaginal microbiota in BV, explore geographical differences in vaginal microbiota, and argue that novel BV therapeutics should be tailored specifically to meet the needs of African women.

Recent findings

Cervicovaginal microbiota dominated by Lactobacillus crispatus are optimal, although these are uncommon in African women. Besides socio-behavioural and environmental influences on the vaginal microbiota, host and microbial genetic traits should be considered, particularly those relating to glycogen metabolism. Novel microbiome-directed approaches being developed to treat BV should employ transfers of multiple microbial strains to ensure sustained colonization and BV cure.

Summary

Improving the efficacy and durability of BV treatment with microbiome-directed therapies by appropriately accounting for host and microbial genetic factors, could potentially reduce the risk of HIV infection in African women.

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

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