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Fernandes T, Baxi K, Sawarkar S, Sarmento B, das Neves J. Vaginal multipurpose prevention technologies: promising approaches for enhancing women's sexual and reproductive health. Expert Opin Drug Deliv 2020; 17:379-393. [PMID: 32036727 DOI: 10.1080/17425247.2020.1728251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Multipurpose prevention technologies (MPTs) have the potential to avert multiple concomitant sexual and reproductive health issues in women such as sexually transmitted infections and unintended pregnancy. MPTs incorporate one or more active pharmaceutical ingredients in a single product, which adds more convenience for users and may promote increased adherence. Various vaginal dosage forms/delivery systems have been studied for designing MPTs. However, several challenges remain that are mainly related to requirements of individual drugs or intended multiple applications.Areas covered: This review focuses on the emerging need and development of vaginal MPTs. It illustrates numerous examples that are currently in the preclinical and clinical development pipeline, highlighting the concept behind vaginal MPTs. The article also highlights the challenges associated with formulation design and development, including regulatory issues that need to be addressed.Expert opinion: Vaginal MPTs present great potential to empower women with novel, efficient, and safe products for protection against sexually transmitted infections and unintended pregnancy. However, several technological issues and regulatory gaps still need to be addressed in order to meet real-world needs.
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Affiliation(s)
- Trinette Fernandes
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Krishna Baxi
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Sujata Sawarkar
- Department of Pharmaceutics, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, University of Mumbai,India
| | - Bruno Sarmento
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra, Portugal
| | - José das Neves
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal.,INEB - Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal.,CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra, Portugal
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van der Veer C, Bruisten SM, van Houdt R, Matser AA, Tachedjian G, van de Wijgert JHHM, de Vries HJC, van der Helm JJ. Effects of an over-the-counter lactic-acid containing intra-vaginal douching product on the vaginal microbiota. BMC Microbiol 2019; 19:168. [PMID: 31345159 PMCID: PMC6659218 DOI: 10.1186/s12866-019-1545-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/18/2019] [Indexed: 12/26/2022] Open
Abstract
Background Over-the-counter intra-vaginal lactic-acid containing douches are marketed as vaginal hygiene products that support optimal vaginal pH balance. We report the effect of a commercially available douche (Etos®) on the vaginal microbiota (VM) in a prospective study. Results Twenty-five healthy women were recruited through advertisements in 2015–2017 (ethical approval: METC-2014_413) and followed over three menstrual cycles. The participants had a median age of 24 years [IQR: 22–29], were mostly Dutch-Caucasian (88%), and 60% used combined oral contraceptives. All participants douched three times a week during the second cycle, starting on the first day of that cycle. Participants completed a questionnaire at baseline, kept a daily diary to report douching, menses, and sexual activity, self-collected vaginal swabs every other day during the first and third cycle and daily during the second cycle, and measured vaginal pH mid-cycle. A median of 44 vaginal swabs [inter-quartile range (IQR): 41–50] were assessed per participant by 16S rRNA gene (V3-V4 region) sequencing and a Candida albicans PCR was done at four time-points. At baseline, 21 participants (84%) had Lactobacillus-dominated VM (Lactobacillus crispatus (n = 14), L. iners (n = 6), or diverse Lactobacillus species (n = 1) and 4 participants (16%) had VM consisting of diverse anaerobes. In multinomial logistic regression models, a trend towards increased odds were observed for having diverse anaerobic VM in the second and third cycle, compared to the first cycle, after adjusting for menses [odds ratio (OR) = 1.4 (95% CI: 0.9–2.1) and OR = 1.7 (95% CI: 0.9–3.1), respectively] (p = 0.376). Douching did not affect vaginal pH. Menses increased the odds for having VM consisting of diverse anaerobes almost two-fold (OR = 1.7; 95% CI: 1.0–2.8), while douching during menses increased the odds 2.6 fold (OR = 2.6; 95% CI: 1.0–6.5), compared to not menstruating (p = 0.099). Participants were more likely to test positive for C. albicans after cycle 2, compared to cycle 1 [OR = 3.0 (95% CI: 1.2–7.2); p = 0.017]. Conclusion The Etos® douche did not significantly affect the vaginal pH or VM composition, although increased odds for having diverse anaerobic VM was observed, especially when douching during menses. Furthermore, douching may promote C. albicans infections. Electronic supplementary material The online version of this article (10.1186/s12866-019-1545-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C van der Veer
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.
| | - S M Bruisten
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.,Amsterdam Infection & Immunity Institute Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - R van Houdt
- Department of Medical Microbiology and Infection prevention, VU University Medical Center, Amsterdam, the Netherlands
| | - A A Matser
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands
| | - G Tachedjian
- Disease Elimination Program Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Clayton, Victoria, Australia.,Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - J H H M van de Wijgert
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H J C de Vries
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.,Amsterdam Infection & Immunity Institute Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Academic Medical Centers, Department of Dermatology, Amsterdam, the Netherlands
| | - J J van der Helm
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands
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Sexual Behavior and Vaginal Practices During Pregnancy and Postpartum: Implications for HIV Prevention Strategies. J Acquir Immune Defic Syndr 2017; 74:142-149. [PMID: 27828872 DOI: 10.1097/qai.0000000000001225] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Understanding sexual behaviors and vaginal practices of pregnant and breastfeeding women in sub-Saharan Africa is critical to inform HIV prevention strategies during these periods. METHODS HIV-uninfected women presenting for antenatal care in western Kenya were enrolled and followed through 36 weeks postpartum. Sexual behavior and vaginal practices were ascertained by structured questionnaires. Logistic regression was used to assess correlates of unprotected sex, vaginal washing, and vaginal drying. RESULTS Among 1252 women enrolled, 78.4% were married (of whom 15.1% were in polygamous unions), 1.4% had a known HIV-infected partner, and 33.6% had a partner of unknown HIV status. At enrollment, 58.5% reported sex in the past month (94.3% unprotected) and 4.5% reported forced sex. Odds of unprotected sex at enrollment was >11-fold higher in married than in unmarried women (P < 0.001) and lower among women who reported partners of unknown HIV status or HIV-infected compared with HIV-uninfected partners. Median time to postpartum resumption of sex was 7 weeks (interquartile range 4-12). Prevalence of unprotected sex in the past week increased from 6.6% to 60.0% between 2 and 36 weeks postpartum (P < 0.001). Vaginal washing was reported by 60.1% of women at enrollment and prevalence remained stable postpartum; vaginal drying was reported by 17.9% at enrollment and decreased to 6.1% at 36 weeks postpartum (P < 0.001). Vaginal washing and drying were associated with forced sex. CONCLUSIONS High rates of unknown partner HIV status, polygamy, and less frequent condom use among pregnant/postpartum women underscore the need for female-controlled HIV prevention interventions. Vaginal washing and drying may present challenges to microbicide use.
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Seay JS, Mandigo M, Kish J, Menard J, Marsh S, Kobetz E. Intravaginal practices are associated with greater odds of high-risk HPV infection in Haitian women. ETHNICITY & HEALTH 2017; 22:257-265. [PMID: 27774794 DOI: 10.1080/13557858.2016.1246423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Haitian women have the highest incidence of cervical cancer within the Western hemisphere. Intravaginal hygiene practices have been linked with human papilloma virus (HPV) infection and cervical dysplasia. These practices, known as 'twalet deba' in Haitian Creole, are common among Haitian women and are performed with various natural and synthetic agents. As part of a community-based participatory research initiative aimed at reducing cervical cancer disparities in rural Haiti, we explored the use of intravaginal agents and their associations with high-risk HPV infection. DESIGN Community Health Workers recruited 416 women for cervical self-sampling from two neighborhoods within Thomonde, Haiti. Participants were interviewed regarding intravaginal hygiene practices and completed a cervical self-sampling procedure. Cervical samples were analyzed for the presence of high-risk HPV infection. Associations between each intravaginal agent and high-risk HPV infection were examined via univariate logistic regression analyses, as well as via multivariate analyses controlling for sociodemographic factors and concurrent agent use. RESULTS Nearly all women (97.1%) performed twalet deba, using a variety of herbal and commercially produced intravaginal agents. Approximately 11% of the participants tested positive for high-risk HPV. Pigeon pea and lime juice were the only agents found to be associated with high-risk HPV in the univariate analyses, with women who used these agents being approximately twice as likely to have high-risk HPV as those who did not. Only pigeon pea remained significantly associated with high-risk HPV after controlling for sociodemographic factors and concurrent agent use. CONCLUSION Two agents, pigeon pea and lime juice, may contribute to risk for HPV infection in this population. Results suggest that in addition to cervical cancer screening interventions, future preventive initiatives should focus on minimizing risk by advocating for the use of less-toxic twalet deba alternatives.
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Affiliation(s)
- Julia S Seay
- a Miller School of Medicine , University of Miami , Miami , FL , USA
| | - Morgan Mandigo
- a Miller School of Medicine , University of Miami , Miami , FL , USA
- b Department of Gynecology and Obstetrics , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | | | - Janelle Menard
- d Center for Multicultural Wellness & Prevention, Inc. , Orlando , FL , USA
| | | | - Erin Kobetz
- a Miller School of Medicine , University of Miami , Miami , FL , USA
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Audet CM, Blevins M, Cherry CB, González-Calvo L, Green AF, Moon TD. Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique. CULTURE, HEALTH & SEXUALITY 2017; 19:616-629. [PMID: 27921861 PMCID: PMC5460297 DOI: 10.1080/13691058.2016.1257739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Intra-vaginal drying and tightening and labia minora elongation are commonly practised in some parts of southern Africa. We sought to capture data on these practices among women living in Zambézia province, Mozambique. Information was gathered from 3543 female heads of household on > 500 variables, including vaginal practices, in 2014. Women who planned to use intra-vaginal tightening substances had 1.84 times higher odds of ever receiving an HIV test (p < 0.001) and 1.40 times higher odds of at least one antenatal care visit attended during last pregnancy (p = 0.015). Women who had or planned to undergo labia minora elongation had 2.61 times higher odds of receiving an HIV test in the past (p < 0.001) and 1.60 times higher odds of attending at least one antenatal care visit during their last pregnancy (p < 0.001). There was little evidence for a relationship between self-reported HIV status and anticipated use of intra-vaginal tightening substances (p = 0.21). Current or anticipated participation in labia elongation showed a protective effect on HIV infection (p = 0.028). Given documented associations between intra-vaginal substance use, vaginal infections and HIV acquisition, understanding the prevalence of vaginal practices is an essential component to addressing the epidemic.
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Affiliation(s)
- Carolyn M Audet
- a Department of Health Policy , Vanderbilt University Medical Center , Nashville , USA
| | - Meridith Blevins
- b Department of Biostatistics , Vanderbilt University Medical Center , Nashville , USA
| | | | - Lazaro González-Calvo
- d Friends in Global Health , Impact and Project Evaluation Department , Quelimane , Mozambique
| | - Ann F Green
- c Institute for Global Health , Vanderbilt University Medical Center , Nashville , USA
| | - Troy D Moon
- e Department of Pediatrics , Vanderbilt University , Nashville , USA
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Birse KD, Romas LM, Guthrie BL, Nilsson P, Bosire R, Kiarie J, Farquhar C, Broliden K, Burgener AD. Genital Injury Signatures and Microbiome Alterations Associated With Depot Medroxyprogesterone Acetate Usage and Intravaginal Drying Practices. J Infect Dis 2017; 215:590-598. [PMID: 28011908 PMCID: PMC5388302 DOI: 10.1093/infdis/jiw590] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/01/2016] [Indexed: 01/01/2023] Open
Abstract
Background Increasing evidence suggests depot medroxyprogesterone acetate (DMPA) and intravaginal practices may be associated with human immunodeficiency virus (HIV-1) infection risk; however, the mechanisms are not fully understood. This study evaluated the effect of DMPA and intravaginal practices on the genital proteome and microbiome to gain mechanistic insights. Methods Cervicovaginal secretions from 86 Kenyan women, including self-reported DMPA users (n = 23), nonhormonal contraceptive users (n = 63), and women who practice vaginal drying (n = 46), were analyzed using tandem-mass spectrometry. Results We identified 473 human and 486 bacterial proteins from 18 different genera. Depot medroxyprogesterone acetate use associated with increased hemoglobin and immune activation (HBD, HBB, IL36G), and decreased epithelial repair proteins (TFF3, F11R). Vaginal drying associated with increased hemoglobin and decreased phagocytosis factors (AZU1, MYH9, PLAUR). Injury signatures were exacerbated in DMPA users who also practiced vaginal drying. More diverse (H index: 0.71 vs 0.45; P = .009) bacterial communities containing Gardnerella vaginalis associated with vaginal drying, whereas DMPA showed no significant association with community composition or diversity. Conclusions These findings provide new insights into the impact of DMPA and vaginal drying on mucosal barriers. Future investigations are needed to confirm their relationship with HIV risk in women.
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Affiliation(s)
- Kenzie D Birse
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada
| | - Laura M Romas
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada
| | - Brandon L Guthrie
- Departments of Global Health and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Peter Nilsson
- Affinity Proteomics, SciLife Lab, School of Biotechnology, KTH-Royal Institute of Technology, Stockholm, Sweden
| | - Rose Bosire
- Kenya Medical Research Institute, Nairobi, Kenya
| | - James Kiarie
- Department of Obstetrics and Gynecology, University of Nairobi, Kenya
| | - Carey Farquhar
- Department of Medicine, University of Washington, Seattle, USA
| | - Kristina Broliden
- Department of Medicine, Solna, Unit of Infectious Diseases, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Adam D Burgener
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada
- Department of Medicine, Solna, Unit of Infectious Diseases, Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Obiero JA, Waititu KK, Mulei I, Omar FI, Jaoko W, Mwethera PG. Baboon vaginal microbial flora. J Med Primatol 2016; 45:147-55. [DOI: 10.1111/jmp.12217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jael A. Obiero
- Reproductive Health and Biology; Institute of Primate Research; Nairobi Kenya
| | - Kenneth K. Waititu
- Reproductive Health and Biology; Institute of Primate Research; Nairobi Kenya
| | - Isaac Mulei
- Veterinary Pathology; University of Nairobi; Nairobi Kenya
| | - Farah I. Omar
- Reproductive Health and Biology; Institute of Primate Research; Nairobi Kenya
| | - Walter Jaoko
- Medical Microbiology; University of Nairobi; Nairobi Kenya
| | - Peter G. Mwethera
- Reproductive Health and Biology; Institute of Primate Research; Nairobi Kenya
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Brown JM, Poirot E, Hess KL, Brown S, Vertucci M, Hezareh M. Motivations for Intravaginal Product Use among a Cohort of Women in Los Angeles. PLoS One 2016; 11:e0151378. [PMID: 26967165 PMCID: PMC4788422 DOI: 10.1371/journal.pone.0151378] [Citation(s) in RCA: 19] [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: 08/06/2015] [Accepted: 02/09/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Intravaginal practices-including behaviors such as intravaginal cleansing and insertion of products-have been linked to a number of adverse reproductive health outcomes, including increased risk for bacterial vaginosis, sexually transmitted infections, and HIV. Currently, little is known about the motivations for intravaginal practices among women in the United States. The objective of this study was to identify and describe motivations for intravaginal washing and intravaginal insertion of products among women of differing ages and racial/ethnic groups. METHODS Between 2008 and 2010, we enrolled a convenience sample of sexually active women aged 18-65 years living in Los Angeles recruited through community education and outreach activities in HIV/AIDS service organizations, women's health clinics, community-based organizations, and HIV testing sites. At the enrollment visit, women completed a self-administered, computer-assisted questionnaire covering demographics, sexual behaviors, intravaginal practices, and motivations for intravaginal practices over the past month and past year. RESULTS We enrolled 141 women; 34% of participants were Caucasian, 40% African American, and 26% Latina. Peri-sexual intravaginal washing was common in all groups, whether to clean up after sex (70%) or to prepare for sex (54%). African American women were more likely to report learning to wash intravaginally from their mothers compared to Latina or Caucasian women (70% vs. 49%, P = 0.04). Sixty-one percent of African American women reported using a douching device over the past year compared to 41% of Latina and 40% of Caucasian women (p = 0.02). Younger women were more likely to report that their male partners wanted them to wash intravaginally than older women (77% vs. 24%, P<0.01), and more likely to report the removal of odors as a motive than older women (65% vs. 40%, P = 0.04). The most commonly used intravaginal products included sexual lubricants, petroleum jelly, body lotions, oils, and wet wipes. Use of these products varied by race, and motives given included increasing lubrication, preparing for sex, smelling good, and preventing sexually transmitted infections. CONCLUSION Women's intravaginal practices and motivations for these practices differ across race and age. Motivations for use also vary by type of intravaginal product used. Given that some intravaginal practices have been shown to be harmful, interventions, programs and counseling messages to encourage less harmful practices are needed, and should consider underlying motivations that influence women's vaginal practices. Practitioners may use these results to better support women in achieving vaginal health.
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Affiliation(s)
- Joelle M. Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology, University of California Los Angeles, Los Angeles, California, United States of America
- * E-mail:
| | - Eugenie Poirot
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Kristen L. Hess
- Department of Epidemiology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Stephen Brown
- AIDS Research Alliance of America, Los Angeles, California, United States of America
| | - Michele Vertucci
- Department of Epidemiology, University of California Los Angeles, Los Angeles, California, United States of America
- AIDS Research Alliance of America, Los Angeles, California, United States of America
| | - Marjan Hezareh
- AIDS Research Alliance of America, Los Angeles, California, United States of America
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Alcaide ML, Chisembele M, Malupande E, Arheart K, Fischl M, Jones DL. A cross-sectional study of bacterial vaginosis, intravaginal practices and HIV genital shedding; implications for HIV transmission and women's health. BMJ Open 2015; 5:e009036. [PMID: 26553833 PMCID: PMC4654361 DOI: 10.1136/bmjopen-2015-009036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP) are an important risk factor for developing BV. The relationship between IVP, BV and HIV lower genital shedding, responsible for HIV transmission, has not been examined in women receiving antiretrovirals in Zambia. DESIGN Cross-sectional study. SETTING Community Health Center in Lusaka, Zambia. PARTICIPANTS AND METHODS Participants were HIV-infected women receiving antiretroviral therapy and engaging in IVP (n=128). Participants completed audio computer-administered self-interviews to assess IVP and underwent a vaginal examination. BV was diagnosed using Nugent criteria. HIV-1 lower genital shedding was assessed by measuring HIV-1 RNA in cervicovaginal lavages. RESULTS Most women engaged in IVP daily (114, 89.0%) and 81 (63.3%) of the participants had BV. HIV-1 genital shedding was detected in 18 (14.2%) participants. BV was associated with daily use of IVP (prevalence ratio, PR=4.58, CI 1.26 to 16.64, p=0.02) and weekly use of traditional medicines for IVP (PR=1.33, CI 1.05 to 1.68, p=0.02). The only factor associated with HIV-1 lower genital shedding was plasma viraemia (PR=4.61, CI 2.02 to 10.54, p<0.001). Neither IVP nor BV were associated with HIV shedding. CONCLUSIONS Despite the frequency of IVP and high prevalence of BV, plasma viraemia was the primary factor associated with HIV lower genital shedding. These findings support early initiation of antiretrovirals as an HIV prevention tool. Given adverse health outcomes associated with BV, the association between frequent IVP and BV, and the powerful local norms and traditions encouraging IVP, there is a need for studies assessing culturally tailored interventions to decrease BV in high-prevalence settings.
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Affiliation(s)
- Maria L Alcaide
- Division of Infectious Diseases, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | | | - Emeria Malupande
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Kristopher Arheart
- Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Margaret Fischl
- Division of Infectious Diseases, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami, Miller School of Medicine, Miami, Florida, USA
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Alcaide ML, Chisembele M, Mumbi M, Malupande E, Jones D. Examining targets for HIV prevention: intravaginal practices in Urban Lusaka, Zambia. AIDS Patient Care STDS 2014; 28:121-7. [PMID: 24568672 DOI: 10.1089/apc.2013.0309] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Intravaginal practices (IVP) are the introduction of products inside the vagina for hygienic, health, or sexuality reasons. The influence of men and Alengizis, traditional marriage counselors for girls, in promoting IVP has not been explored. We conducted gender-concordant focus groups and key informant interviews with Alengizis. The responses were conducted grouped into three themes: (1) cultural norms, (2) types and reasons for IVP, and (3) health consequences. We found that IVP were used by all participants in our sample and were taught from generation to generation by friends, relatives, or Alengizis. The reasons for women to engage in IVP were hygienic, though men expect women to engage in IVP to enhance sexual pleasure. Approximately 40% of women are aware that IVP can facilitate genital infections, but felt they would not feel clean discontinuing IVP. All men were unaware of the vaginal damage caused by IVP, and were concerned about the loss of sexual pleasure if women discontinued IVP. Despite the health risks of IVP, IVP continue to be widespread in Zambia and an integral component of hygiene and sexuality. The frequency of IVP mandates exploration into methods to decrease or ameliorate their use as an essential component of HIV prevention.
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Affiliation(s)
- Maria L Alcaide
- Department of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | - Deborah Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
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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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12
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Francis SC, Baisley K, Lees SS, Andrew B, Zalwango F, Seeley J, Vandepitte J, Ao TT, van de Wijgert J, Watson-Jones D, Kapiga S, Grosskurth H, Hayes RJ. Vaginal practices among women at high risk of HIV infection in Uganda and Tanzania: recorded behaviour from a daily pictorial diary. PLoS One 2013; 8:e59085. [PMID: 23555618 PMCID: PMC3608607 DOI: 10.1371/journal.pone.0059085] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Accepted: 02/11/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intravaginal practices (IVP) are highly prevalent in sub-Saharan African and have been implicated as risk factors for HIV acquisition. However, types of IVP vary between populations, and detailed information on IVP among women at risk for HIV in different populations is needed. We investigated IVP among women who practice transactional sex in two populations: semi-urban, facility workers in Tanzania who engage in opportunistic sex work; and urban, self-identified sex workers and bar workers in Uganda. The aim of the study was to describe and compare IVP using a daily pictorial diary. METHODOLOGY/PRINCIPAL FINDINGS Two hundred women were recruited from a HIV prevention intervention feasibility study in Kampala, Uganda and in North-West Tanzania. Women were given diaries to record IVP daily for six weeks. Baseline data showed that Ugandan participants had more lifetime partners and transactional sex than Tanzanian participants. Results from the diary showed that 96% of Tanzanian participants and 100% of Ugandan participants reported intravaginal cleansing during the six week study period. The most common types of cleansing were with water only or water and soap. In both countries, intravaginal insertion (e.g. with herbs) was less common than cleansing, but insertion was practiced by more participants in Uganda (46%) than in Tanzania (10%). In Uganda, participants also reported more frequent sex, and more insertion related to sex. In both populations, cleansing was more often reported on days with reported sex and during menstruation, and in Uganda, when participants experienced vaginal discomfort. Participants were more likely to cleanse after sex if they reported no condom use. CONCLUSIONS While intravaginal cleansing was commonly practiced in both cohorts, there was higher frequency of cleansing and insertion in Uganda. Differences in IVP were likely to reflect differences in sexual behaviour between populations, and may warrant different approaches to interventions targeting IVP. Vaginal practices among women at high risk in Uganda and Tanzania: recorded behaviour from a daily pictorial diary.
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Affiliation(s)
- Suzanna C Francis
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Priddy FH, Wakasiaka S, Hoang TD, Smith DJ, Farah B, del Rio C, Ndinya-Achola J. Anal sex, vaginal practices, and HIV incidence in female sex workers in urban Kenya: implications for the development of intravaginal HIV prevention methods. AIDS Res Hum Retroviruses 2011; 27:1067-72. [PMID: 21406032 DOI: 10.1089/aid.2010.0362] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Multiple intravaginal HIV prevention methods, including microbicide gels, barriers, and intravaginal rings, are in clinical development in Africa. Development of intravaginal HIV prevention products requires an understanding of sexual behavior, sexually transmitted infection (STI), and vaginitis prevalences, and sexual and vaginal practices in potential target populations. We assessed these factors in a cohort of Kenyan female sex workers (FSW). Women who reported exchanging sex for money/gifts at least three times in the past month and who were HIV uninfected were enrolled and followed for 6 months. STI prevalence and HIV incidence were analyzed by multivariate logistic regression analysis, controlling for demographic and behavioral factors. Thirty-seven percent (74/200) reported having had anal sex. Frequency of anal sex was higher with regular and casual partners than with primary partners. Women were less likely to use condoms for anal sex than for vaginal sex with regular or casual partners. Vaginal washing was universal (100%). HIV incidence was 5.6 per 100 person-years (95% CI 1.62, 11.67). HIV incidence was not associated with any demographic or risk behavior. The relatively high rate of anal sex and universal vaginal washing may complicate both safety and efficacy evaluation of intravaginal products and should be taken into account in trial design. This FSW population had significant HIV incidence and needs continued HIV prevention interventions.
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Affiliation(s)
- Frances H. Priddy
- Emory University School of Medicine, Atlanta, Georgia and the International AIDS Vaccine Initiative, New York, New York
| | | | - Tina D. Hoang
- Northern California Institute for Research and Education, San Francisco, California
| | | | | | - Carlos del Rio
- Emory University Center for AIDS Research, Rollins School of Public Health and School of Medicine, Atlanta, Georgia
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Multipurpose prevention technologies: biomedical tools to prevent HIV-1, HSV-2, and unintended pregnancies. Infect Dis Obstet Gynecol 2011; 2011:1-10. [PMID: 21836811 PMCID: PMC3152961 DOI: 10.1155/2011/429403] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 06/15/2011] [Indexed: 11/18/2022] Open
Abstract
Statistics clearly show an unmet need for highly effective contraception, especially in less developed countries. Many of these countries are at the core of the HIV/AIDS epidemic and show very high prevalence rates for other sexually transmitted infections (STIs) such as that caused by HSV-2. A woman at risk of unintended pregnancy due to unprotected intercourse is also at risk for HIV/STI. Owing to their causative interrelationship, combining protection against these conditions will result in enhanced prevention and health benefits. Existing multipurpose prevention modalities such as condoms and physical barriers, albeit efficacious, face cultural hurdles that have so far hindered their widespread use. Success has recently been demonstrated in large clinical trials, demonstrating proof of concept of microbicides in reducing the incidence of HIV-1 and HSV-2 among at-risk populations. The challenge heretofore is to refine these products to make them more potent, convenient, accessible, and acceptable. Potent antiviral drugs released topically in the female reproductive tract by innovative delivered systems and formulations will provide safe, effective, and acceptable multipurpose prevention tools. This paper provides an overview of existing and novel approaches to multipurpose prevention strategies.
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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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Hilber AM, Francis SC, Chersich M, Scott P, Redmond S, Bender N, Miotti P, Temmerman M, Low N. Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis. PLoS One 2010; 5:e9119. [PMID: 20161749 PMCID: PMC2817741 DOI: 10.1371/journal.pone.0009119] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 01/07/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intravaginal practices are commonly used by women to manage their vaginal health and sexual life. These practices could, however, affect intravaginal mucosal integrity. The objectives of this study were to examine evidence for associations between: intravaginal practices and acquisition of HIV infection; intravaginal practices and vaginal infections; and vaginal infections and HIV acquisition. METHODOLOGY/PRINCIPAL FINDINGS We conducted a systematic review of prospective longitudinal studies, searching 15 electronic databases of journals and abstracts from two international conferences to 31(st) January 2008. Relevant articles were selected and data extracted in duplicate. Results were examined visually in forest plots and combined using random effects meta-analysis where appropriate. Of 2120 unique references we included 22 publications from 15 different studies in sub-Saharan Africa and the USA. Seven publications from five studies examined a range of intravaginal practices and HIV infection. No specific vaginal practices showed a protective effect against HIV or vaginal infections. Insertion of products for sex was associated with HIV in unadjusted analyses; only one study gave an adjusted estimate, which showed no association (hazard ratio 1.09, 95% confidence interval, CI 0.71, 1.67). HIV incidence was higher in women reporting intravaginal cleansing but confidence intervals were wide and heterogeneity high (adjusted hazard ratio 1.88, 95%CI 0.53, 6.69, I(2) 83.2%). HIV incidence was higher in women with bacterial vaginosis (adjusted effect 1.57, 95%CI 1.26, 1.94, I(2) 19.0%) and Trichomonas vaginalis (adjusted effect 1.64, 95%CI 1.28, 2.09, I(2) 0.0%). CONCLUSIONS/SIGNIFICANCE A pathway linking intravaginal cleaning practices with vaginal infections that increase susceptibility to HIV infection is plausible but conclusive evidence is lacking. Intravaginal practices do not appear to protect women from vaginal infections or HIV and some might be harmful.
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Affiliation(s)
| | - Suzanna C. Francis
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew Chersich
- Faculty of Medicine and Health Sciences, International Center for Reproductive Health, Ghent University, Ghent, Belgium
- Reproductive Health and HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Pippa Scott
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Shelagh Redmond
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nicole Bender
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Paolo Miotti
- Office of AIDS Research, United States National Institutes of Health, Bethesda, Maryland, United States of America
| | - Marleen Temmerman
- Faculty of Medicine and Health Sciences, International Center for Reproductive Health, Ghent University, Ghent, Belgium
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- * E-mail:
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Hassan WM, Lavreys L, Chohan V, Richardson BA, Mandaliya K, Ndinya-Achola JO, Kiarie J, Jaoko W, Holmes KK, McClelland RS. Associations between intravaginal practices and bacterial vaginosis in Kenyan female sex workers without symptoms of vaginal infections. Sex Transm Dis 2007; 34:384-8. [PMID: 17065846 DOI: 10.1097/01.olq.0000243624.74573.63] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bacterial vaginosis (BV) is highly prevalent among African women and has been associated with adverse pregnancy outcomes, sexually transmitted diseases, and HIV-1. GOAL The goal of this study was to analyze the relationship among intravaginal practices, bathing, and BV. STUDY DESIGN The authors conducted a cross-sectional study of HIV-1-seronegative Kenyan female sex workers without symptoms of vaginal infections. RESULTS Of 237 women enrolled, 206 (87%) reported vaginal washing using either a finger or cloth. Increasing frequency of vaginal washing was associated with a higher likelihood of BV (chi(2) test for trend, P = 0.05). In multivariate analysis, vaginal lubrication with petroleum jelly (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.4-5.6), lubrication with saliva (OR = 2.3, 95% CI = 1.1-4.8), and bathing less than the median for the cohort (14 times/week; OR = 4.6, 95% CI = 1.2-17.5) were associated with a significantly higher likelihood of BV. CONCLUSIONS Modification of intravaginal and general hygiene practices should be evaluated as potential strategies for reducing the risk of BV.
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Affiliation(s)
- Wisal M Hassan
- Department of Epidemiology, University of Washington, Seattle, Washington, USA.
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Myer L, Wright TC, Denny L, Kuhn L. Nested Case–Control Study of Cervical Mucosal Lesions, Ectopy, and Incident HIV Infection Among Women in Cape Town, South Africa. Sex Transm Dis 2006; 33:683-7. [PMID: 16614588 DOI: 10.1097/01.olq.0000216026.67352.f9] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to test whether cervical mucosal lesions and ectopy increase women's susceptibility to HIV infection. STUDY DESIGN HIV-seronegative women ages 35 to 65 years (n = 5773) enrolled into a cervical cancer screening trial were followed for up to 36 months. All HIV seroconverters (n = 86) in the cohort were compared with randomly selected controls (n = 324) who did not seroconvert. Magnified photographs of the cervix taken during speculum examination at enrollment were evaluated for cervical mucosal lesions and ectopy using standard criteria. RESULTS The presence of mucosal lesions (observed among 19% of controls) was associated with increased risk of HIV seroconversion (adjusted odds ratio [AOR] = 1.93; 95% confidence interval [CI] = 1.07-3.48). Ectopy extending over >20% of the cervix was also associated with HIV seroconversion (AOR = 2.18; 95% CI = 1.01-4.69). CONCLUSIONS Visible lesions of cervical mucosa and cervical ectopy may be markers of increased susceptibility to HIV infection among women. Protection of the mucosa of the cervix may provide an important approach for new HIV prevention technologies.
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Affiliation(s)
- Landon Myer
- Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
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van de Wijgert J, Morrison C, Salata R, Padian N. Is vaginal washing associated with increased risk of HIV-1 acquisition? AIDS 2006; 20:1347-8; author reply 1348-9. [PMID: 16816573 DOI: 10.1097/01.aids.0000232252.74157.f9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Myer L, Kuhn L, Stein ZA, Wright TC, Denny L. Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms. THE LANCET. INFECTIOUS DISEASES 2005; 5:786-94. [PMID: 16310150 DOI: 10.1016/s1473-3099(05)70298-x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.
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Affiliation(s)
- Landon Myer
- Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Myer L, Denny L, De Souza M, Barone MA, Wright TC, Kuhn L. Intravaginal Practices, HIV and Other Sexually Transmitted Diseases Among South African Women. Sex Transm Dis 2004; 31:174-9. [PMID: 15076931 DOI: 10.1097/01.olq.0000114942.41998.58] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Intravaginal practices, including wiping, douching, or inserting substances into the vagina, have been hypothesized to increase women's risk of HIV infection. However, data on the prevalence of these practices, and associations with HIV and other sexually transmitted diseases (STD), are limited. STUDY DESIGN We interviewed 2,897 women participating in a gynecologic screening study in Cape Town, South Africa, about their intravaginal practices. After clinical examination, cervical and blood samples were collected and tested for HIV and other STD [corrected]. RESULTS Of the 831 (29%) women reporting some type of intravaginal practice, 48% reported using only water and cloth to clean inside the vagina, whereas 17% reported using antiseptics or detergents. Most women (53%) reported practices as part of regular hygiene. Intravaginal practices were strongly associated with behavioral risk factors, and recent multiple sexual partners [corrected]. Intravaginal practices were associated with prevalent HIV infection (adjusted odds ratio, 1.74; 95% confidence interval, 1.37-2.20), but were not associated with other STDs. CONCLUSION Prospective studies that include detailed measurements of correlated sexual risk behaviors are required to discern whether this association is causal in nature; if so, these behaviors could represent an important area for future HIV prevention interventions.
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Affiliation(s)
- Landon Myer
- School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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