Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya

Prevalence of sexually transmitted infections (STIs), associations with sociodemographic and behavioural factors, and assessment of the syndromic management of vaginal discharge in women with urogenital complaints in Mozambique

In Mozambique, sexually transmitted infections (STIs) are estimated to be prevalent, but diagnosis and treatment of curable STIs rely only on syndromic management. We examined the prevalence of four non-viral STIs and HIV-1/2, based on etiological diagnosis, associations with sociodemographic and behavioural factors, and the STI diagnostic accuracy of the vaginal discharge syndromic management in women with urogenital complaints in Maputo, Mozambique. A cross-sectional study was performed in Maputo, Mozambique, February 2018-January 2019, enrolling 924 women of reproductive age with urogenital complaints. Endocervical/vaginal swabs were sampled and chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium infections were diagnosed using a multiplex real-time PCR (AmpliSens; InterLabServices). Serological testing was performed for HIV-1/2. A structured questionnaire collected metadata. All data were analyzed in STATA/IC 12.1 using descriptive statistics, chi-square tests and logistic regression model. About 40% of the women were less than 24 years old, 50.8% were single, 62.1% had their sexual debut between 12 and 17 years of age, and the main complaint was vaginal discharge syndrome (85%). The prevalence of chlamydia was 15.5%, trichomoniasis 12.1%, gonorrhoea 4.0%, M. genitalium 2.1%, and HIV-1/2 22.3%. The vaginal discharge syndrome flowchart had a sensitivity of 73.0%-82.5% and a specificity of 14%-15% for the detection of any individual non-viral STI in women with urogenital complaints. In total, 19.2% of the symptomatic women with chlamydia, trichomoniasis or gonorrhoea would not be detected and accordingly treated using the vaginal discharge syndromic management (missed treatment) and 70.0% of the women would be treated despite not being infected with any of these three STIs (overtreatment). In conclusion, a high prevalence of especially chlamydia, trichomoniasis, and HIV-1/2 was found in women of childbearing age with urogenital complaints in Maputo, Mozambique. Syndromic management of vaginal discharge revealed low accuracy in the detection of STIs in symptomatic women, especially low specificity, which resulted in under-treatment of STI-positive cases and incorrect or over-treatment of women with urogenital complaints, many of whom were negative for all the non-viral STIs. Etiological diagnosis is imperative for effective management of STIs in symptomatic and asymptomatic women.

Associations between intravaginal practices and incidence of sexually transmitted infections and bacterial vaginosis among women enrolled in the dapivirine vaginal ring trial (The Ring Study) in southwestern Uganda: a retrospective secondary analysis

OBJECTIVES

We assessed associations between intravaginal practices (IVPs) and the incidence of sexually transmitted infections (STIs) and bacterial vaginosis (BV) among women using the dapivirine vaginal ring (DVR) or placebo vaginal ring in southwestern Uganda.

METHODS

This was a retrospective secondary analysis of data collected from women at risk of HIV infection recruited into the Ring Study. The latter evaluated the safety and efficacy of the DVR between 2013 and 2016. At baseline, a behavioural questionnaire was administered to obtain information on sexual activity and IVP (exposure) defined as; insertion inside the vagina of any items aimed at cleaning the vagina for any reason before, during or after sex other than practices to manage menses. Each participant self-inserted the DVR/placebo and replaced it every 4 weeks for 2 years. Outcomes were diagnosis of STIs, that is, Chlamydia trachomatis, Neisseria gonorrhoea, Trichomonas vaginalis (TV), HIV and BV. The incidence rate of STI/BV was estimated, overall, by IVP and trial arm in single-event-per-participant and multiple-event-per-participant analyses.

RESULTS

Of the 197 women enrolled, 66 (33.5%) were <25 years of age. Overall, 93 (47.2%) practised at least one form of IVP. During the follow-up, 172 (87.3%) women were diagnosed with an STI/BV at least once. The majority had TV (73.6%, n=145). Overall rate of STI/BV was 51.9/100 person-years, 95% CI 44.7 to 60.3 (IVP: yes, 51.0 (40.8-63.8) vs no, 52.6 (43.0-64.4)). IVPs were not statistically significantly associated with rate of individual STIs/BV. Similar results were observed when the analyses were conducted separately for each trial arm.

CONCLUSIONS

IVP was not associated with risk of STIs/BV in the Ring Study.

TRIAL REGISTRATION NUMBER

NCT01539226.

Internal vaginal douching increases the incidence of vaginal infection among IUD users: a cross-sectional study

Background

We compared the rate, type and severity of vulvovaginitis in women who are practicing internal vaginal douching (IVD) or not while using an intrauterine contraceptive device (IUCD).

It is a cross-sectional study on 604 consecutive attendees of the outpatient clinics using IUCD for at least 6 months prior to recruitment. Eligible participants were divided into two groups: group 1 (302 women) performing IVD and group 2 (302 women) not practicing this habit (NIVD). The frequency of vaginal infections in IUCD users who perform IVD compared to women who were abstaining from this habit was our primary outcome.

Results

They are IUCD users who were practicing IVD more frequent history of vaginal infection (VI) compared with NIVD-IUCD users [260 (88.1%) versus 151(43.4%); respectively] (P < 0.001). Current diagnosis of VI was significantly higher in IVD group (275; 91.05%) compared to NIVD group (115; 38.1%) (P < 0.001). Bacterial vaginosis was the most common infection (287; 47.5%) followed by candida vulvovaginitis (278; 46.03%). Moreover, both types of infections were significantly more common in IVD.

Conclusion

The use of IUCD may not increase occurrence of vulvovaginitis, but IVD does increase vaginal infection rate either with or without IUCD use. When vaginal infection happens with IUCD, BV is the most common type of infection followed by Candida albicans.

The Vaginal Microbiome in Health and Disease-What Role Do Common Intimate Hygiene Practices Play?

The vaginal microbiome is a dynamic, sensitive microenvironment. The hallmark of a 'healthy' vaginal microbiome is currently believed to be one dominated by Lactobacillus spp., which acidifies the vaginal environment and help to protect against invading pathogens. However, a 'normal' microbiome is often difficult, if not impossible, to characterise given that it varies in response to numerous variables, including pregnancy, the menstrual cycle, contraceptive use, diet, ethnicity, and stress. A Lactobacillus-depleted microbiome has been linked to a variety of adverse vaginal health outcomes, including preterm birth (PTB), bacterial vaginosis (BV), and increased risk of sexually transmitted infections. The latter two of these have also been associated with feminine intimate hygiene practices, many of which are practised without any evidence of health benefits. The most extensively studied practice is vaginal douching, which is known to cause vaginal dysbiosis, predisposing women to BV, pelvic inflammatory disease, and PTB. However, little is known of the impact that intimate hygiene practices and associated products have on the vaginal microbiome. This review aims to outline the major factors influencing the vaginal microbiome and common vaginal infections, as well as to summarise current research surrounding the impact of hygiene products and practices on the vaginal microbiome.

Attributes of HIV infection over decades (1982-2018): A systematic review and meta-analysis

Understanding the risk factors for HIV infection is the foundation of successful preventive strategies, which must bundle sociocultural, behavioural and biomedical interventions to halt disease transmission. We aimed in this study to provide a pooled estimation of HIV risk factors and trace changes across decades in order to drive consensus and accurate assessment of disease transmission risk. We comprehensively searched PubMed, ISI Web of Knowledge, Medline, EMBASE, ScienceDirect, Ovid, EBSCO, Google Scholar and the Egyptian Universities Library Consortium from October to December 2018. Two independent reviewers extracted data from eligible studies. Funnel plots were inspected to identify publication bias. Heterogeneity across studies was checked using the Q and I² statistics. The results were reported based on the pooled odds ratio (pOR) with 95% CI using a random-effects model. Meta-analysis of HIV risk factors revealed a superior role for risky sexual practices (unprotected vaginal/anal sex), injecting drug use (IDU), sharing needles, sexually transmitted infections (STIs), child sexual abuse and vertical transmissions. Trends across decades (1982-1999 and 2000-2018, respectively) showed rising evidence for prostitution [pOR (95% CI)= 2.3 (1.12-4.68) versus 2.69 (1.67-4.32)] and men who have sex with men (MSM) [pOR (95% CI)= 2.28 (1.64-3.17) versus 3.67 (1.88-7.17)], while transmission through IDU [pOR (95% CI)= 3.42 (2.28-5.12) versus 2.16 (1.74-2.70)], alcoholism [pOR (95% CI)= 2.35 (0.73-7.59) versus 1.71(1.08-2.72)], and sharing syringes [pOR (95% CI)= 6.10 (2.57-14.5) versus 2.70 (2.01-6.35)] showed notable decline. Harm reduction programs and condom use have been recognized as chief HIV prevention strategies, while male circumcision contributed a partial role. Collectively, sexual risk factors continue to be a key driver of the global HIV epidemic. Persistent and emerging risk factors identified in our analysis should constitute the forefront targets of HIV prevention programmes to accelerate efforts towards HIV elimination.

Prevalence and associated factors of Chlamydia trachomatis and Neisseria gonorrhoeae among female commercial sex workers in Hawassa City, Southern Ethiopia

Background

Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens causing genital tract infections. Female commercial sex workers (FCSWs) are the key population to be affected by sexually transmitted infections (STIs). In Ethiopia, little is known about C. trachomatis and N. gonorrhoeae infections in most at risk population. Therefore, this study aimed to assess the prevalence of these bacterial STIs among FCSWs.

Methods

A cross-sectional study was conducted at the confidential clinic in Hawassa City, Southern Ethiopia from January to April, 2017. A total of 338 FCSWs were selected using systematic random sampling technique and enrolled in the study. Information about socio-demography and associated factors was collected using structured questionnaires. Endocervical swab samples were also collected from the study participants and tested for C. trachomatis using rapid immunochromatography assay. Samples were also cultured to isolate N. gonorrhoeae according to the standard bacteriological method.

Results

The prevalence of N. gonorrhoeae and C. trachomatis among FCSWs was 3.3% [95% confidence interval (CI): 1.5–5.3] and 6.8% (95% CI: 3.9–9.5), respectively. FCSWs who consistently practiced sex without condom in the last 6 months had 6.3 times (AOR 6.3; 95% CI 1.61–24.86, P = 0.008), and 4.0 times (AOR 4.0; 95% CI 1.06–15.31, p = 0.040) higher odds of acquiring N. gonorrhoeae and C. trachomatis infections, respectively.

Conclusion

The observed rates of C. trachomatis and N. gonorrhoeae infections among FCSWs warrant the need to strengthen intervention efforts. In this regard, screening FCSWs for the specified infections and improving the practice of condom use would be important.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vaginal microbiota and susceptibility to HIV

: Bacterial vaginosis, characterized by the replacement of the Lactobacillus-dominant microbiota with anaerobic bacteria and facultative Gram-negative rods, has been associated with adverse reproductive health outcomes including HIV acquisition. With the advent of newer molecular techniques, the vaginal microbiota can be investigated in more detail and the association with HIV examined more thoroughly. This review examines recent evidence suggesting that vaginal dysbiosis with increased microbial diversity, specific vaginal bacterial communities, and the presence and concentrations of some individual bacterial species, may increase HIV susceptibility. Potential mechanisms through which vaginal microbiota could impact HIV susceptibility are discussed. On the basis of the available data, this review finds that there is a modest, but growing, body of evidence linking vaginal microbiota to HIV susceptibility in women. The evidence could be strengthened through two main pathways. First, laboratory studies such as ex-vivo or animal experiments are needed to move from plausible mechanisms towards proven mechanisms that explain an effect of the vaginal microbiota on HIV susceptibility. Second, experimental evidence could directly test the hypothesis that sustaining optimal microbiota reduces HIV risk, though there are important obstacles to conducting such studies. Finally, this review examines strong evidence from a recent publication suggesting that deviations from an optimal vaginal microbiome, and particularly the presence of some bacterial communities with high relative abundance of Gardnerella vaginalis, reduces the efficacy of vaginal tenofovir-based microbicides.

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

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

High Levels of Inflammatory Cytokines in the Reproductive Tract of Women with BV and Engaging in Intravaginal Douching: A Cross-Sectional Study of Participants in the Women Interagency HIV Study

High levels of inflammatory cytokines in the genital tract suggest mucosal vulnerability and increased risk of HIV and sexually transmitted infection (STI) acquisition. Intravaginal douching is associated with bacterial vaginosis (BV) in women in the United States, and both douching and BV are linked to HIV and STI acquisition. This study evaluates inflammatory cytokines in the genital tract to increase understanding of the effects of both BV and intravaginal douching to the vaginal mucosa. A cross-sectional study of participants in the Miami WIHS investigated 72 reproductive age women (45 HIV⁺ and 27 high-risk HIV^-) who completed intravaginal douching questionnaires and underwent collection of vaginal swabs and cervicovaginal lavages (CVLs). BV was assessed using the Nugent score. Inflammatory cytokines in the CVLs (interleukin [IL]-6, IL-8, IL-1α, IL-1β, soluble intracellular adhesion molecule-1 [sICAM-1], interferon [IFN]α2, chemokine C ligand 5 (CCL5), vascular endothelial growth factor (VEGF), monocyte chemotactic protein-1 (MCP1), tumor necrosis factor alpha (TNFα), and secretory leukocyte protease inhibitor [SLPI]) were measured. Fourteen (19%) women reported intravaginal douching; 24 (33%) had BV. BV, intravaginal douching, and HIV were associated with higher levels of inflammatory cytokines. After controlling for demographic and risk factors and HIV status, women who had BV and douched had higher levels of inflammatory cytokines than those without BV and who did not douche, or who only had BV or only douched. These findings suggest that BV and douching are associated with greater mucosal inflammation and may facilitate HIV acquisition and transmission. Although longitudinal studies are needed to determine temporal associations and causality, interventions to decrease rates of intravaginal douching and BV could significantly decrease women's risks of acquiring STIs and HIV and limit the spread of HIV.

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

OBJECTIVES

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

DESIGN

Cross-sectional study.

SETTING

Community Health Center in Lusaka, Zambia.

PARTICIPANTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence and risk factors of bacterial vaginosis among pregnant women: a prospective study in Maanshan city, Anhui Province, China

AIM

The aim of this study was to identify the incidence and risk factors of bacterial vaginosis among pregnant women.

MATERIAL AND METHODS

Prospective data from a cohort of 668 pregnant women were used to identify potential risk factors for bacterial vaginosis during pregnancy by Cox proportional hazards regression.

RESULTS

A total of 204 incident cases of bacterial vaginosis were diagnosed in 274.8 woman-years of follow-up. The bacterial vaginosis incidence rate was 0.74 per 1 woman-year and median prevalence during follow-up was 15.6%. In the adjusted model, changing underwear nearly everyday, miscarriage history, urinary tract infection during follow-up, husbands' education level, and concurrent trichomoniasis and candidiasis remained significantly associated with bacterial vaginosis (adjusted hazard ratio and 95% confidence interval were 1.87 [1.26-2.77]; 2.96 [1.96-4.47]; 2.41 [1.05-5.49]; 0.50 [0.32-0.77]; 1.82 [1.02-3.25]; 1.88 [1.30-2.70], respectively).

CONCLUSION

Bacterial vaginosis during pregnancy can be affected by many factors, and some are indirectly acting factors. Further prospective studies that include a larger sample size and more information on the development of bacterial vaginosis are needed.

Prevalence of HIV, sexually transmitted infections, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among female sex workers (FSWs) in Nairobi, Kenya. Women aged 18 years and older who reported selling sex to a man at least once in the past 3 months were eligible to participate. Consenting FSWs completed a behavioral questionnaire and were tested for HIV and sexually transmitted infections (STIs). Adjusted population-based prevalence and 95 % confidence intervals (CI) were estimated using RDS analysis tool. Factors significantly associated with HIV infection were assessed using log-binomial regression analysis. A total of 596 eligible participants were included in the analysis. Overall HIV prevalence was 29.5 % (95 % CI 24.7-34.9). Median age was 30 years (IQR 25-38 years); median duration of sex work was 12 years (IQR 8-17 years). The most frequent client-seeking venues were bars (76.6 %) and roadsides (29.3 %). The median number of clients per week was seven (IQR 4-18 clients). HIV testing was high with 86.6 % reported ever been tested for HIV and, of these, 63.1 % testing within the past 12 months. Of all women, 59.7 % perceived themselves at 'great risk' for HIV infection. Of HIV-positive women, 51.0 % were aware of their infection. In multivariable analysis, increasing age, inconsistent condom use with paying clients, and use of a male condom as a method of contraception were independently associated with unrecognized HIV infection. Prevalence among STIs was low, ranging from 0.9 % for syphilis, 1.1 % for gonorrhea, and 3.1 % for Chlamydia. The data suggest high prevalence of HIV among FSWs in Nairobi. Targeted and routine HIV and STI combination prevention strategies need to be scaled up or established to meet the needs of this population.

Vaginal douching and sexually transmitted infections among female sex workers: a cross-sectional study in three provinces in China

Though vaginal douching is a common practice among female sex workers that could increase the risk of HIV and adverse reproductive health outcomes, it has drawn limited attention. From November 2010 to January 2011, a convenience sample of female sex workers was recruited in three cities in China. Face-to-face interviews were conducted to gather socio-demographic and behavioural information. Blood samples were collected for syphilis serological tests. Endo-cervical swabs were collected and tested for Neisseria gonorrhoeae and Chlamydia trachomatis by polymerase chain reaction. A logistic regression model was used to determine factors associated with vaginal douching and the association between vaginal douching and sexually transmitted infection. A total of 1032 eligible female sex workers were enrolled. The overall prevalence of any sexually transmitted infection (syphilis, Chlamydia trachomatis or Neisseria gonorrhoeae) and vaginal douching with disinfectant were 23.4% and 23.1%, respectively. Factors independently associated with douching practice included study sites, venue types, ethnicity, having regular partner and sexually transmitted infection history. No significant association was found between vaginal douching and current sexually transmitted infection. Vaginal douching with disinfectant after sex with clients seemed to be a prevalent practice among female sex workers in China. Prevention programmes targeting female sex workers should incorporate components about the adverse health outcomes associated with vaginal douching.

Conceptualizations of heterosexual anal sex and HIV risk in five East African communities

Heterosexual anal sex is underresearched and little understood, particularly in the African context. Existing prevalence data indicate that heterosexual anal sex is a widespread practice, yet little is known about the way in which it is conceptualized and understood. Describing findings from qualitative research conducted in Kenya, Tanzania, and Uganda, we shed light on conceptualizations of heterosexual anal sex and its relation to human immunodeficiency virus (HIV). These findings suggest that penile-anal sex is practiced by men and women in Africa for a range of reasons, including virginity maintenance, contraception, fulfillment of male pleasure, relationship security, menstruation, in the presence of vaginal complications, financial gain, fidelity, and prestige. Despite anal sex being the most efficient way to transmit HIV sexually, there is widespread lack of knowledge about its risks. These findings describe the ways in which anal sex is conceptualized in five East African communities, highlighting how penile-anal intercourse is often not considered "sex" and how the omission of anal sex in safe-sex messaging is interpreted as meaning that anal sex is safe. In light of its frequency and risks, greater attention must be paid to heterosexual anal sex in Africa to ensure a comprehensive approach to HIV prevention.

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

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

•

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

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

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

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

Hormonal contraception is associated with a reduced risk of bacterial vaginosis: a systematic review and meta-analysis

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.

Vaginal douching by women with vulvovaginitis and relation to reproductive health hazards

Background

Vaginal douching (VD) is a common practice among married women all over the world specially those in the Middle East. It is used for personal hygiene or for other aesthetic reasons in many countries. The current study investigates the prevalence of VD among patients with vulvovaginitis in Egypt. It also compares the reproductive health hazards among women performing routine VD with those using external hygiene. It also investigates why, and how women practice this douching.

Methods

A cross sectional observational study was conducted in a tertiary university affiliated hospital in Assiut, Egypt. An interview administered questionnaire was administered to 620 women by two trained clinic nurses. Women presented to the outpatient clinic and diagnosed to have any type of vaginal infections were approached for participation. The principle outcome was the history of preterm labor in women who routinely performed VD versus those who did not (upon which sample size was estimated). Other outcome measures were the types of vaginal infections, and reproductive implications comprising, ectopic pregnancy, abortion and pelvic inflammatory disease (PID).

Results

The participants were predominantly multiparas from semi-urban background and middle socioeconomic level. Considering VD as a religious duty and a kind of personal cleanliness were the most common reasons for performing VD in 88.9% and 80.6% of the studied population, respectively. History of preterm labor was reported in 19.2% versus 11.9% (p=0.048), while history of PID in 13.2% versus 6.0% (p=0.008) in women performing VD compared to those not performing this habit, respectively. There were no significant differences between the two groups as regard the history of ectopic pregnancy or the number of previous abortions.

Conclusion

Vaginal douching is a prevalent practice in Egypt and has traditional and religious roots within the community. There are many misbeliefs around this habit in Egypt. Vaginal douching increases certain reproductive health hazards especially preterm labor and PID. Much effort and awareness campaigns are needed to increase women awareness about health hazards of this incorrect practice and to limit its use.

Anal sex and associated HIV-related sexual risk factors among female sex workers in Andhra Pradesh, India

BACKGROUND

This study aims to understand the correlates of anal sex practices among female sex workers (FSWs) and examine the association of anal sex with HIV-related sexual risk factors in Andhra Pradesh, India.

METHODS

A cross-sectional behavioural survey was conducted in 2011 among 795 FSWs aged 18 years or older. Probability-based cluster sampling was used to select respondents from sex work hotspots.

RESULTS

One-quarter (23%) of FSWs had practiced anal sex in the last year. The odds of practicing anal sex were higher among FSWs aged 35 years or more than in those aged less than 25 years (adjusted odds ratio (AOR): 2.05, P<0.05), in those formerly married compared to those currently married (AOR: 1.88, P<0.01), in those having an income only from sex work compared to those having additional sources of income (AOR: 1.54, P<0.05), those reporting heavy alcohol consumption compared to those who did not (AOR: 2.80, P<0.01) and those who experienced violence compared to those who had not (AOR: 2.80, P<0.01). FSWs practicing anal sex were more likely to experience sexually transmissible infection (STI) related symptoms than those practicing only vaginal sex. There was no association between anal sex practice and condom use.

CONCLUSIONS

Anal sex is associated with STI symptoms, a factor for HIV risk. HIV intervention programmes need to educate FSWs about the risks associated with anal sex.

Vaginal cleansing practices in HIV infected Zambian women

Vaginal practices are a variety of behavioral techniques that women use to manage their sexual life and personal hygiene. Women perceive vaginal practices as a beneficial practice. However, vaginal cleansing has been identified as one of the main risk factors for bacterial vaginosis and is potentially implicated in Human Immune Deficiency Virus (HIV) and sexually transmitted infection transmission. This study examined the prevalence of vaginal practices and the types of practices used among a sample of HIV positive women living in Lusaka, Zambia. Over 90% of all women recruited engaged in vaginal practices. Certain practices, such as use of water or soap, were more frequently used for hygiene reasons. Herbs and traditional medicines were mainly used to please sexual partner. Strategies to decrease VP appear urgently needed in the Zambian community.

An intervention to decrease intravaginal practices in hiv-infected women in Zambia: a pilot study

Intravaginal practices (IVP) are those in which women introduce products inside the vagina for hygienic, health, or sexuality reasons. IVP are associated with bacterial vaginosis (BV) and potentially implicated in HIV transmission. This report presents the results of a pilot study of a behavioral intervention to decrease IVP in HIV-infected women in Zambia. At baseline, all of the enrolled women (n =40) engaged in IVP and rates of BV were high. Women receiving the intervention reported a decrease of the insertion of water and cloths inside the vagina. Communication with sexual partners regarding IVP was higher for women receiving the intervention. Results from this study suggest that a behavioral intervention could decrease IVP in HIV-infected women in Zambia and this may have an impact in decreasing HIV transmission from women to sexual partners and newborns.

Male sex workers who sell sex to men also engage in anal intercourse with women: evidence from Mombasa, Kenya

Objective

To investigate self-report of heterosexual anal intercourse among male sex workers who sell sex to men, and to identify the socio-demographic characteristics associated with practice of the behavior.

Design

Two cross-sectional surveys of male sex workers who sell sex to men in Mombasa, Kenya.

Methods

Male sex workers selling sex to men were invited to participate in surveys undertaken in 2006 and 2008. A structured questionnaire administered by trained interviewers was used to collect information on socio-demographic characteristics, sexual behaviors, HIV and STI knowledge, and health service usage. Data were analyzed through descriptive and inferential statistics. Bivariate logistic regression, after controlling for year of survey, was used to identify socio-demographic characteristics associated with heterosexual anal intercourse.

Results

From a sample of 867 male sex workers, 297 men had sex with a woman during the previous 30 days – of whom 45% did so with a female client and 86% with a non-paying female partner. Within these groups, 66% and 43% of male sex workers had anal intercourse with a female client and non-paying partner respectively. Factors associated with reporting recent heterosexual anal intercourse in bivariate logistic regression after controlling for year of survey participation were being Muslim, ever or currently married, living with wife only, living with a female partner only, living with more than one sexual partner, self-identifying as basha/king/bisexual, having one’s own children, and lower education.

Conclusions

We found unexpectedly high levels of self-reported anal sex with women by male sex workers, including selling sex to female clients as well as with their own partners. Further investigation among women in Mombasa is needed to understand heterosexual anal sex practices, and how HIV programming may respond.

Socio-demographic characteristics and behavioral risk factors of female sex workers in sub-saharan Africa: a systematic review

Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.

HIV type 1 subtype distribution, multiple infections, sexual networks, and partnership histories in female sex workers in Kampala, Uganda

We investigated for the first time the subtype distribution, prevalence of multiple HIV-1 infections, sexual networks, and partnership histories in a cohort of women engaged in high-risk sexual behavior such as female sex workers (FSWs) and women employed in entertainment facilities. Viral RNA was extracted from blood samples collected from 324 HIV-1-positive women; the gp-41 and pol-IN genes were directly sequenced. Women found to have closely related viruses and those with recombinant viruses were further analyzed in the pol-IN gene by clonal sequencing to determine HIV-1 multiple infections. Individual partnership histories were used to provide information on when sex work was undertaken and where. Subtyping in both gp-41 and pol-IN was successfully done in 210/324 (64.8%) women. Subtype distribution in these two genes was 54.3% (n=114) A/A, 2.9% (n=6) C/C, 24.3% (n=51) D/D, 11.9% (n=25) A/D, 4.8% (n=10) D/A, 0.5% (n=1) C/A, 1.0% (n=2) B/A, and 0.5% (n=1) B/D. Sexual networks were identified in six pairs and one triplet of women with closely related subtype A viruses. Partnership histories showed that women having phylogenetically similar viruses had worked in the same localities. Five cases of multiple infections were confirmed: four dual infections and one triple infection. In this first molecular epidemiology study among FSWs in Kampala, subtype A was the predominant subtype. About 9% of a subgroup had multiple infections. Partnership histories and multiple infections observed in this population suggest sexual mixing of the FSWs and their clients confirming their high-risk characteristics.

Prevalence and correlates of recent vaginal douching among African American adolescent females

STUDY OBJECTIVE

To describe the prevalence and correlates of vaginal douching among urban African American adolescents and to examine the association between douching and sexually transmitted infection (STI) status.

DESIGN

Demographic, psychosocial, and behavioral data were collected through cross-sectional, self-administered surveys. Self-collected vaginal swabs were assayed using nucleic acid amplification tests for trichomoniasis, chlamydia, and gonorrhea.

SETTING

Sexual health clinic in a large metropolitan area of the southeastern United States.

PARTICIPANTS

African American females (N = 701), ages 14-20, participating in a human immunodeficiency virus prevention intervention.

MAIN OUTCOME MEASURE

The outcome of interest was the association between vaginal douching (lifetime, past 90 days, and past 7 days) with demographic characteristics (eg, age, education, and socioeconomic status), physical and mental health status, STI status, sexual behavior (eg, number of vaginal sexual partners, age of sex partners, consistent condom use in the past 90 days, sex while self/partner was high on drugs or alcohol), and psychosocial characteristics (eg, sexual adventurism, social support, peer norms, sexual satisfaction, self-efficacy for sex refusal, self-esteem, relationship power, risk avoidance).

RESULTS

Forty-three percent reported ever douching, and 29% reported douching in the past 90 days. In bivariate analyses, recent douching was associated with demographic, behavioral, and psychosocial variables, but not current STI status. In multivariate analyses, recent douching was associated with age (odds ratio [AOR] = 1.13, confidence interval [CI] = 1.02-1.25), lower socioeconomic status (AOR = 1.25, CI = 1.05-1.47), and having sex with much older partners (AOR = 1.87, CI = 1.22-2.86).

CONCLUSION

Increased age, lower socioeconomic status, and older partners may be salient risk factors for douching behavior among African American young women.

Preventive measures against sexually transmitted infections among female sex workers in Lanzhou, China

BACKGROUND

We assessed the effects of preventive practices on sexually transmitted infections (STIs) and reproductive tract infections (RTIs) among female sex workers (FSWs) in Lanzhou, China.

METHODS

A cross-sectional survey was conducted among 350 FSWs from November 2008 to January 2009. Demographic information and behavioural factors associated with STIs were collected from all the participants. Blood samples and cervical swabs were obtained, and genital and cervical examinations were done at the collection site. A multivariate logistic regression model was used to analyze the relationships between preventive measures and the incidences of STIs and RTIs.

RESULTS

The utilization rates of vaginal douching (VD), regular intravenous infusion (RII), and prophylactic oral antibiotics (POA) among FSWs were 72.9%, 35.7%, and 36.3%, respectively. The preventive measures had no impact on diagnosed STIs. On the contrary, the use of VD + POA could increase the risk of vaginal infection by 2-fold (odds ratio (OR) 2.9, 95% credible interval (95% CI) 1.3-6.7). Moreover, the risk for cervical infection increased with the use of POA alone (OR 4.0, 95% CI 1.1-15.4), VD + POA (OR 4.2, 95% CI 1.7-10.3), and VD + RII (OR 2.5, 95% CI 1.1-5.7).

CONCLUSIONS

VD, RII, and POA, which were used widely by FSWs to prevent STIs after sex with their clients, were assumed to prevent STIs. Instead, our study indicates that they could increase the risk of vaginal or cervical infections. Therefore, FSWs should be informed of proper preventive strategies to reduce the incidence.

Anal sex, vaginal practices, and HIV incidence in female sex workers in urban Kenya: implications for the development of intravaginal HIV prevention methods

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.

Co-occurrence of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women

Trichomonas vaginalis (TV) and bacterial vaginosis (BV) were examined among human immunodeficiency virus+ women. The prevalence rates were 28.0% for TV, 51.4% for BV, and 17.5% for TV/BV co-infection. Among human immunodeficiency virus+/TV+ women, the rate of BV was 61.0%. Research is needed to examine how BV affects the clinical course and treatment of T. vaginalis.

Evidence for the innate immune response as a correlate of protection in human immunodeficiency virus (HIV)-1 highly exposed seronegative subjects (HESN)

The description of highly exposed individuals who remain seronegative (HESN) despite repeated exposure to human immunodeficiency virus (HIV)-1 has heightened interest in identifying potential mechanisms of HIV-1 resistance. HIV-specific humoral and T cell-mediated responses have been identified routinely in HESN subjects, although it remains unknown if these responses are a definitive cause of protection or merely a marker for exposure. Approximately half of HESN lack any detectible HIV-specific adaptive immune responses, suggesting that other mechanisms of protection from HIV-1 infection also probably exist. In support of the innate immune response as a mechanism of resistance, increased natural killer (NK) cell activity has been correlated with protection from infection in several high-risk cohorts of HESN subjects, including intravenous drug users, HIV-1 discordant couples and perinatally exposed infants. Inheritance of protective NK KIR3DL1(high) and KIR3DS1 receptor alleles have also been observed to be over-represented in a high-risk cohort of HESN intravenous drug users and HESN partners of HIV-1-infected subjects. Other intrinsic mechanisms of innate immune protection correlated with resistance in HESN subjects include heightened dendritic cell responses and increased secretion of anti-viral factors such as β-chemokines, small anti-viral factors and defensins. This review will highlight the most current evidence in HESN subjects supporting the role of epithelial microenvironment and the innate immune system in sustaining resistance against HIV-1 infection. We will argue that as a front-line defence the innate immune response determines the threshold of infectivity that HIV-1 must overcome to establish a productive infection.

Intravaginal insertion in KwaZulu-Natal: sexual practices and preferences in the context of microbicide gel use

Intravaginal insertion is often associated with the concept of 'dry' sex. All HIV-prevention microbicides tested to date have been vaginally applied lubricant-based gels. In this paper, we examine whether the use of intravaginal insertions could be in conflict with the introduction of vaginal microbicide gels. The Africa Centre site was part of the Microbicides Development Programme evaluating PRO2000/5 microbicide gel. We conducted in-depth-interviews and focus-group discussions with women enrolled in the trial as well as women and men from the community. The analysis focused on people's knowledge of intravaginal insertion in the community and trial participants' experience of using trial gels. Intravaginal use of a variety of products was widely acknowledged. We found that the experience of using trial gels - which made sex 'hot', 'tight' and 'dry' - matched the desired outcomes of intravaginal insertion. We found that vaginal 'dryness' described the removal of excessive amounts of unusual discharge, rather than the removal of normal vaginal secretions and that intravaginal insertion is not exclusively associated with a desire for 'dry' sex. Study findings provide evidence that vaginal microbicide gels may be more acceptable in communities where intravaginal insertion is practiced than was previously thought.

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

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

Are women who work in bars, guesthouses and similar facilities a suitable study population for vaginal microbicide trials in Africa?

BACKGROUND

A feasibility study was conducted to investigate whether an occupational at-risk cohort of women in Mwanza, Tanzania are a suitable study population for future phase III vaginal microbicide trials.

METHODOLOGY/PRINCIPAL FINDINGS

1573 women aged 16-54 y working in traditional and modern bars, restaurants, hotels, guesthouses or as local food-handlers were enrolled at community-based reproductive health clinics, provided specimens for HIV/STI and pregnancy testing, and asked to attend three-monthly clinical follow-up visits for 12-months. HIV positive and negative women were eligible to enter the feasibility study and to receive free reproductive health services at any time. HIV prevalence at baseline was 26.5% (417/1573). HIV incidence among 1156 sero-negative women attending at baseline was 2.9/100PYs. Among 1020 HIV sero-negative, non-pregnant women, HIV incidence was 2.0/100PYs, HSV-2 incidence 12.7/100PYs and pregnancy rate 17.8/100PYs. Retention at three-months was 76.3% (778/1020). Among 771 HIV sero-negative, non-pregnant women attending at three-months, subsequent follow-up at 6, 9 and 12-months was 83.7%, 79.6%, and 72.1% respectively. Older women, those who had not moved home or changed their place of work in the last year, and women working in traditional bars or as local food handlers had the highest re-attendance.

CONCLUSIONS/SIGNIFICANCE

Women working in food outlets and recreational facilities in Tanzania and other parts of Africa may be a suitable study population for microbicide and other HIV prevention trials. Effective locally-appropriate strategies to address high pregnancy rates and early losses to follow-up are essential to minimise risk to clinical trials in these settings.

Probiotics for the treatment of bacterial vaginosis

BACKGROUND

The dominance of lactobacilli in healthy vaginal microbiota and its depletion in bacterial vaginosis (BV) has given rise to the concept of oral or vaginal instillation of probiotic Lactobacillus strains for the management of this condition.

OBJECTIVES

To ascertain the efficacy of probiotics in the treatment of BV.

SEARCH STRATEGY

We searched electronic databases irrespective of publication status or language. These included: Cochrane Central Register of Controlled Trials (CENTRAL), the HIV/AIDS and STD Cochrane Review Groups' specialized registers, the Cochrane Complementary Medicine Field's Register of Controlled Trials, MEDLINE (1966 to 2008), EMBASE (1980 to 2007), ISI science citation index (1955 to 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature (1982 to 2007).We handsearched of specialty journals, conference proceedings and publications list on the website of the International Scientific Association of Probiotics and Prebiotics (http://www.isapp.net/default.asp).For unpublished studies or ongoing trials, we contacted authors from relevant publications, nutraceutical companies and probiotic-related scientific associations. We searched electronic databases on ongoing clinical trials.

SELECTION CRITERIA

Randomized controlled trials using probiotics for the treatment of women of any age diagnosed with bacterial vaginosis, regardless of diagnostic method used. The probiotic preparation could be single or "cocktail" of strains, any preparation type/dosage/route of administration. Studies comparing probiotics with placebo, probiotics used in conjunction with conventional antibiotics compared with placebo or probiotics alone compared with conventional antibiotics were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We screened titles and abstracts , obtained full reports of relevant trialsand independently appraised them for eligibility. A data extraction form was used to extract data from the four included studies. For dichotomous outcomes, odds ratios (OR) and 95% confidence intervals (CI) were derived for each study using RevMan (versions 4.2 and 5). We did not perform meta-analysis due to significant differences in the probiotic preparations and trial methodologies.

MAIN RESULTS

Analysis suggests beneficial outcome of microbiological cure with the oral metronidazole/probiotic regimen (OR 0.09 (95% CI 0.03 to 0.26)) and the probiotic/estriol preparation (OR 0.02, (95% CI 0.00 to 0.47)). For the probiotic/estriol preparation, the OR and 95% CI for physician-reported resolution of symptoms was OR 0.04 (95% CI 0.00 to 0.56).

AUTHORS' CONCLUSIONS

The results do not provide sufficient evidence for or against recommending probiotics for the treatment of BV. The metronidazole/probiotic regimen and probiotic/estriol perparation appear promising but well-designed randomized controlled trials with standardized methodologies and larger patient size are needed.

Knowledge and practice among healthcare providers in rural Vietnam regarding sexually transmitted infections

OBJECTIVES

To assess knowledge and reported practice regarding sexually transmitted infections (STI) among healthcare providers in rural Vietnam and to examine background characteristics possibly associated with knowledge and practice.

METHODS

A cross-sectional study using a self-completed questionnaire was carried out in 2006 among 465 healthcare providers in rural Vietnam. The questionnaire included questions on providers' characteristics, STI knowledge, and case scenarios of 4 common STI syndromes. Correct answer was scored 1, "do not know" or incorrect answer was scored 0. Linear and logistic regressions were applied.

RESULTS

Diseases considered as STI were gonorrhea and syphilis by 83% of the respondents, 70% believed partner treatment necessary for bacterial vaginosis or candidiasis cases. Sharing clothes/food or kissing was commonly mentioned as transmission routes (60%). Median scores of knowledge and reported practice were 29 (range: 0-50) and 2 (range: 0-20), respectively. Among the respondents, 34% had a knowledge score of less than 25 and 78% had a practice score of less than 10. Characteristics predicting higher level of knowledge were being a medical doctor, assistant medical doctor, midwife, or serving STI patients. Characteristics predicting higher level of practice were serving STI patients, being a midwife or female provider, and having participated in STI or reproductive tract infection training courses. Respondents who reported treating STI patients had a higher level of knowledge and reported practice than the others.

A descriptive study of douching practices in Turkish women

Vaginal douching is a common hygiene practice for many women all over the world. Little is known about the beliefs and attitudes that promote and maintain douching practices. Therefore, the aim of this study is to evaluate the status of vaginal douching practices of women in the Erzurum province of Turkey. The present study was a descriptive and cross-sectional quality. All participants were 15-49 years of age and all were married. Data analysis included descriptive statistics and chi(2) test. The present study revealed that the frequency of douching was 51.4% among women and that the most common reason for their habit was feminine hygiene and the most popular material used was water. A statistically significant relationship was found between the habit of doing the vaginal douching and the educational level, age of marriage, number of births, case of genital infections within the last year and presence of complaints indicating vaginal infections for the last month. This study provides preliminary information about women's douching practices and attitudes. It might also provide information to health-care practitioners in their efforts to educate women on the adverse effects of vaginal douching.

HIV-1 RNA dysregulates the natural TLR response to subclinical endotoxemia in Kenyan female sex-workers

Background

Subclinical endotoxemia has been reported in HIV-1 infected persons and may drive systemic immune activation and pathogenesis. Proinflammatory responsiveness to endotoxin (LPS) is mediated by Toll-like receptor 4 (TLR4). We therefore examined the association between plasma LPS levels, HIV RNA, and TLR4 expression and cytokine responses in the blood of HIV infected and uninfected participants in a cohort of female sex-workers in Kenya.

Methodology/Principal Findings

Ex vivo plasma and peripheral blood mononuclear cells (PBMC) were assessed for LPS and TLR mRNA, respectively. The effects of HIV single stranded RNA, a TLR8 ligand, on TLR4 and LPS signaling were further assessed in short term PBMC culture. Both HIV uninfected and infected subjects frequently had low detectable LPS levels in their plasmas. Significantly increased LPS levels were associated with chronic HIV-1 infection, both treated and untreated, but not with other acute or semi-chronic conditions reported. In HIV-uninfected subjects, TLR4 mRNA expression levels correlated inversely with plasma LPS levels, suggesting chronic endotoxin ‘tolerance’ in vivo. A similar effect of reduced TLR4 mRNA was seen in short term PBMC culture after stimulation with LPS. Interestingly, the apparent in vivo tolerance effect was diminished in subjects with HIV infection. Additionally, pre-stimulation of PBMC with LPS lead to proinflammatory (TNF-α) tolerance to subsequent LPS stimulation; however, pre-treatment of PBMC with HIV single-stranded RNA40, could enhance TLR4-mediated LPS responsiveness in vitro.

Conclusions/Significance

Thus, dysregulation of endotoxin tolerance by HIV-1 RNA may exacerbate HIV chronic immune activation and pathogenesis.

Bacterial vaginosis among pregnant women in Burkina Faso

OBJECTIVES

Bacterial vaginosis (bv) is a common cause of abnormal or altered vaginal discharge in women of childbearing age. Its association with obstetric and gynecologic complications and HIV are increasingly recognized. Few population-based surveys of BV have been conducted in Africa. The objective of the study was to examine the role of genital infections including Herpes simplex virus type 2 (HSV-2) and demographic factors on the prevalence of BV among pregnant women in Burkina Faso.

METHODS

Consenting pregnant women from Burkina Faso answered a face-to-face interview on their demographic characteristics. Then, genital and blood swabs were collected and tested for BV and other genital infections. Univariable and multivariable models were used to investigate the risk factors of BV.

RESULTS

Among the 2133 women included in the analyses (over 2284 enrolled), the prevalence of BV was 6.4% [95% confidence interval (CI), 5.5%-7.6%], ranging from 3% to 12% between regions. In multivariable analyses, HSV-2 [odds ratio (OR), 1.64; 95% CI 1.04-2.59) was the only genital infection that remained significantly associated with BV. Other factors related to BV were history of abortion (OR, 1.57; 95% CI, 1.01-2.43) and geographical origin. HIV infection (OR, 1.98; 95% CI, 0.90-5.20) and polygamy (OR, 1.48; 95% CI, 1.00-2.36) tended to be associated with BV without reaching statistical significance.

CONCLUSION

The prevalence of BV among pregnant women was lower than expected, with large geographical disparities. Our data confirm the potential interaction between BV and HSV-2.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

Counseling to discourage douching may reduce STI risk in adolescents.

Sexually transmitted infections and risk factors for gonorrhea and chlamydia in female sex workers in Soc Trang, Vietnam

GOAL

To determine the prevalence of selected STIs and correlates of chlamydia (CT) and gonorrhea (GC) infection among (FSWs) in Soc Trang province, Vietnam.

STUDY DESIGN

Four hundred and six FSWs in Soc Trang province participated in a cross-sectional study between May and August, 2003. The study subjects were interviewed to obtain information about socio-demographic and behavioral characteristics and gynecologic and STI history, using a standardized interview. They underwent a physical examination during which cervical swabs were collected for GC and CT testing by polymerase chain reaction (PCR). Vaginal wet mount microscopy was performed to detect candidiasis and trichomoniasis (TV), and blood was drawn for testing for syphilis using rapid plasma reagin (RPR)+ Treponema pallidum hemagglutination assay (TPHA). Univariate and multivariate analyses were used to assess the associations of GC, CT, and GC/CT with selected variables.

RESULTS

Prevalences were 14.9% for GC, 48.4% for CT, 54.9% for GC/CT, 3.8% for syphilis, 8.9% for trichomoniasis, and 12.2% for candidiasis. Increased risk for CT was associated with sex work for more than 6 months (aOR = 2.40, 95% CI: 0.99-5.82), receiving $4 US or less per sexual transaction (aOR = 1.91, 95% CI 1.13-3.23), and ever having terminated a pregnancy (aOR = 1.68, 95% CI 1.00-2.82). Reduced likelihood of CT was associated with older age (aOR = 0.96, 95% CI: 0.93-1.00) and ever having douched in the past month (aOR = 0.60, 95% CI 0.36-1.00). Only ever douching in the past month was associated with decreased risk for GC (aOR = 0.47, 95% CI 0.25-0.87). Higher likelihood of GC/CT was associated with having more than 4 clients per month (OR = 2.35, 95% CI 1.02-5.41) and receiving $4 US or less per sexual transaction (aOR = 1.74, 95% CI 1.04-2.93).

CONCLUSIONS

The prevalence of GC/CT is high amongst FSWs in Soc Trang. Therefore, periodic presumptive treatment (PPT) for cervicitis, together with World Health Organization-recommended periodic syndromic sexually transmitted disease management, for FSWs and further interventions should be considered, and a 100% condom use program should be promptly implemented. The existing STI health education program for FSWs should be strengthened, with special consideration of the correlates observed in this study.

Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies

OBJECTIVES

To assess and summarize the published literature on the extent to which bacterial vaginosis may increase the risk of HIV acquisition.

DESIGN

Meta-analysis of published studies.

METHODS

Medline and other electronic databases were systematically searched for eligible publications. The association between bacterial vaginosis and incident HIV was separately analyzed from that between bacterial vaginosis and prevalent HIV. The latter was further analyzed, stratified by bacterial vaginosis diagnostic method, HIV risk profile of the study population, and whether or not adjusted estimates were presented.

RESULTS

Twenty-three eligible publications were identified, including a total of 30,739 women. Bacterial vaginosis was associated with an increased risk of HIV acquisition in HIV-incidence studies (relative risk = 1.6, 95% confidence interval: 1.2, 2.1). All but one of 21 HIV-prevalence studies reported estimates above the null. The latter results were heterogeneous and showed some evidence of funnel plot asymmetry, precluding the estimation of a single summary measure. The association between bacterial vaginosis and HIV in prevalence studies appeared stronger for women without high-risk sexual behavior.

CONCLUSION

Bacterial vaginosis was consistently associated with an increased risk of HIV infection. High bacterial vaginosis prevalence may result in a high number of HIV infections being attributable to bacterial vaginosis. More prospective studies are needed to accurately evaluate the role of bacterial vaginosis in HIV acquisition in low-risk versus high-risk women. Furthermore, randomized clinical trials may be worth considering to determine the effect of bacterial vaginosis control measures on HIV acquisition.

Probiotics: potential to prevent HIV and sexually transmitted infections in women

Women are at significant risk of human immunodeficiency virus (HIV) and sexually transmitted infection (STI) acquisition with the genital mucosa serving as the main portal of infection. Exogenously supplied lactobacillus used as a probiotic may prove a cost-effective, female-initiated method to prevent HIV and STI infection in women. A probiotic may act indirectly through treating and preventing recurrent bacterial vaginosis or directly by secreting endogenous (e.g., hydrogen peroxide) and exogenous substances that block HIV and STI transmission. This review summarizes the preclinical and clinical studies that have been conducted so far to test probiotic bacteria for these purposes. Although significant progress has been made in this field, more fundamental research is required to better understand vaginal ecology to maximize probiotic formulations. Once identified, a suitable product will require testing in a well-designed, randomized, placebo-controlled trial to measure its effectiveness in augmenting antibiotic treatment to prevent bacterial vaginosis. If results from such a trial demonstrate efficacy, future studies should be designed to determine whether a probiotic can significantly lower the risk for HIV and STIs in at-risk female populations.

The effect of vaginal douching cessation on bacterial vaginosis: a pilot study

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.

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

Vaginal douching and development of bacterial vaginosis among women with normal and abnormal vaginal microflora

OBJECTIVES

To evaluate the relationship between douching and bacterial vaginosis (BV) among women with and without prior abnormal vaginal flora.

STUDY DESIGNS

1193 women had vaginal swabs obtained for Gram stain for BV, culture for vaginal microflora, and DNA amplification for Neisseria gonorrhoeae and Chlamydia trachomatis at baseline and 6, 12, 24, and 36 months. Self-reported douching was queried every 6 months.

RESULTS

In cross-sectional analyses, douching at least once per month was associated with BV among women who had BV at the immediately preceding visit but not among women with normal or intermediate flora. In prospective analyses, douching increased the risk of acquisition for BV among women with intermediate flora (adj. HR 1.5, 95% CI 1.1-2.4) but not among women with normal flora.

CONCLUSIONS

Douching appeared to be associated with BV among women with already imbalanced flora but not among women with normal flora.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pregnancy among sex workers participating in a condom intervention trial highlights the need for dual protection

BACKGROUND

Little is known about pregnancy rates among sex workers (SWs) or the factors that predispose SWs to this risk. We aimed to estimate the pregnancy incidence rate among Madagascar SWs participating in an intervention trial promoting use of male and female condoms and assess the influence of various predictive factors on pregnancy risk.

METHODS

SWs from two study clinics in Madagascar participated in a randomized trial to assess the effect of peer education and clinic-based counseling on use of male and female condoms and prevalence of sexually transmitted infections (STIs). Women were seen every 2 months for up to 18 months; they received structured interviews at every visit, and physical exams at baseline and every 6 months thereafter. Site staff recorded information on pregnancies during interviews; pregnancy data were then merged with trial data for this analysis.

RESULTS

Of 935 SWs in the analysis population, 250 became pregnant during follow-up. The cumulative probability of pregnancy was 0.149 at 6 months and 0.227 at 12 months. Comparable proportions of nonpregnant and pregnant SWs reported using highly effective contraception at baseline (approximately 16%); these users were younger and were more consistent condom users. Method switching and discontinuation were frequent. In multivariate analysis, nonuse of effective contraceptives and any self-reported unprotected sex were associated with higher incidence of pregnancy. Approximately 51% of women delivered, 13% reported a spontaneous abortion, 13% reported an induced abortion and 23% had missing pregnancy outcomes.

CONCLUSIONS

Women traditionally targeted for STI/HIV preventive interventions need more comprehensive reproductive health services. In particular, SWs could benefit from targeted family planning counseling and services.

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

BACKGROUND

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

GOAL

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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