Intravaginal Practices, Bacterial Vaginosis, and HIV Infection in Women: Individual Participant Data Meta-analysis

Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
PLoS Medicine (Impact Factor: 14.43). 02/2011; 8(2):e1000416. DOI: 10.1371/journal.pmed.1000416
Source: PubMed


Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition.
We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I(2) values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively.
This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated. Please see later in the article for the Editors' Summary.

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    • "A similar explanation has been postulated for the presence of vaginal Trichomonas vaginalis in Zambian girls aged 13–16 who reported no previous sexual contact [37]. Intravaginal cleansing may additionally increase the risk of HPV infection through vaginal mucosal abrasions, allowing HPV to access target basal membrane cells, or through alteration of the vaginal microbiome, which has been associated with increased risk of other viral STIs, including HIV [38]. "
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    ABSTRACT: Background. Human papillomavirus (HPV) vaccines are recommended for girls prior to sexual debut because they are most effective if administered before girls acquire HPV. Little research has been done on HPV prevalence in girls who report not having passed sexual debut in high HPV-prevalence countries. Methods. Using attendance registers of randomly selected primary schools in the Mwanza region of Tanzania, we enrolled girls aged 15–16 years who reported not having passed sexual debut. A face-to-face interview on sexual behavior and intravaginal practices, and a nurse-assisted self-administered vaginal swab were performed. Swabs were tested for 13 high-risk and 24 low-risk HPV genotypes. Results. HPV was detected in 40/474 (8.4%; 95% confidence interval [CI], 5.9–11.0) girls. Ten different high-risk and 21 different low-risk genotypes were detected. High-risk genotypes were detected in 5.3% (95% CI, 3.5–7.8). In multivariable analysis, only intravaginal cleansing (practiced by 20.9%) was associated with HPV detection (adjusted odds ratio = 2.19, 95% CI, 1.09–4.39). Conclusion. This cohort of adolescent Tanzanian girls had a high HPV prevalence prior to self-reported sexual debut, and this was associated with intravaginal cleansing. This most likely reflects underreporting of sexual activity, and it is possible that intravaginal cleansing is a marker for unreported sexual debut or nonpenetrative sexual behaviors.
    The Journal of Infectious Diseases 04/2014; 210(6). DOI:10.1093/infdis/jiu202 · 6.00 Impact Factor
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    • "Although these cleanses may not be directly associated with sepsis or infections, they may have a role in either preventing vaginal infections or increasing infections by disturbing vaginal flora. Although some research has explored the role of intravaginal practices in increased HIV infections [15-17,74], more research is needed to draw further conclusions on the role of vaginal cleansing in women’s reproductive healthcare, and more generally sepsis and infections. "
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    • "Additional factors such as incomplete adherence to therapy and active sexually transmitted infections may increase the risk of sexual transmission [23], [28]–[30]. Some intravaginal practices among African women disrupt the vaginal flora, increase the risk of vaginosis, and are associated with intermittent HIV-RNA shedding in the genital tract [31]. Thus, local inflammation due to intravaginal use of aggressive products, rather than the subsequent vaginosis, could trigger intermittent local HIV-RNA transcription by activated HIV-infected lymphocytes. "
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