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). 02/2011; 8(2):e1000416. DOI: 10.1371/journal.pmed.1000416
Source: PubMed

ABSTRACT 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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Available from: Deborah Watson-Jones, Aug 16, 2015
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    • "IVP, in particular intravaginal cleansing, increase the risk of bacterial vaginosis (BV), the most common cause of vaginal discharge and malodor in women (Fethers, Fairley, Hocking, Gurrin, & Bradshaw, 2008). Although BV is not considered a sexually transmitted infection (STI), it is known to increase susceptibility and transmission of HIV and STIs to sexual partners and newborns (Farquhar et al., 2010; Fonck et al., 2001; Low et al., 2011). It is believed that IVP could increase HIV transmission by both facilitating BV and by causing irritation and inflammation of the vaginal mucosa (Fonck et al., 2001; Hilber, Francis, et al., 2010; McClelland et al., 2006). "
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    ABSTRACT: 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.
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    • "The population-level prevalence of these practices is largely unknown. This is important information as concerns have long been raised that the risk for acquiring HIV infection is higher among women who use cloth or paper to wipe out the vagina or apply products, insert products intended to dry or tighten the vagina, or clean with soap intravaginally (Low et al., 2011). "
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    ABSTRACT: Vaginal practices have been linked with an increase in risk for HIV transmission, as well as other harms. In 2007, a household survey of 919 women was conducted in Tete province, Mozambique, as part of the WHO Multi-country Study on Gender, Sexuality and Vaginal Practices. Women between 18 and 60 years were interviewed to determine prevalence and motivations for vaginal practices. A large range of practices were identified, and are used very frequently. Nearly 80% reported three or more current practices and virtually all had used at least three practices in their lifetime. Elongation of the vaginal labia minora was universal (99% of women), while a quarter stated they had made small vaginal cuts or incisions at least once. Ninety-two percent of women also reported ever use of intravaginal cleansing, and insertion of substances in the vagina was practiced by 72%. Around half (48%) reported ingestion of substances to affect the vagina, mostly to heat, tighten or loosen the vagina. Application of substances on the genitalia (16%) or steaming (15%) were less popular. To prepare for sexual intercourse, women reported products were commonly applied, ingested, inserted or steamed. Pregnancy, delivery and post-partum were also associated with ingestion (26%), steaming (39%) and cutting (32%). Adoption of microbicides and condom use may be influenced by vaginal practices. HIV prevention messages and interventions, including future microbicides, need to take into account the high prevalence of vaginal practices and motivations for their use. Further attention needs to be given to potentially harmful practices in HIV prevention efforts in Mozambique.
    International Journal of Sexual Health 07/2012; DOI:10.1080/19317611.2012.691443 · 0.36 Impact Factor
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    • "Understanding this large, disproportionate racial and ethnic disparity in the distribution of HIV/AIDS cases among women demands an analysis, not only of the gender issues involved, but also broader social, economic, and cultural issues. Traditional Theoretical Models in HIV Prevention are Inadequate for Women Despite important efforts (see Depadilla, Windle, Wingood, Cooper, & Diclemente, 2011; Traube, Holloway, & Smith 2011), there continues to be a dearth of comprehensive and well-tested theoretical models specifically for preventing HIV among women. "
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