These are described in the text.
ReviewIntravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms
Introduction
As the HIV pandemic continues its expansion around the globe, women of reproductive age face persistent high risks of HIV infection. In sub-Saharan Africa, where an estimated 8% of all adults are infected with HIV, approximately 60% of all infections are among women,1 and in some parts of southern Africa as many of one-third of pregnant women attending antenatal clinics are infected with the virus.2
Women's risk of HIV infection continues despite the relatively low probability of male-to-female HIV transmission by vaginal intercourse under normal conditions.3, 4, 5, 6, 7, 8 Although biological exposures that facilitate transmission of HIV are widely thought to have an important role in the population spread of the disease, only a handful of cofactors have been conclusively identified to date. Most notable among these cofactors are sexually transmitted diseases, including ulcerative and non-ulcerative infections.9, 10, 11, 12, 13 A range of other factors have been postulated to enhance women's biological susceptibility to HIV, with mixed findings for intercourse during menses8 and the use of hormonal contraceptives.14, 15 A number of other factors that may be important in increasing the transmissibility of HIV, including the dynamics of acute HIV infection and lack of male circumcision, are under investigation.16, 17 Given the continued high incidence of HIV in many parts of the world, determining the circumstances that increase women's risk of HIV infection is important for focusing ongoing HIV prevention efforts.
Women's intravaginal practices have been linked anecdotally to increased susceptibility to HIV infection.18, 19, 20 Commonly referred to as “dry sex” practices, a broader concept of intravaginal practices has emerged in recent years that encompasses wiping, cleansing, douching, or the insertion of substances into the vagina.21 These behaviours have been documented in a range of settings, including the USA,22, 23 the Caribbean,24 southeast Asia,25 and sub-Saharan Africa.26, 27, 28, 29 In Africa, there is evidence to suggest that intravaginal practices may be common in many settings where HIV is most prevalent. Although many behaviours associated with increased risk of HIV infection (eg, non-use of condoms) have proven difficult to modify,30 intravaginal practices may be more amenable to intervention.21 If intravaginal practices do truly increase women's risk of HIV, these practices may be an important avenue for future prevention efforts. In addition to the possible role of reduced intravaginal practices as an intervention for HIV prevention, better understandings of the mechanisms by which intravaginal products may influence women's susceptibility to HIV are relevant for other forms of HIV prevention. There is particular interest in how intravaginal practices may affect cervicovaginal flora or epithelial tissues, or both, and evidence in this area may have important implications for the development of vaginal microbicides for HIV prevention.31, 32
Here we systematically review the evidence for the association between women's intravaginal practices and HIV infection. To help understand the potential for intravaginal practices to function as a cofactor in HIV transmission, we also review evidence for the biological mechanisms that are commonly postulated to be involved in the association, including alterations in vaginal flora characteristic of bacterial vaginosis and epithelial disruptions to the cervix or vagina.
Section snippets
Search strategy and selection criteria
Materials for this review were identified though searches of Medline, Current Contents, and Popline, as well as abstracts from International AIDS Conferences between 1996 and 2004. Database search terms included “intravaginal practices”, “douche” or “douching”, “vaginal cleaning”, “dry sex”, “sexually transmitted diseases”, and “HIV”. Additional sources were identified through references from relevant articles as well as contacts with leading investigators in the field. Articles were included
Results
From 289 articles identified during the literature search, 93 articles were identified for inclusion in the review because they presented primary data on women's intravaginal practices and/or the putative mechanisms that may be involved in increasing the risk of HIV or other sexually transmitted infections. Of these articles, 25 studies presented data on the prevalence of intravaginal practices; the key features of these studies are summarised in the table. 12 of the 25 studies were included in
Discussion
Existing research into the mechanisms of sexual transmission of HIV to women has focused on different physiological and immunological vulnerabilities of the female reproductive tract, and factors that may enhance susceptibility to infection. Although a range of pathways have been suggested, there is still no definitive understanding of how HIV infects the female reproductive tract, and as a result, vaginal microbicides and other new HIV prevention technologies have targeted a number of
Search strategy and selection criteria
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2019, Annals of EpidemiologyCitation Excerpt :The vaginal microbiome offers protection in part through the influential action of Lactobacillus spp. Species of vaginal Lactobacillus spp. can provide broad-spectrum protection through production of copious amounts of lactic acid [36], bacteriocins [29,32,37–39], antagonistic bacteriocin-like substances [40], and biosurfactants [41] and through their ability to adhere to mucus, forming a physical barrier against incoming pathogens [42] and disrupting biofilms [43]. Considering behavioral pathways, high perceived stress has been associated with a 2.4-fold greater odds of reporting problems using condoms, and depression was associated with 50% lower odds of using condoms consistently [44].