Abstract
BackgroundIntravaginal practices are commonly used by women to manage their vaginal health and sexual life. These practices could, however, affect intravaginal mucosal integrity. The objectives of this study were to examine evidence for associations between: intravaginal practices and acquisition of HIV infection; intravaginal practices and vaginal infections; and vaginal infections and HIV acquisition.Methodology/Principal FindingsWe conducted a systematic review of prospective longitudinal studies, searching 15 electronic databases of journals and abstracts from two international conferences to 31st January 2008. Relevant articles were selected and data extracted in duplicate. Results were examined visually in forest plots and combined using random effects meta-analysis where appropriate. Of 2120 unique references we included 22 publications from 15 different studies in sub-Saharan Africa and the USA. Seven publications from five studies examined a range of intravaginal practices and HIV infection. No specific vaginal practices showed a protective effect against HIV or vaginal infections. Insertion of products for sex was associated with HIV in unadjusted analyses; only one study gave an adjusted estimate, which showed no association (hazard ratio 1.09, 95% confidence interval, CI 0.71, 1.67). HIV incidence was higher in women reporting intravaginal cleansing but confidence intervals were wide and heterogeneity high (adjusted hazard ratio 1.88, 95%CI 0.53, 6.69, I2 83.2%). HIV incidence was higher in women with bacterial vaginosis (adjusted effect 1.57, 95%CI 1.26, 1.94, I2 19.0%) and Trichomonas vaginalis (adjusted effect 1.64, 95%CI 1.28, 2.09, I2 0.0%).Conclusions/SignificanceA pathway linking intravaginal cleaning practices with vaginal infections that increase susceptibility to HIV infection is plausible but conclusive evidence is lacking. Intravaginal practices do not appear to protect women from vaginal infections or HIV and some might be harmful.
Highlights
Intravaginal practices comprise a variety of behaviors that women use to positively manage their health and sexual life [1]
Of the 22 included publications (Table 1), seven investigated the association between intravaginal practices and HIV acquisition in five studies [7,14,15,16,24,34,39]; eight explored associations between intravaginal practices and prevalent vaginal infections [14,25,27,33,34,35,38,39] in six separate studies; 11 publications in nine studies investigated associations between bacterial vaginosis and HIV acquisition [14,16,28,29,30,31,32,34,36,37,39]; nine publications in seven studies reported on the association between trichomoniasis and HIV-1 [11,16,24,26,28,29,31,34,37]; and six publications in five different studies reported on the association between vaginal yeast and HIV [14,26,28,31,37,39]
The only statistical evidence of small study biases in summary effects was for unadjusted (Egger test p = 0.003) estimates of the association between bacterial vaginosis and HIV
Summary
Intravaginal practices comprise a variety of behaviors that women use to positively manage their health and sexual life [1]. Insertion or application of substances like herbs, pulverized rock, or commercial products to prepare the vagina for sexual intercourse can cause physical or chemical abrasions [4] that could be exacerbated during intercourse [3]. These kinds of practices have previously been referred to as ‘dry sex’ [5,6]. The specific objectives were to examine associations between: 1) intravaginal practices and HIV acquisition; 2) intravaginal practices and vaginal infections; and 3) vaginal infections and HIV acquisition in prospective studies in women
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