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


Low, N; Chersich, MF; Schmidlin, K; Egger, M; Francis, SC; van de Wijgert, JH; Hayes, RJ; Baeten, JM; Brown, J; Delany-Moretlwe, S; Kaul, R; McGrath, N; Morrison, C; Myer, L; Temmerman, M; van der Straten, A; Watson-Jones, D; Zwahlen, M; Hilber, AM; (2011) Intravaginal Practices, Bacterial Vaginosis, and HIV Infection in Women: Individual Participant Data Meta-analysis. PLoS medicine, 8 (2). e1000416. ISSN 1549-1277 DOI: https://doi.org/10.1371/journal.pmed.1000416

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Abstract

BACKGROUND: 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.<br/> METHODS AND FINDINGS: 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.<br/> CONCLUSIONS: 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.<br/>

Item Type: Article
Keywords: RANDOMIZED CONTROLLED-TRIAL, SIMPLEX-VIRUS TYPE-2, SOUTH-AFRICAN WOMEN, VAGINAL PRACTICES, INCREASED RISK, SEX WORKERS, ACQUISITION, PREVENTION, TANZANIA, TRANSMISSION
Faculty and Department: Faculty of Epidemiology and Population Health > Dept of Infectious Disease Epidemiology
Faculty of Infectious and Tropical Diseases > Dept of Clinical Research
Faculty of Infectious and Tropical Diseases > Dept of Disease Control
Research Centre: Centre for Global Non-Communicable Diseases (NCDs)
Tropical Epidemiology Group
PubMed ID: 21358808
Web of Science ID: 287657600010
URI: http://researchonline.lshtm.ac.uk/id/eprint/1093

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