Adriane Martin Hilber

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

Pooling of data from 14,874 women in an individual participant data meta-analysis by Nicola Low and colleagues reveals that some intravaginal practices increase the risk of HIV acquisition.

Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis

Background Intravaginal 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 Findings We 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/Significance A 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.

Chlamydia control activities in Europe: cross-sectional survey

BACKGROUND Chlamydia is the most commonly reported bacterial sexually transmitted infection in Europe. The objective of the Screening for Chlamydia in Europe (SCREen) project was to describe current and planned chlamydia control activities in Europe. METHODS The authors sent a questionnaire asking about different aspects of chlamydia epidemiology and control to public health and clinical experts in each country in 2007. The principles of sexually transmitted infection control were used to develop a typology comprising five categories of chlamydia control activities. Each country was assigned to a category, based on responses to the questionnaire. RESULTS Experts in 29 of 33 (88%) invited countries responded. Thirteen of 29 countries (45%) had no current chlamydia control activities. Six countries in this group stated that there were plans to introduce chlamydia screening programmes. There were five countries (17%) with case management guidelines only. Three countries (10%) also recommended case finding amongst partners of diagnosed chlamydia cases or people with another sexually transmitted infection. Six countries (21%) further specified groups of asymptomatic people eligible for opportunistic chlamydia testing. Two countries (7%) reported a chlamydia screening programme. There was no consistent association between the per capita gross domestic product of a country and the intensity of chlamydia control activities (P = 0.816). CONCLUSION A newly developed classification system allowed the breadth of ongoing national chlamydia control activities to be described and categorized. Chlamydia control strategies should ensure that clinical guidelines to optimize chlamydia diagnosis and case management have been implemented before considering the appropriateness of screening programmes.

Vaginal practices as women's agency in sub-Saharan Africa: a synthesis of meaning and motivation through meta-ethnography

This paper reports on a systematic review of qualitative research about vaginal practices in sub-Saharan Africa, which used meta-ethnographic methods to understand their origins, their meanings for the women who use them, and how they have evolved in time and place. We included published documents which were based on qualitative methods of data collection and analysis and contained information on vaginal practices. After screening, 16 texts were included which dated from 1951 to 2008. We found that practices evolve and adapt to present circumstances and that they remain an important source of power for women to negotiate challenges that they face. Recent evidence suggests that some practices may increase a womans susceptibility to HIV and other sexually transmitted infections. The success of new female-controlled prevention technologies, such as microbicides, might be determined by whether they can and will be used by women in the course of their daily life.

Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: Findings from a multicountry household survey

BACKGROUND Women worldwide use various vaginal practices to clean or modify their vulva and vagina. Additional population-level information is needed on prevalence and motivations for these practices, characteristics of users, and their adverse effects. METHODS This was a household survey using multistage cluster sampling in Tete, Mozambique; KwaZulu-Natal, South Africa; Yogyakarta, Indonesia; and Chonburi, Thailand. In 2006-2007, vaginal practices and their motivations were examined using structured interviews with women 18-60 years of age (n=3610). RESULTS Prevalence, frequency, and motivations varied markedly. Two thirds of women in Yogyakarta and Chonburi reported one or more practices. In Yogyakarta, nearly half ingest substances with vaginal effects, and in Chonburi, external washing and application predominate. In Tete, half reported three or four current practices, and a quarter reported five or more practices. Labial elongation was near universal, and 92% of those surveyed cleanse internally. Two thirds in KwaZulu-Natal practiced internal cleansing. Insertion of traditional solid products was rare in Chonburi and Yogyakarta, but one tenth of women in KwaZulu-Natal and nearly two thirds of women in Tete do so. Multivariate analysis of the most common practice in each site showed these were more common among less educated women in Africa and young urban women in Asia. Explicit sexual motivations were frequent in KwaZulu-Natal and Tete, intended for pleasure and maintaining partner commitment. Practices in Chonburi and Yogyakarta were largely motivated by femininity and health. Genital irritation was common at African sites. CONCLUSIONS Vaginal practices are not as rare, exotic, or benign as sometimes assumed. Limited evidence of their biomedical consequences remains a concern; further investigation of their safety and sexual health implications is warranted.

Using human rights to improve maternal and neonatal health: history, connections and a proposed practical approach

We describe the historical development of how maternal and neonatal mortality in the developing world came to be seen as a public-health concern, a human rights concern, and ultimately as both, leading to the development of approaches using human rights concepts and methods to advance maternal and neonatal health. We describe the different contributions of the international community, womens health advocates and human rights activists. We briefly present a recent effort, developed by WHO with the Harvard Program on International Health and Human Rights, that applies a human rights framework to reinforce current efforts to reduce maternal and neonatal mortality.

A systematic review of supportive supervision as a strategy to improve primary healthcare services in Sub-Saharan Africa

It may be assumed that supportive supervision effectively builds capacity, improves the quality of care provided by frontline health workers, and positively impacts clinical outcomes. Evidence on the role of supervision in Sub‐Saharan Africa has been inconclusive, despite the critical need to maximize the workforce in low‐resource settings.

Prevalence and Motivations of Vaginal Practices in Tete Province, Mozambique

ABSTRACT. Vaginal practices have been linked with an increase in risk for HIV transmission and other harms. In 2007, a household survey of 919 women was conducted in Tete province, Mozambique, as part of the World Health Organization Multicountry Study on Gender, Sexuality, and Vaginal Practices. Women aged 18 to 60 years old were interviewed to determine prevalence and motivations for vaginal practices. A large range of frequently used practices was identified. Nearly 80% of women 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%) and steaming (15%) were less popular. To prepare for sexual intercourse, women reported products were commonly applied, ingested, inserted, or steamed. Pregnancy, delivery, and postpartum 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.

Integrating Sexual Health Services Into Primary Care: An Overview of Health Systems Issues and Challenges in Developing Countries

ABSTRACT Current attempts to address the high burden of sexual health morbidity and mortality in developing countries remain limited in scale due to a range of health system constraints. We conducted a literature review of the policy and programmatic issues that influence the integration of sexual health into primary care services in developing countries. Forty-seven reports were identified from a search of both peer-reviewed and gray literature. Key issues identified were intersectoral and intergovernmental coordination; management and organizational issues including decentralization, health sector reform, logistics, and referral systems; human resources, including training and support required to increase service scope; relationships between the public and private sectors; and scaling-up and financing issues.

Determinants of Vaginal Cleansing, Application, and Insertion in Tete Province, Mozambique, and Products Used

ABSTRACT Objective: In this article, we review insertion, application, and cleansing as they include the use of products other than water and have a number of harmful effects. Method: In 2007, a household survey of 919 women carried out in Tete Province, Mozambique, examined 8 vaginal practices. Results: Overall, 10% of the sexually active women reported regularly using these 3 vaginal practices concurrently. Of the women who practiced insertion, 65% used natural substances. A wider variety of products was used for applying substances on the external genitalia and for cleansing purposes. Conclusions: These findings have important implications for future HIV prevention, including in the use of microbicides.