Allahna Esber

Risk of Bacterial Vaginosis Among Women With Herpes Simplex Virus Type 2 Infection: A Systematic Review and Meta-analysis

BACKGROUND Bacterial vaginosis (BV) is a perturbation of vaginal flora characterized by reduced levels of lactobacilli and concomitant overgrowth of anaerobic bacterial species. BV is highly prevalent and associated with multiple adverse outcomes, including enhanced human immunodeficiency virus transmission. Because recent reports reveal that herpes simplex virus type 2 (HSV-2) infection may increase BV risk, we initiated a systematic review and meta-analysis of the link between HSV-2 infection and BV. METHODS We searched the MEDLINE, EMBASE, and CENTRAL databases to identify articles posted before 1 December 2014. Two screeners independently reviewed the titles and abstracts of all identified articles, reviewed the full text of articles deemed potentially eligible, and extracted data from 14 cross-sectional and 3 prospective studies. Using random-effects models, we computed separate pooled estimates for cross-sectional and prospective studies. RESULTS The pooled odds ratio for cross-sectional studies was 1.60 (95% confidence interval, 1.32-1.94). Stronger support for the causal effect of HSV-2 infection on BV risk was revealed by the summary relative risk for the prospective studies, which was 1.55 (95% confidence interval, 1.30-1.84), with minimal heterogeneity (I(2) = 0). CONCLUSIONS These analyses imply that HSV-2 infection is an important BV risk factor. Pharmacologic HSV-2 suppression may reduce BV incidence and BV-associated adverse events.

High prevalence of rectal gonorrhea and Chlamydia infection in women attending a sexually transmitted disease clinic.

BACKGROUND Testing women for urogenital Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) is common in sexually transmitted disease (STD) clinics. However, women may not be routinely tested for rectal GC/CT. This may lead to missed infections in women reporting anal intercourse (AI). METHODS This was a retrospective review of all women who underwent rectal GC/CT testing from August 2012 to June 2013 at an STD clinic in Columbus, Ohio. All women who reported AI in the last year had a rectal swab collected for GC/CT nucleic acid amplification testing (n=331). Using log-binomial regression models, we computed unadjusted and adjusted associations for demographic and behavioral factors associated with rectal GC/CT infection. RESULTS Participants (n=331) were 47% African-American, with median age of 29 years. Prevalence of rectal GC was 6%, rectal CT was 13%, and either rectal infection was 19%. Prevalence of urogenital GC and CT was 7% and 13% respectively. Among women with rectal GC, 14% tested negative for urogenital GC. Similarly, 14% of women with rectal CT tested negative for urogenital CT. In unadjusted analyses, there was increased rectal GC prevalence among women reporting sex in the last year with an injection drug user, with a person exchanging sex for drugs or money, with anonymous partners, and while intoxicated/high on alcohol or illicit drugs. After multivariable adjustment, no significant associations persisted, but a trend of increased rectal GC prevalence was observed for women <26 years of age (p=0.06) and those reporting sex while intoxicated/high on alcohol or drugs (p=0.05). For rectal CT, only age <26 years was associated with prevalent infection in unadjusted models; this association strengthened after multivariable adjustment (prevalence ratio: 6.03; 95% confidence interval: 2.29-15.90). CONCLUSION Nearly one in five women who reported AI in the last year had rectal GC or CT infection. Urogenital testing alone would have missed 14% of rectal infections. Standardized guidelines would increase rectal GC/CT testing in women and help detect missed infections.

Cessation of intravaginal practices to prevent bacterial vaginosis: a pilot intervention in Zimbabwean women

Objectives Intravaginal practices—including behaviours such as washing with soap or other materials, using fingers or cloth, or insertion of herbs, powders or other products to dry, cleanse or ‘tighten’ the vagina—may increase womens risk of bacterial vaginosis by disrupting the vaginal microbiota. In Zimbabwe, intravaginal practices are common. The objective of this study was to assess the feasibility of an intervention based on the transtheoretical model of behaviour change (also called the ‘stages of change’ model) to encourage cessation of vaginal practices among a sample of Zimbabwean women. Methods We conducted a 12-week behaviour change intervention to encourage cessation of intravaginal practices (other than cleansing with water) among 85 Zimbabwean women who reported these practices. Results Self-reported intravaginal practices declined significantly over follow-up, with 100% of women reporting at least one intravaginal practice at enrolment compared with 8% at the final visit. However, we found no significant effect of this reduction on bacterial vaginosis prevalence in unadjusted or adjusted multivariable models (adjusted prevalence ratio for any practice vs none: 0.94, 95% CI 0.61 to 1.43). Conclusions While the intervention was successful in reducing womens self-reported engagement in intravaginal practices, we observed no corresponding benefit to vaginal health.

Partner approval and intention to use contraception among Zanzibari women presenting for post-abortion care.

OBJECTIVE We examined the effect of partner approval of contraception on intention to use contraception among women obtaining post-abortion care in Zanzibar. STUDY DESIGN Our data source was a 2010 survey of 193 women obtaining post-abortion care at a large public hospital in Zanzibar. We used multivariable logistic regression analysis to assess associations between partner approval and intention to use contraception. RESULTS Overall, 23% of participants had used a contraceptive method in the past, and 66% reported intending to use contraception in the future. We found that partner approval of contraception and ever having used contraception in the past were each associated with intending to use contraception in the future. In the multivariable model, adjusting for past contraception use, partner approval of contraception was associated with 20 times the odds of intending to use contraception (odds ratio, 20.25; 95% confidence interval, 8.45-48.56). CONCLUSIONS We found a strong association between partner approval and intention to use contraception. Efforts to support contraceptive use must include both male and female partners. IMPLICATIONS Public health and educational efforts to increase contraceptive use must include men and be targeted to both male and female partners. Given that male partners are often not present when women obtain health care, creative efforts will be required to meet men in community settings.

Intravaginal practices among a cohort of rural Malawian women

BACKGROUND Intravaginal practices (IVP) are highly prevalent and commonly performed in many countries for a variety of purposes related to genital health, hygiene and sexual pleasure. However, IVP may also have harmful side effects, including associations with bacterial vaginosis and HIV. METHODS The prevalence and motivations for IVP among 650 women participating in the baseline survey of a community-based cohort study on sexual and reproductive health in rural Lilongwe District, Malawi, were characterised. Key variables included the type and frequency of IVP, and motivations for engaging in IVP. RESULTS Most women (95%) had engaged in IVP in the past 30 days: 88% reported internal vaginal cleansing with water only, 87% reported cleansing with soap and water, and 84% reported inserting cotton, cloth or tissue. A majority (60%) reported at least three practices. Very frequent engagement in at least one type of IVP was also common; among those who inserted cotton, cloth or tissue, 43% did so more than once a day; among those who cleansed internally with soap and water, 51% did so more than once a day. Women reported many reasons for using IVP. The most commonly reported reasons were to remove odours (91%), to remove extra moisture (58%), to prevent disease (49%), to relieve symptoms of disease (41%) and to improve sex for a partner (40%). CONCLUSION IVP are highly prevalent and frequently performed among these rural Malawian women. Future research should investigate the associations between IVP and sexually transmissible infection prevalence.

Factors influencing Malawian women's willingness to self-collect samples for human papillomavirus testing.

Background Malawi has the highest incidence of cervical cancer in the world. Only 3% of Malawian women have ever been screened for cervical cancer. Self-collection of samples for human papillomavirus (HPV) testing could increase screening among under-screened and hard-to-reach populations. However, little is known about the acceptability of self-collection in rural African settings. Aim We aimed to characterise Malawian womens willingness to self-collect vaginal samples for HPV testing and to identify potential barriers. Design We used data from the baseline wave of a community-based cohort study, collected from July 2014 to February 2015. Setting Participants were enrolled from the catchment area of a clinic in rural Lilongwe District, Malawi. Methods We enrolled women aged 15–39 years (n=824). Participants answered questions assessing willingness to self-collect a sample for HPV testing, concerns about testing and other hypothesised correlates of willingness to self-collect. Results Two-thirds (67%) of the women reported willingness to self-collect a vaginal sample in their homes. Awareness of cervical cancer, supportive subjective norms, perceived behavioural control, and clinician recommendations were all positively associated with increased willingness to self-collect samples for HPV testing. Identified barriers to self-testing endorsed by women included: concerns that the test might hurt (22%), that they might not do the test correctly (21%), and that the test might not be accurate (17%). Conclusions This study suggests that self-collection for HPV testing could be an acceptable cervical cancer screening method in this rural population. Findings identify modifiable beliefs and barriers that can inform the development of effective screening programmes.

The Relationship Between Ambivalent and Indifferent Pregnancy Desires and Contraceptive Use Among Malawian Women

CONTEXT Pregnancy ambivalence and pregnancy indifference are thought to be associated with nonuse of contraceptives, but their conceptualization and measurement vary, and their relationship to contraceptive use in developing countries is poorly understood. METHODS Data from the Umoyo wa Thanzi research program in rural Lilongwe, Malawi, were used to classify the pregnancy desires of 592 women aged 15-39 as antinatal, pronatal, ambivalent or indifferent, according to both the womens desire to conceive and their desire to avoid pregnancy. Logistic regression was used to assess the relationship between each of the four pregnancy desire categories and use of modern contraceptives. RESULTS Overall, 12% of women were classified as ambivalent, 32% as indifferent, 44% as antinatal and 12% as pronatal. In the logistic regression analysis, the odds of contraceptive use among women with indifferent pregnancy desires (having both a desire not to avoid pregnancy and a desire not to conceive) were twice those of women with pronatal desires (odds ratio, 2.2) and were similar to those among women with antinatal desires (2.7). In contrast, the odds of contraceptive use among women with ambivalent pregnancy desires (having both a desire to avoid pregnancy and a desire to conceive) did not differ from those of women who had pronatal desires. CONCLUSIONS Ambivalent and indifferent pregnancy desires are common in Malawi and are associated with modern contraceptive use in different ways. Understanding the complex nature of pregnancy desires may be valuable in improving family planning programs.

Intravaginal Practices and Prevalence of Sexual and Reproductive Tract Infections Among Women in Rural Malawi.

Background Many women engage in intravaginal practices (IVP) with a goal of improving genital hygiene and increasing sexual pleasure. Intravaginal practices can disrupt the genital mucosa, and some studies have found that IVP increases risk of acquisition of HIV and bacterial vaginosis (BV). Limited prior research also suggests significant associations between IVP, herpes simplex virus type 2 (HSV-2), and high-risk types of human papillomavirus (HPV). Methods We examined associations between IVP and HPV, BV, and HSV-2 among 200 women in rural Malawi participating in a clinic-based study on sexual and reproductive tract infections. We calculated prevalence ratios for the associations between frequency and type of IVP and outcomes of HPV, BV, and HSV-2. Results Intravaginal practices were commonly performed, with 95% of women reporting current use of at least 1 practice. Infections were also frequently detected: Twenty-two percent of the sample had at least 1 high-risk HPV type, 51% had BV, and 50% were HSV-2 seropositive. We observed no significant associations between type of IVP, frequency of IVP, or a combined measure capturing type and frequency of IVP—and any of the infection outcomes. Conclusions Although both IVP and our outcomes of interest (BV, HPV, and HSV-2) were common in the study population, we did not detect associations between IVP type or frequency and any of the 3 infections. However, the high prevalence and frequency of IVP may have limited our ability to detect significant associations.

The impact of joint partner decision making on obstetric choices and outcomes among Malawian women

To determine the effects of joint partner decision making on obstetric choices and outcomes in Malawi.

Infertility and self-rated health among Malawian women

ABSTRACT Infertility is prevalent and stigmatized in sub-Saharan Africa. Self-rated health, a subjective indicator that has been consistently related to objectively measured health, may be useful in evaluating the relationship between women’s infertility and health. Data were from surveys conducted from July 2014 to January 2015 with women aged 15–39 years (n = 915) as part of the initial assessment in a cohort study in Lilongwe district, Malawi. We first assessed correlates of self-reported infertility among women in rural Malawi. We then used multiple logistic regression to examine associations between infertility and self-rated health. Of women surveyed, 20 percent had a history of infertility. Compared to women who had not experienced infertility, women with a history of infertility were older (p = 0.05), less educated (p = 0.01), and more likely to report depressive symptoms (p = 0.02) and forced first intercourse (p = 0.02) and to have been previously diagnosed with a sexually transmitted infection (p = 0.05). However, women with a history of infertility were not significantly more likely to report poor self-rated health (adjusted odds ratio: 1.69; 95 percent confidence interval: 0.70–4.07). Infertility was prevalent in our sample of Malawian women but was not significantly related to self-rated health, an instrument widely used in public-health research.