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Intravaginal practices, bacterial vaginosis and HIV infection in women: individual woman data meta-analysis

Intravaginal practices, bacterial vaginosis and HIV infection in women: individual woman data meta-analysis
Intravaginal practices, bacterial vaginosis and HIV infection in women: individual woman data meta-analysis
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.

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.

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.
1549-1277
Low, N.
8c6c55da-d9a4-4d4c-9149-8685fce82ada
Chersich, M.F.
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Schmidlin, K.
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Egger, M.
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Francis, S.C.
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van de Wijgert, J.H.
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Hayes, R.J.
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Baeten, J.M.
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Brown, J.
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Delany-Moretlwe, S.
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Kaul, R.
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McGrath, N.
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Morrison, C.
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Myer, L.
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Temmerman, M.
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van der Straten, A.
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Watson-Jones, D.
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Zwahlen, M.
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Hilber, A.M.
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Low, N.
8c6c55da-d9a4-4d4c-9149-8685fce82ada
Chersich, M.F.
9770fd36-376a-4aa3-ada9-9ea5544a0ac6
Schmidlin, K.
9e61542f-78bb-472e-9e92-b0b915ef077b
Egger, M.
95d232d3-852e-4d4b-8070-c0aff86ebe60
Francis, S.C.
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van de Wijgert, J.H.
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Hayes, R.J.
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Baeten, J.M.
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Brown, J.
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Delany-Moretlwe, S.
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Kaul, R.
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McGrath, N.
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Morrison, C.
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Myer, L.
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Temmerman, M.
9fd6c365-8e57-4703-8fa7-c77e1dc0a294
van der Straten, A.
a6450725-b9dc-46b2-b2c0-96fd0a3f6245
Watson-Jones, D.
bf4ce52e-b71a-4323-8b89-94147b3ea582
Zwahlen, M.
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Hilber, A.M.
cbd4faf4-3d8a-4513-879c-9b1e3eb7e8b8

Low, N., Chersich, M.F., Schmidlin, K., Egger, M., Francis, S.C., van de Wijgert, J.H., Hayes, R.J., Baeten, J.M., Brown, J., Delany-Moretlwe, S., Kaul, R., McGrath, N., Morrison, C., Myer, L., Temmerman, M., van der Straten, A., Watson-Jones, D., Zwahlen, M. and Hilber, A.M. (2011) Intravaginal practices, bacterial vaginosis and HIV infection in women: individual woman data meta-analysis. PLoS Medicine, 8 (2). (doi:10.1371/journal.pmed.1000416). (PMID:21358808)

Record type: Article

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.

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.

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.

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e-pub ahead of print date: 15 February 2011
Organisations: Faculty of Health Sciences

Identifiers

Local EPrints ID: 350260
URI: http://eprints.soton.ac.uk/id/eprint/350260
ISSN: 1549-1277
PURE UUID: 3c613821-ea10-4c42-b563-1418caa9d831
ORCID for N. McGrath: ORCID iD orcid.org/0000-0002-1039-0159

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Date deposited: 20 Mar 2013 14:44
Last modified: 17 Dec 2019 01:37

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Contributors

Author: N. Low
Author: M.F. Chersich
Author: K. Schmidlin
Author: M. Egger
Author: S.C. Francis
Author: J.H. van de Wijgert
Author: R.J. Hayes
Author: J.M. Baeten
Author: J. Brown
Author: S. Delany-Moretlwe
Author: R. Kaul
Author: N. McGrath ORCID iD
Author: C. Morrison
Author: L. Myer
Author: M. Temmerman
Author: A. van der Straten
Author: D. Watson-Jones
Author: M. Zwahlen
Author: A.M. Hilber

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