Intravaginal practices in a cohort of women at high risk

in North-West Tanzania:

Baseline associations with HIV

Suzanna Francis, Tony Ao, Joseph Chilongani, Bahati Andrew, Deborah Watson-Jones, Saidi Kapiga, Richard

Hayes

Funded by the UK British Medical Research Council (MRC) and the European and Developing Countries Clinical Trials Partnership (EDCTP)

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Intravaginal practices (IVP): cleansing and insertion

IVP are highly prevalent among women in many parts of sub-Saharan Africa

Meta-analysis concluding that some types of IVP are a risk factor for HIV infection

IVP may affect the impact of female controlled HIV prevention methods, such as vaginal microbicides

Why are we interested in IVP?

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Observational cohort of women at high risk for HIV in three urban settlements close to mines in North- West Tanzania

Objectives:– To describe and quantify reported IVP– To investigate associations between IVP and HIV at

the screening visit

Background

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Screening visits: Aug 2008 to Aug 2009 Study population: Women at high risk

– Food vendors– Restaurant / grocery workers– Bar, disco, local brew sellers– Guesthouse / hotel workers

N = 1,800 Screening visit had a face to face questionnaire and

HIV testing

Methods

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Overall HIV Prevalence 21%

HIV Prevalence by occupation– Food vendors 11%

– Restaurant / grocery workers 17%– Bar, disco, local brew sellers 33%– Guesthouse / hotel workers 39%

Results

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Percentage of women reporting IVP

0%

20%

40%

60%

80%

100%

Cleansing Insertion

Description of reported IVP in the past 3 months

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Substances used for cleansing

0%

20%

40%

60%

80%

No cleansing Water only Soap or soapywater

Other

Description of reported IVP in the past 3 months

8

Application methods used for cleansing

0%

20%

40%

60%

80%

No cleansing Fingers only Cloth Cotton, paper,other

Description of reported IVP in the past 3 months

9

Frequency of cleansing

0%

10%

20%

30%

40%

Nocleansing

< daily x1/ day x2/ day x3/ day ≥4/ day

Description of reported IVP in the past 3 months

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Type of substance inserted

0%

5%

10%

15%

20%

Anyinsertion

Herbs ortraditionalmedicine

Detergent Lemon Gels Other

Description of reported IVP in the past 3 months

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Unadjusted associations between IVP and HIV

IVP Type HIV+/Total(%) OR (95% CI)Cleansing 353/1,579 (22%) 1.8 (1.2–2.7)

- water only with fingers 57/264 (22%) 1.7(1.0-2.8)

- water & soap with fingers 252/1,107 (23%) 1.8 (1.2-2.8)

- cloth 25/143 (18%) 1.3 (0.7-2.3) - cotton, paper, other 15/47 (32%) 2.8 (1.4-5.9)No cleansing 27/192 (14%) 1

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Unadjusted associations between IVP and HIV

IVP Type HIV+/Total(%) OR (95% CI)Cleansing 353/1,579 (22%) 1.8 (1.2–2.7)

- < once daily 6/43 (14.0%) 1.0 (0.4-2.5)- x1 / day 29/147 (19.7%) 1.5 (0.8-2.6)- x2 / day 144/652 (22.1%) 1.7 (1.1-2.7)- x3 / day 125/530 (23.6%) 1.9 (1.2-2.9)- +4 / day 45/182 (24.7%) 2.0 (1.2-3.4)

No cleansing 27/192 (14%) 1p-trend = 0.002

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Unadjusted associations between IVP and HIV

IVP Type HIV+/Total(%) OR (95% CI)Insertion 73/276 (26.5%) 1.3 (1.0–1.9)

- Herbs 27/102 (26.5%) 1.3 (0.9-2.1)- Detergent 24/93 (25.8%) 1.3 (0.8-2.1)- Lemon 5/29 (17.2%) 0.8 (0.3-2.0)- Gels 26/93 (27.5%) 1.4 (0.9-2.3)- Other 8/31 (25.8%) 1.3 (0.6-2.9)

No insertion 307/1,492 (20.6%) 1

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Adjusted associations between IVP and HIV

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IVP type Unadjusted Adjusted*Insertion 1.3 (1.0–1.9) 1.3 (0.9-1.7)Cleansing 1.8 (1.2–2.7) 1.5 (1.0-2.3)

- water only with fingers 1.7(1.0-2.8) 1.4 (0.8-2.3)

- water & soap with fingers 1.8 (1.2-2.8) 1.5 (1.0-2.4)

- cloth 1.3 (0.7-2.3) 1.3 (0.7-2.3)- cotton, paper,

other 2.8 (1.4-5.9) 2.7 (1.2-5.7)

No cleansing 1 1* Age group, employment, and number of sex partners in the last

three months as these were independently associated with prevalent HIV

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Adjusted associations between IVP and HIV

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IVP type Unadjusted Adjusted*Cleansing 1.8 (1.2–2.7) 1.5 (1.0-2.3)

- < once daily 1.0 (0.4-2.5) 0.9 (0.3-2.3)- x1 / day 1.5 (0.8-2.6) 1.2 (0.7-2.2)- x2 / day 1.7 (1.1-2.7) 1.5 (0.9-2.3)- x3 / day 1.9 (1.2-2.9) 1.7 (1.1-2.7)- +4 / day 2.0 (1.2-3.4) 1.7 (1.0-2.3)

No cleansing 1 1* Age group, employment, and number of sex partners in the last

three months. Adjusted p-trend = 0.006

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Most common type of IVP is cleansing with soap and fingers

Evidence of an association between cleansing and prevalent HIV

Strong evidence of a dose-response with frequency of cleansing and prevalent HIV

Some evidence of an association between insertion and prevalent HIV

Summary

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Baseline, cross-sectional analysis Small numbers reporting some types of IVP Possible reporting bias Limited variables to assess confounding as

there was no other STI testing or physical examination

Limitations

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Incidence analysis combining data from Tanzanian sites and our sister site in Kampala, Uganda

Diary study in both Tanzania and Uganda describing the patterns of IVP behavior in more detail

Future work

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The participants in the study

Study teams and team leaders in Geita, Shinyanga, and Kahama

Data team lead by Clemens Masesa

Laboratory staff lead by Aura Andreasen and John Changalucha

Acknowledgements