Dyspareunia, Signs of Epithelial Disruption, and HIV Serostatus in Female Sex Workers and Men Who Have Sex With Men in Nairobi: an Observational Study

Background: This study investigated HIV infection risk in men who have sex with men (MSM) and female sex workers (FSWs) by analysing signs of anal and vaginal epithelial trauma. It reconsidered the unique role of sexual abstinence for HIV seroconversion from a previous case-control analysis on FSWs in Nairobi who acquired HIV after previously fulfilling criteria of HIV resistance. The approach was based on a similarly unique role of intercourse frequency for anal dyspareunia. We considered confounding behavioural and individual HIV infection risks among the sex workers, who also assessed factors influencing discomfort and pain during sex from a subjective perspective. Methods: At two key population facilities in Nairobi, 322 FSWs and 231 MSM provided data on HIV infection status, sexual dysfunction, intercourse frequency and abstinence behaviour. Additional data addressed sexual debut, relationship status, lubricants, foreplay, the number of sex partners, condom use, group and anonymous sex, vaginal births, intravaginal practices, sex toys, other sexually transmitted infections, alcohol and drug use. Statistical tests included t-tests for the equality of means for abstinence gaps and intercourse frequencies, the number of sex partners, vaginal births, and age of sexual debut. Non-parametric tests were used to compare HIV status and the ordinal variables of sexual behaviour, individual factors, dyspareunia and signs of trauma scores. Subjective assessments of variables for sexual dysfunction were given as percentages of the assessment options. Results: Among FSWs, significant associations were found between HIV status and the longest abstinence gap for vaginal intercourse in the previous month, early sexual debut, foreplay, having anonymous partners, intravaginal practices, drugs and alcohol use, and all the sexual dysfunction or epithelial disruption signs. No significant association between HIV status and sexual dysfunction variables or sexual abstinence gaps could be found in the MSM sample. FSWs agreed that steady partnerships, regularity of intercourse, foreplay and lubrication or artificial lubricants alleviate discomfort and painful intercourse. Conclusions: Dyspareunia and epithelial trauma signs were highly prevalent in FSWs and MSM, indicating considerable limitations to sexual health. Complaint levels were positively associated with HIV infection, suggesting that reducing epithelial disruption may be a novel HIV prevention approach.

“Feeling clean”: stigma and intravaginal practices among female entertainment workers in Cambodia

Background Intravaginal practices (IVPs), methods used by women most often to manage vaginal hygiene and address perceived disruptions to vaginal health, may increase the risk of contracting human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This qualitative study explores the social, professional, and peer context surrounding IVPs, the experiences of self-cleaning or getting cleaned from a health professional, and the perceived impacts of IVPs among female entertainment workers (FEWs) in Cambodia. Methods In 2017, we conducted 27 focus group discussions from four provinces, and 16 follow-up semi-structured in-depth interviews with purposively selected participants in two provinces. Data collection occurred over three weeks, with concurrent data transcription and translation. The data from the transcripts were analyzed using Dedoose, an online, open-access qualitative analysis software. Two researchers independently labeled sections of transcripts associated with broader categories and subcategories based on the initial content analysis matrix and created codes. This process continued iteratively until a final coding schema and conceptual model was created. Results We found that IVPs are widely practiced among FEWs in Cambodia and are associated with internalized and enacted stigma. Stigma was an overarching theme that impacted the sub-themes of (1) messages about cleaning, (2) the cleaning process, and (3) the impact of cleaning. Experiences of enacted stigma and internalized stigma permeated conversations about IVP, including feeling pressured by peers to keep themselves clean, practicing internal cleaning after transactional sex, and being called dirty by health providers. Conclusions FEWs who practice IVP talk about it in the context of their lived experiences stigma and discrimination. Highly stigmatized practices such as IVP among FEWs may benefit from a harm reduction approach that emphasizes positive changes without judgment, coercion, or discrimination.

Consideration of Cultural Practices When Characterizing the Vaginal Microbiota Among African and African American Women

This manuscript considers intravaginal practices prevalent among African and African-American women, with the aim of providing a framework for how these practices may affect vaginal health and the vaginal microbiota, and consequently, impact pregnancy outcomes. Intravaginal practices are influenced by traditional socio-cultural beliefs and gender norms, with prominent practices including intravaginal insertion of substances (herbs and traditional medicines), intravaginal cleansing (douching), and anatomical modification of the female organs (labia elongation and female genital mutilation). Common motivations for such practices included hygiene, prevention of infection, enhancement of sexual pleasure, and compliance with societal or cultural norms. The use of soaps and other chemicals for vaginal douching has been reported to reduce diversity of the vaginal microbiota and lower pH, thus increasing the chances of bacterial vaginosis, but the evidence is minimal. The practice of vaginal insertion of natural or other substances is associated with physical abrasions, disruption of the vaginal flora, bacterial vaginosis, and HIV and other infections, but effects on pregnancy outcomes and the vaginal microbiota are unclear. Finally, female genital mutation has been reported to have immediate and prolonged physiological and psychological effects, including frequent infections and chronic inflammation, but similar to most other practices, consequences for preterm birth remain understudied and for the vaginal microbiota, unknown. Overall, findings identify the need for additional research, focusing on how these common practices influence both birth outcomes and the vaginal microbiota, so that nurses, midwives, physicians, and other providers worldwide are better equipped to assess and care for pregnant women.