Correspondence

More on Vaginal Inflammation in Africa

N Engl J Med 1993; 328:888-889March 25, 1993

Article

To the Editor:

The conclusions drawn by Brown et al. (Aug. 20 issue)1 illustrate one of the dangers of limited investigations in Africa and the pitfalls of inadequately controlled studies. The lack of microbiologic studies of the women studied in Zaire and the absence of observations in comparable prostitutes with wet vaginas or vaginal discharge, symptomatic of acute inflammation, who enjoy sexual intercourse detract from the study. However, the use of intravaginal medicaments or traditional medicinal preparations has been reported to be common among prostitutes in some African countries2. They are used primarily for preventive purposes against sexually transmitted diseases, not to produce dryness and enhance sexual pleasure. This practice is not universal in Africa but is relatively common among rural and poor women and prostitutes. It is likely that the epithelial changes visualized on colposcopy in these women are due to sexually transmitted diseases rather than to the sole effects of the powders used intravaginally or to both factors combined. This can be verified by in vitro studies. There is a need to look into this sociocultural practice and its efficacy in relation to the prevention of sexually transmitted diseases in general and the heterosexual transmission of AIDS in particular3.

A. Olufemi Williams, M.D., F.R.C.P.
National Cancer Institute, Bethesda, MD 20892

3 References

1. 1

   Brown RC, Brown JE, Ayowa OB. Vaginal inflammation in Africa. N Engl J Med 1992;327:572-572
   Full Text | Web of Science | Medline

2. 2

   Williams EE, Hearst N, Udofia O. Sexual practices and HIV infection of female prostitutes. In: Proceedings of the Fifth International Conference on AIDS, Montreal, June 4-9, 1989. Ottawa, Ont.: International Development Research Centre, 1989:985.
   

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   Williams AO. AIDS: an African perspective. Boca Raton, Fla.: CRC Press, 1992:12.
   

To the Editor:

In their recent description of a group of women from central Zaire who inserted leaves and powders into their vaginas to enhance sexual stimulation, Brown et al. called for other investigations of this practice. The use of intravaginal preparations is also found in Kinshasa, in western Zaire. According to 124 Zairian men and women interviewed in 1987,1 intravaginal substances used include pastes, powders, and extracts of chili pepper, ginger root, cola nuts, kapok and cassava leaves, mango-tree bark, and gunpowder. The study participants claimed that these substances are most commonly used by women with multiple sex partners, such as prostitutes, to stimulate the male partner by drying or tightening the vagina or to treat or mask abnormal vaginal discharge. At least some of these substances are reported to have irritant, astringent, or desiccant effects on skin and mucous membranes in humans and other mammals2-6. Dallabetta and others (Dallabetta G: personal communication) reported that 35 percent of women attending an antenatal clinic in Blantyre, Malawi, used traditional substances (including herbs, silica powder, and aluminum hydroxide) to treat vaginal discharge, and 12 percent used them to tighten the vagina during sex. This practice is also found in Lusaka, Zambia, where a study is under way to determine whether vaginal irritants facilitate the acquisition of the human immunodeficiency virus (HIV) by women (Lurie P: personal communication). These studies demonstrate that the use of traditional intravaginal preparations is widespread throughout sub-Saharan Africa.

Traditional vaginal preparations may promote the heterosexual transmission of HIV through several mechanisms. First, these substances are often used to treat or mask vaginal discharge, which may be a symptom of an ulcerative or nonulcerative sexually transmitted disease, a demonstrated cofactor for the transmission of HIV7. Second, if vaginal irritants induce the proliferation of lymphocytes, the target cells for HIV, they could increase a woman's risk of acquiring HIV. The proliferation of HIV-infected lymphocytes could also enhance a woman's ability to infect male sex partners. Third, by dehydrating the vaginal mucosa, these substances could increase the risk of traumatic sex, a factor that may enhance HIV acquisition in women8,9. Fourth, intravaginal substances may alter the normal pH of the vagina10,11 or impair its mucosal immunity12 -- factors that may protect against HIV acquisition. Finally, as Brown et al. observed in women and as others have observed in animals,13 some substances may damage the protective vaginal epithelium, allowing viruses to pass directly into the bloodstream. The risk of acquisition or transmission of HIV associated with intravaginal irritants would be greatest among women who have multiple sex partners and a high prevalence of HIV infection, such as prostitutes,14 in whom the use of these substances may be fairly common1.

Kathleen Irwin, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30333

Ndilu Mibandumba, M.D.
Kashama Mbuyi, R.N.
Robert Ryder, M.D.
Projet SIDA, Kinshasa, Zaire

Denise Sequeira, M.D.
Canadian International Development Agencies, Ottawa, ON K1N 9K7, Canada

14 References

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   Peterman TA. Facilitators of HIV transmission during sexual contact. In: Alexander NJ, Gabelnick HL, Speiler JM, eds. Heterosexual transmission of AIDS. New York: Wiley-Liss, 1990:55-68.
   

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   Siraprapasiri T, Thanprasertsuk S, Rodklay A, Srivanichakorn S, Sawanpanyalert P, Temtanarak J. Risk factors for HIV among prostitutes in Chiangmai, Thailand. AIDS 1991;5:579-582
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    Johnson AM, Laga M. Heterosexual transmission of HIV. In: Alexander NJ, Gabelnick HL, Speiler JM, eds. Heterosexual transmission of AIDS. New York: Wiley-Liss, 1990:9-24.
    

Citing Articles (7)

Citing Articles

1. 1

   R Scott McClelland, Ludo Lavreys, Wisal M Hassan, Kishorchandra Mandaliya, Jeckoniah O Ndinya-Achola, Jared M Baeten. (2006) Vaginal washing and increased risk of HIV-1 acquisition among African women: a 10-year prospective study. AIDS 20:2, 269-273
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   Gérard Grésenguet, Jean Séhonou, Bouba Bassirou, Jean de Dieu Longo, Jean-Elie Malkin, Tom Brogan, Laurent Bélec. (2002) Voluntary HIV Counseling and Testing: Experience Among the Sexually Active Population in Bangui, Central African Republic. JAIDS Journal of Acquired Immune Deficiency Syndromes 31:1, 106-114
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   Judith E. Brown, Richard C. Brown. (2000) Traditional Intravaginal Practices and the Heterosexual Transmission of Disease. Sexually Transmitted Diseases 27:4, 183-187
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4. 4

   JEFFREY LAURENCE. (1999) "Amplified Perversity": Trends in Heterosexual HIV. AIDS Patient Care and STDs 13:12, 683-688
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   Guy La Ruche, Nogbou Messou, Lea Ali-Napo, Valentin Noba, Hortense Faye-Ketté, Patrice Combe, Dominique Bonard, Fatoumata Sylla-Koko, Djokouéhi Dhéha, Christiane Welffens-Ekra, Mireille Dosso, Philippe Msellati. (1999) Vaginal Douching: Association With Lower Genital Tract Infections in African Pregnant Women. Sexually Transmitted Diseases 26:4, 191-196
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   Peter H. Kilmarx, Khanchit Limpakarnjanarat, Somsak Supawitkul, Supaporn Korattana, Nancy L. Young, Bharat S. Parekh, Richard A. Respess, Timothy D. Mastro, Michael E. St Louis. (1998) Mucosal disruption due to use of a widely-distributed commercial vaginal product. AIDS 12:7, 767-773
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7. 7

   Gérard Gresenguet, Joan K. Kreiss, Michael K. Chapko, Sharon L. Hillier, Noel S. Weiss. (1997) HIV infection and vaginal douching in Central Africa. AIDS 11:1, 101-106
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