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Intravaginal practices and lactobacilli colonization among women in Accra, Ghana

  • Francisca Nana-Aba McCarthy1,
  • Nicholas Israel Nii-Trebi1Email author,
  • Billal Obeng Musah1 and
  • Richard Harry Asmah1
Contributed equally
BMC Women's Health201515:46

https://doi.org/10.1186/s12905-015-0205-2

Received: 1 December 2014

Accepted: 28 May 2015

Published: 4 June 2015

Abstract

Background

Intravaginal practices may affect the colonization of vaginal flora and lead to vaginal infections due to the potential effects on the vaginal environment. This study investigated the vaginal practices and their possible effects on vaginal lactobacilli flora colonization in women in Accra.

Methods

A cross-sectional, descriptive single-site study was carried out on 141 women assessing medical care at the Obstetrics and Gynaecology Department of the Korle-Bu Teaching Hospital (KBTH) in Accra. Study-relevant information on participants was obtained by means of questionnaire. Vaginal swab samples were collected and processed for laboratory analyses.

Results

All the participants (141/141, 100.0 %) indicated they performed intravaginal practices using various methods. Almost half (46.1 %) of these women were between the ages of 25–34 years and 65.0 % were married. Internal douching (82.3 %; p > 0.05) was the commonest practice reported. Other practices such as insertion and wiping with hands and objects, as well as use of locally prepared concoctions and certain commercial products were also reported. The reason most commonly given was for hygienic purpose (83.0 %); a few (10.6 %) did it for sexual satisfaction, while others indicated vaginal tightness (5.7 %) and wound healing (0.7 %) as reasons for their practice. No Lactobacillus sp. was detected in as many as 78.7 % of the sample. Association tests by the Pearson correlation analysis showed strong significant negative correlation (r = −0.954, p < 0.05) between use of traditional herbs/concoction and vaginal lactobacilli colonization; and douching being the least negatively (r = −0.601, p > 0.05) correlated practice.

Conclusions

Vaginal practices were common among the women studied. A more elaborate prospective, case–control study into intravaginal practices and their impact on the health of women in Ghana should be explored.

Keywords

Intravaginal practices Lactobacillus colonization Women Accra

Background

The lower female genital tract normally harbours mutually coexisting microflora that largely consist of lactobacilli [1, 2]. Studies have shown four distinct lactobacilli species, namely L. crispatus, L. jensenii, L. gasseri and L. iners to be commonly found in the lower genital tract of many women [35]. Of these, L. iners has been suggested to predominate by some studies; and it has also been described as marker of changes in the vaginal flora [6, 7]. Predominant vaginal colonization by lactobacilli is believed to be intrinsically beneficial in conferring antimicrobial protection to the vaginal epithelium against colonization by other microorganisms [810]. The colonization by lactobacillus microflora has also been associated with lower rates of infection with a number of sexually transmitted infectious diseases; whilst low level of vaginal lactobacilli predisposes to infections such as trichomoniasis, gonorrhoea, chlamydiosis and HIV [1115]. However, vaginal lactobacilli dominance and the inherent antimicrobial potential fail in a number of women and their association with health and/or transition from health to disease or vice versa appear to be species-dependent [1618]. For example, the presence of hydrogen peroxide (H2O2)-producing lactobacilli, L. crispatus and L. jensenii, has been associated with a lower occurrence of bacterial vaginosis (BV); and a longitudinal analysis of the vaginal microflora in pregnancy suggests that L. crispatus promotes the stability of the normal vaginal microflora while L. gasseri and/or L. iners to some extent predispose to the occurrence of abnormal vaginal microflora [1922].

The extent of inter-individual differences in vaginal lactobacilli flora composition, and the factors associated with loss of vaginal lactobacilli remain to be fully explored. It is conceivable that non-microbial factors including menstruation, sexual intercourse as well as vaginal practices engaged in by women to manage their vaginal health and sexual life could possibly disturb the vaginal ecological conditions such as the low pH, which enable lactobacilli to inhibit overgrowth by other microorganisms in the vagina [2325].

Intravaginal practices are commonly performed by women worldwide and varies in methods and substances used in different populations across sub-Saharan Africa [26, 27]. Methods such as internal cleansing or washing inside the vagina, which includes wiping the internal genitalia with fingers or other substances; douching, which is the pressurised shooting or pumping of water or solution into the vagina; and insertion of locally made or commercial cleansing products and objects into the vagina have been described [28]. Various studies have also recorded a variety of substances used, which include lemon juice, traditional herbs, commercially available products and detergents. Solid items applied include cloth, cotton wool, paper and stones [29, 30]. Even though these practices are undertaken for a range of purposes including hygiene, sexual satisfaction, prevention of disease or pregnancy, or merely following cultural norms [31, 32], several problems could be associated. Importantly, insertion or pushing of substances such as powders, creams, herbs, tablets, sticks, stones, pulverized rock, leaves or some local and commercial products can cause physical abrasions and potentially disrupt vaginal flora, leading to bacterial vaginosis (BV) [7, 9] and other sexually transmitted infections including HIV [26, 29, 33]. Knowledge on the occurrence of these practices and their effects on women’s health remain to be fully explored.

This study was therefore conducted to primarily describe intravaginal practices among Ghanaian women in Accra and assess possible association between observed practices and lactobacilli colonization as vaginal flora, in a single-site cross-sectional study.

Methods

Study area and design

The study was carried out at the Department of Obstetrics and Gynaecology and Central Laboratory of the Korle-Bu Teaching Hospital, Accra. The Korle-Bu Teaching Hospital is the largest and a major referral hospital located in the nation's capital, Accra, which offers medical services to people from any part of the country. The Central Laboratory is the hospital's biggest laboratory where all samples are sent for laboratory investigations. The study was cross-sectional. It investigated the occurrence of vaginal practices and levels of vaginal Lactobacilli sp. colonization in women.

Subject selection and specimen collection

Women who met the study inclusion criteria were sampled for the investigation. All women assessing care at the Obstetrics and Gynaecology department between March and July, 2013 were approached. Participation was voluntary and reasons were not obtained from the few women who declined participation. Qualified and consenting women were recruited for the study. They were briefed about the study and a voluntary written informed consent was sought from those willing to participate. The consent, available in English, was translated into a local language (either Twi or Ga) for better understanding according to the respondent's wish. Details about the study regarding importance and potential risks were explained to all respondents. Once all questions had been answered, those willing to participate indicated consent by appending their signature or thumb print on the form. Consenting respondents who were between 18 to 50 years and were not on antibiotic medication were eligible for the study. Other exclusion criteria were pregnancy, vaginal antimicrobial usage in the previous 14 days, severe physical handicaps, menstruation and inability to speak English, Twi or Ga.

One hundred and forty one (141) women were enrolled for the study. Questionnaires were administered to obtain study-relevant information from participants. The information required included the socio-demographic characteristics (age, education, marital status); intravaginal practices (knowledge, methods, reasons, time of the practices); sexual behaviour (numbers of sex partners, frequency of sex, sex during menstruation, general condom use, use of lubricants during sex) and contraceptive use (hormonal contraception by way of oral pills, insertion of capsules or injection; insertion of intrauterine device, other method of birth control) by the participants (see Additional file 1 for full details of the study questionnaire). Data collection by the questionnaire lasted 30 minutes on average per participant.

With the assistance of a qualified nurse high vaginal swab (HVS) was taken (by using a sterile disposable speculum) at the emergency room of the Obstetrics/Gynaecology Department. The samples were placed in transport medium and transported to the Central laboratory of the Korle-Bu Teaching Hospital (KBTH) for laboratory investigation.

Laboratory analysis

Microscopic examination

Initially, microscopic procedures were followed to investigate Lactobacilli sp. presence using wet mount preparation with normal saline. Briefly, about 1 ml of normal saline (0.85gNaCl) was dispensed into the transport medium within which the swab stick is placed and was shaken gently to allow homogenisation. A drop of the saline was placed on a labelled grease-free slide to make a wet preparation and cover-slipped. The wet preparation was examined systematically under the light microscope using 10× objective lens for scanning materials and 40× for identification of the organisms.

Culture and biochemical assays

Standard culture and biochemical techniques for the identification and confirmation of Lactobacilli sp. were followed [34]. Briefly, the swab on the stick was used to make a pool under aseptic conditions on both Blood agar and Chocolate agar plates. The inoculum was evenly streaked by use of a sterilized wire loop to ensure discrete colonies. The culture plates were incubated overnight at 37 °C. Identification of the organism was done by colonial morphology and confirmed by Gram staining and biochemical test. Colonial morphology was done by examining and grouping the colonies based on the shape, colour, border, texture, and general appearance of the colonies of bacteria on each plate. Gram staining was performed on the bacterial colonies and examined with 100× objective lens and bacteria were identified as either Gram positive or Gram negative based on the staining properties. The Gram positive cocci bacteria were identified by Catalase and Coagulase tests to confirm the presence of Lactobacilli sp.

Data analysis

Results obtained from the study were entered into a database and analysed statistically using Microsoft Excel® software and Statistical Package for Social Sciences (SPSS) version 20 statistical software for windows and summaries were presented using descriptive statistics. A Pearson correlation run was used to determine any significant correlation at p < 0.05 between the intravaginal practices and the occurrence of vaginal Lactobacilli sp.

Ethics

Ethical approval was obtained from the Research and Ethical Protocol Review Committee of the School of Biomedical and Allied Health Sciences, College of Health Sciences of the University of Ghana. Voluntary written informed consent was obtained from the study participants.

Results

A total of 141 eligible females attending clinic at the Obstetrics and Gynaecology Department of the KBTH and aged between 18 and 50 years participated in the study. Findings showed that women of different age groups, marital status and educational level engaged in intravaginal practices. Almost half (46.1 %) of the participants were aged between 25–34 years. Of the number studied, at least 65.0 % were married and quite an appreciable percentage (90.8 %) had at least primary level of education (Table 1).
Table 1

Summary of socio-demographic characteristics of study participants

Variable

Frequency reporting with intravaginal practices

Percentage (%) occurrence

Age (years)

  

18-24

42

29.8

25-34

65

46.1

35-44

24

17.0

45-50

10

7.1

Marital status

  

Single

43

30.5

Married

92

65.2

Divorced

6

4.3

Educational level

  

No formal education

13

9.2

Primary/Secondary

87

61.7

Tertiary

41

29.1

Total participant

141

100.0

The ages of the participants of the study ranged between 18 and 50 years. Close to 50 % of the 141 them were aged between 25 and 34 years. At least 65 % of the participants were married and a good number of them (128/141) had at least primary level of education

Various types of intravaginal practices recorded among participants and the reasons given by the women for the practices are shown in Table 2. Majority (82.3 %) indicated they either used water only or sometimes water and soap (douching). The rest of the participants used other methods such as commercially available creams and products, wiping with hands and objects, and the use of herbs and concoctions among others. A high percentage (83.0 %) of the participants indicated hygienic purposes as reasons for their practice. Others said they do it for sexual satisfaction (10.6 %), vaginal tightness (5.7 %) and a small number (0.7 %) indicated vaginal wound healing as the reason for engagement in the practice. Lactobacilli colonization was detected in 21.3 % of the participants.
Table 2

Intravaginal practices and reasons for engagement by participants

Intravaginal practices

Frequency of participants

Percentage, % (P-Value)

Practicing

141

100.0

Yes

0

0.0

No

  

Method

  

Water only/water and Soap

116

82.3(0.075)

Commercial product

14

9.9(0.030)

Wiping with hand/objects

4

2.8(0.044)

Herbs/concoctions

5

3.6(0.001)

Others

2

1.4(0.060)

Reasons

  

Hygienic purposes

117

83.0

Sexual satisfaction

15

10.6

Vaginal tightness

8

5.7

Wound healing

1

0.7

Total

141

100.0

All the women studied engaged in intravaginal practices. In the Table are listed the methods they use and the reasons for their practices. Predominantly most of the participants use either water only or water with soap for the purpose of maintaining vaginal hygiene

To determine if there exists any correlation and the extent of the relationship between the various intravaginal practices and lactobacilli presence, a Pearson correlation analysis performed showed a strong significant negative correlation (r = −0.954, p < 0.05) between use of Herbs/concoction and vaginal lactobacilli colonization; followed by use of commercial products, also with a strong negative relationship (r = − 0.700, p < 0.05) with Lactobacilli occurrence. The analysis showed douching as being the least negatively correlated practice (r = −0.601, p > 0.05).

Discussion

This study recorded some intravaginal practices among the women studied in Accra. The commonest method practiced is vaginal washing with water only or water with soap. Besides the commonest form of the practice observed, the use of other methods such as insertion and wiping with hands and objects, use of locally prepared concoctions and certain commercial products among others were also found to be practiced. The results of the association tests by the Pearson correlation analysis indicate statistically significant adverse relationship between some of the practices, especially locally prepared and some commercial products, and vaginal flora status. This study did not undertake to confirm vaginal infections and establish causality between infections and intravaginal practice. A case–control study over a period of time is needed in future to describe the effects of various intravaginal practices on vaginal health in Ghanaian women.

Considering the age groups of persons who indicated they indulge in intravaginal practices, the types of practice and the reasons given for each practice, the findings of this study are comparable to what have been described from previous studies in other populations. Of importance is the fact that most of the reports on vaginal practices are from areas of high HIV prevalence [30, 31, 3537] and where heterosexual means accounts for the highest mode of HIV transmission [3840]. This underscores the need for further studies into intravaginal practices in Ghana to determine association with sexually transmitted infections and inform health education.

The results of this study were interpreted and presented in the context of several limitations: data were not obtained on routine physical and pelvic examinations of women; STIs were not diagnosed and confirmed by laboratory analysis; and species level identification of lactobacilli culture isolates was not performed and so we did not attempt to correlate culture results with intravaginal practices. In addition, all the women studied indicated they engaged in intravaginal practices and thus a comparison could not be made about lactobacilli colonization between women reporting and those not reporting intravaginal practices. The study mainly presents data on occurrence of vaginal practices among women in the study site population and documents the level of colonization of lactobacilli as normal vaginal flora of women who engage in intra-vaginal practices.

Conclusions

Various forms of intravaginal practices were engaged in by the women studied; and colonization by lactobacilli, a normal vaginal flora, among the studied women was found to be generally low. The practices were engaged in for the purposes of achieving vaginal hygiene and sexual comfort among others. In Ghana, the vaginal health implications of intravaginal practices have not been well studied and documented. This study therefore concludes that there is evidence of intravaginal practices being performed by some women in Accra and hence there is the need for further, more elaborate study to document the prevalence of intravaginal practices and clarify associations between various intravaginal practices and vaginal health in Ghanaian women.

Notes

Declarations

Acknowledgements

We wish to thank all who participated directly or indirectly in this research. The study population was drawn from women attending clinic at the Department of Obstetrics and Gynaecology of the Korle-Bu Teaching Hospital, Accra. We specially acknowledge Madam Peggy, the Matron of the Department for her role in sample collection in the emergency room of the Obstetrics and Gynaecology Department. We also acknowledge Dr. T.K Adiku, Ag. Head of Central Laboratory Korle-Bu Teaching Hospital for providing access to the laboratory facility. Finally we thank Mrs. Rachael Mills and the staff in the Microbiology Unit of the Central Laboratory of the Korle-Bu Teaching Hospital, Accra, for their technical support. The work was supported with seed grant from the University of Ghana Office of Research, Innovation and Development (ORID).

Authors’ Affiliations

(1)
Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana

References

  1. Todar K: The Bacterial Flora of Humans. Todar’s Online Textbook of Bacteriology; 2008. Available: http://textbookofbacteriology.net/normalflora.html. Accessed 2 June 2015.
  2. Liliana MP, Marı´a BD, Cristina P, Lucila BT. Lactobacillus species isolated from the vagina: identification, hydrogen peroxide production and nonoxynol-9 resistance. Contraception. 2006;73:78–81.View ArticleGoogle Scholar
  3. Antonio MA, Hawes SE, Hillier SL. The identification of vaginal Lactobacillus species and the demographic and microbiologic characteristics of women colonized by these species. J Infect Dis. 1999;180:1950–6.View ArticlePubMedGoogle Scholar
  4. Vasquez A, Jakobsson T, Ahrne S, Forsum U, Molin G. Vaginal lactobacillus flora of healthy Swedish women. J Clin Microbiol. 2002;40:2746–9.View ArticlePubMedPubMed CentralGoogle Scholar
  5. Fredricks DN, Fiedler TL, Marrazzo JM. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 2005;353:1899–911.View ArticlePubMedGoogle Scholar
  6. Spear GT, Gilbert D, Landay AL, Zariffard R, French AL, Patel P, et al. Pyrosequencing of the Genital Microbiotas of HIV-Seropositive and HIV-Seronegative Women Reveals Lactobacillus iners as the Predominant Lactobacillus species. Appl Environ Microbiol. 2011;77:378–81.View ArticlePubMedGoogle Scholar
  7. Jakobsson T, Forsum U. Lactobacillus iners: a marker of changes in the vaginal flora? J Clin Microbiol. 2007;45:3145.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Boris S, Barbés C. Role played by lactobacilli in controlling the population of vaginal pathogens. Microbes Infect. 2000;2:543–6.View ArticlePubMedGoogle Scholar
  9. Hilber AM, Hull TH, Preston-Whyte E, Bagnol B, Smit J, Wacharasin C, et al. A cross cultural study of vaginal practices and sexuality: implications for sexual health. Soc Sci Med. 2010;70:392–400.View ArticleGoogle Scholar
  10. Reid G. Lactobacillus in the Vagina: Why, How, Which Ones and What Do They Do? In Lactobacillus Molecular Microbiology: From Genomics to Probiotics. Edited by: Ljungh A, Wadström T. Norfolk: Caister Academic Press; 2009.Google Scholar
  11. Sobel JD. Bacterial vaginosis. Annu Rev Med. 2000;51:349–56.View ArticlePubMedGoogle Scholar
  12. Martin HL, Richardson BA, Nyange PM, Lavreys L, Hillier SL, Chohan B, et al. Vaginal lactobacilli, microbial flora, and risk of human immunodeficiency virus type 1 and sexually transmitted disease acquisition. JInfect Dis. 1999;180:1863–8.View ArticleGoogle Scholar
  13. Wiesenfeld HC, Hillier SL, Krohn MA, Landers DV, Sweet RL. Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae and Chlamydia trachomatis infection. Clin Infect Dis. 2003;36:663–8.View ArticlePubMedGoogle Scholar
  14. Torok MR, Miller WC, Hobbs MM, Macdonald PD, Leone PA, Schwebke JR, et al. The association between Trichomonas vaginalis infection and level of vaginal lactobacilli in non-pregnant women. J Infect Dis. 2007;196:1102–7.View ArticlePubMedGoogle Scholar
  15. McLean NW, Rosenstein IJ. Characterisation and selection of Lactobacillus species to recolonise the vagina of women with recurrent bacterial vaginosis. J Med Microbiol. 2000;49:543–52.View ArticlePubMedGoogle Scholar
  16. Hay P. Life in the littoral zone: lactobacilli losing the plot. Sex Transm Infect. 2005;81:100–2.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Pavlova SI, Kilic AO, Kilic SS, So JS, Nader-Macias ME, Simoes JA, et al. Genetic diversity of vaginal lactobacilli from women in different countries based on 16S rRNA gene sequences. J Appl Microbiol. 2002;92:451–9.View ArticlePubMedGoogle Scholar
  18. Zhou X, Brown CJ, Abdo Z, Davis CC, Hansmann MA, Joyce P, et al. Differences in the composition of vaginal microbial communities found in healthy Caucasian and black women. ISME J. 2007;1:121–33.View ArticlePubMedGoogle Scholar
  19. Vera DM, Slobodanka VD, Nataša ZO, Milan KD, Lazar TR. Hydrogen peroxide producing lactobacilli in women with vaginal infections. Europ J Obst Gyn Rep Biol. 2006;129:69–76.View ArticleGoogle Scholar
  20. Hillier SL, Krohn MA, Rabe LK, Klebanoff SJ, Eschenbach DA. The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women. Clin Infect Dis. 1993;16:273–81.View ArticleGoogle Scholar
  21. Hawes SE, Hillier SL, Benedetti J, Stevens CE, Koutsky LA, Welncr-Hanssen P, et al. Hydrogen Peroxide-Producing Lactobacilli and Acquisition of Vaginal Infections. J Infect Dis. 1996;174:1058–63.View ArticlePubMedGoogle Scholar
  22. Verstraelen H, Verhelst R, Claeys G, De Backer E, Temmerman M, Vaneechoutte M. Longitudinal analysis of the vaginal microflora in pregnancy suggests that L. crispatus promotes the stability of the normal vaginal microflora and that L. gasseri and/or L. iners are more conducive to the occurrence of abnormal vaginal microflora. BMC Microbiol. 2009;9:116.View ArticlePubMedPubMed CentralGoogle Scholar
  23. Zhou X, Brown CJ, Abdo Z, Davis CC, Hansmann MA, Joyce P, et al. Differences in the composition of vaginal microbial communities found in healthy Caucasian and black women. ISME J. 2007;1:121–33.View ArticlePubMedGoogle Scholar
  24. Vallor AC, Antonio MA, Hawes SE, Hillier SL. Factors associated with acquisition of persistent colonization by vaginal lactobacilli: Role of hydrogen peroxide production. J Infect Dis. 2001;184:1431–6.View ArticlePubMedGoogle Scholar
  25. Aroutcheva A, Gariti D, Simon M, Shott S, Faro J, Simoes JA, et al. Defense factors of vaginal lactobacilli. Am J Obstet Gynecol. 2001;185:375–9.View ArticlePubMedGoogle Scholar
  26. Taha TE, Hoover DR, Dallabetta GA, Kumwenda NI, Mtimavalye LA, Yang LP, et al. Bacterial vaginosis and disturbances of vaginal flora: association with increased acquisition of HIV. AIDS. 1998;12:1699–706.View ArticlePubMedGoogle Scholar
  27. Low N, Chersich MF, Schmidlin K, Egger M, Francis SC, van de Wijgert JHHM, et al. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med. 2011;8:e1000416.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Hull T, Hilber AM, Chersich MF, Bagnol B, Prohmmo A, Smit JA, et al. Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: findings from a multicountry household survey. J Womens Health (Larchmt). 2011;20:1097–109.View ArticleGoogle Scholar
  29. Brown JE, Brown RC. Traditional intravaginal practices and the heterosexual transmission of disease: a review. Sex Transm Dis. 2000;27:183–7.View ArticlePubMedGoogle Scholar
  30. Van de Wijgert JH, Mason PR, Gwanzura l, Mbizvo MT, Chirenje ZM, Iliff V, et al. Intravaginal practices, vaginal flora disturbances, and acquisition of sexually transmitted diseases in Zimbabwean women. J Infect Dis. 2000;181:587–94.View ArticleGoogle Scholar
  31. Imade G, Sagay A, Egah D, Onwuliri V, Grigg M, Egbodo C, et al. Prevalence of HIV and other sexually transmissible infections in relation to lemon or lime juice douching among female sex workers in Jos, Nigeria. Sexual Health. 2008;5:55–60.View ArticlePubMedGoogle Scholar
  32. Van de Wijgert JH, Mbizvo M, Dube S, Mwale M, Nyamapfeni P, Padian N. Intravaginal Practices In Zimbabwe: which women engage in them and why? Cult Health Sex. 2001;3:133–48.View ArticleGoogle Scholar
  33. Scorgie F, Kunene B, Smit JA, Manzini NF, Chersich M, Preston-Whyte EM. In search of sexual pleasure and fidelity: vaginal practices in KwaZulu-Natal, South Africa”. Cult Health Sex. 2009;11:267–83.View ArticlePubMedGoogle Scholar
  34. Cheesbrough M. District Laboratory Practice in Tropical Countries. 2nd ed. UK: Cambridge University press; 2006.View ArticleGoogle Scholar
  35. Zhang J, Thomas AG, Leybovich E. Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health. 1997;87:1207–11.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Myer L, Denny L, De Souza M, Barone MA, Wright Jr TC, Kuhn L. Intravaginal practices, HIV and other sexually transmitted diseases among South African women. Sex Trans Dis. 2004;31:174–9.View ArticleGoogle Scholar
  37. Anderson RM , May RM , Boily MC. , Garnett GP , Rowley JT, May RM: The spread of HIV-1 in Africa: sexual contact patterns and the predicted demographic impact of AIDS. Nature 1991;352:581–589.Google Scholar
  38. Hilber AM, Francis SC, Chersich M, Scott P, Redmond S, Bender N, et al. Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis. PLoS ONE. 2010;5:e9119.View ArticlePubMedPubMed CentralGoogle Scholar
  39. Fethers KA, Fairley CK, Hocking JS, Gurrin LC, Bradshaw CS. Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis. Clin Infect Dis. 2008;47:1426–35.View ArticlePubMedGoogle Scholar
  40. Mbizvo ME, Musya SE, Stray-Pedersen B, Chirenje Z, Hussain A. Bacterial vaginosis and intravaginal practices: association with HIV. Cent Afr J Med. 2004;50:41–6.PubMedGoogle Scholar

Copyright

© McCarthy et al. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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