Investigating the impact of using intravaginal products on cervical lesions, genital inflammation, and curable sexually transmitted infections/ genital infections in adolescent girls and young women in KwaZulu-Natal.

Abstract

Background: Vaginally inserted products (VIPs) are used to cleanse, enhance sexual pleasure or modify the female genital tract to a desired state by young South African adolescent girls and young women (AGYW), in regions of the country that practice “dry sex”. This study hypothesized that sexual immaturity in adolescent females in conjunction with VIP use would exacerbate injury to the cervicovaginal mucosa and increase vaginal inflammatory responses, which may influence the risk of acquiring human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Methods: Sexually active and HIV-uninfected cisgender adolescent girls (n=188, 14-19-years old) and adult women (n=64, 25-35 years old) were enrolled in an HIV endemic rural Vulindlela area, in KwaZulu-Natal (KZN), South Africa. A detailed questionnaire was used to collect demographic, sexual behaviour, and vaginal practices data. Cervical ectopy and other cervical abnormalities were identified by colposcopy. Luminex assay was used to measure the concentrations of various inflammatory cytokines from cervicovaginal secretions. Human papillomavirus (HPV) genotyping was done using a DNA Flow hybridization system. Participants were also tested for the presence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), bacterial vaginosis (BV), yeast and fungal hyphae. Results: This study found that adult women were more likely to be involved in risky sexual behaviour compared to adolescents, although the prevalence of STIs was higher in adolescents compared to adults, particularly CT (p<0.001). Colposcopic observations showed that adults were more likely to have signs of cervical injury and trauma compared to adolescents (p<0.0001), and significantly higher cervicovaginal concentrations of interleukin (IL-)8 (p<0.0001), granulocyte-colony stimulating factor (G-CSF) (p<0.0001) and IL-10 (p<0.0001) compared to adolescents. However, tumour necrosis factor alpha (TNF-) concentrations were significantly higher in adolescents compared to adults (p<0.0001). The use of vagina stimulating products was common in this cohort, with adolescents reporting a wider range than adults. These products were either traditionally made or available commercially, taken orally, or applied internally or externally in the vagina. According to the adolescents and women, the products were used for different reasons and the preferences by age group were different: Adolescents most commonly used alum (a combination of aluminum sulphate and potassium sulphate) while adults most commonly used “ibhodwe labafazi” (translated from Zulu to mean “ladies pot”; a commercially available scented petroleum jelly with unknown ingredients). Adolescents who used alum were likely to have injury signs compared to adolescents who did not use any products (p=0.002). In addition, adult women who used “ibhodwe labafazi” were 20 times more likely to have cervical ectopy compared to adult nonusers (p=0.004). Among adolescents, the users of “ibhodwe labafazi” had significantly elevated cytokine concentrations, remarkably so for IL-1α (p=0.0223), vascular endothelial growth factor (VEGF) (p=0.0198) and IL-17 (p=0.0150) compared to nonusers. However, in adults, there were no remarkable changes in genital tract cytokine concentrations in users compared to nonusers. However, the use of the products did not appear to have a direct link with the prevalence of infections. Conclusion: In adolescents, the use of alum and “ibhodwe labafazi” may cause injury and inflammation, respectively, which are known to increase the risk of HIV acquisition. In addition, in adult women, using “ibhodwe labafazi” were more likely to have ectopy, which is associated with STIs and HIV risk. These findings need to be confirmed by more extensive cohort studies and suggest that the use of some of the vaginal enhancing products may partly contribute to differences in biological risk profiles that influence HIV susceptibility.