1. 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)

2. 2 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?

3. 3 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

4. 4 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

5. 5 Overall HIV Prevalence21% HIV Prevalence by occupation – Food vendors11% – Restaurant / grocery workers17% – Bar, disco, local brew sellers33% – Guesthouse / hotel workers39% Results

6. 6 Description of reported IVP in the past 3 months

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10. 10 Description of reported IVP in the past 3 months

11. 11 Unadjusted associations between IVP and HIV IVP TypeHIV+/Total(%)OR (95% CI) Cleansing353/1,579 (22%)1.8 (1.2–2.7) - water only with fingers57/264 (22%)1.7(1.0-2.8) - water & soap with fingers252/1,107 (23%)1.8 (1.2-2.8) - cloth 25/143 (18%)1.3 (0.7-2.3) - cotton, paper, other15/47 (32%)2.8 (1.4-5.9) No cleansing27/192 (14%)1

12. 12 Unadjusted associations between IVP and HIV IVP TypeHIV+/Total(%)OR (95% CI) Cleansing353/1,579 (22%)1.8 (1.2–2.7) - < once daily6/43 (14.0%)1.0 (0.4-2.5) - x1 / day29/147 (19.7%)1.5 (0.8-2.6) - x2 / day 144/652 (22.1%)1.7 (1.1-2.7) - x3 / day125/530 (23.6%)1.9 (1.2-2.9) - +4 / day45/182 (24.7%)2.0 (1.2-3.4) No cleansing27/192 (14%)1 p-trend = 0.002

13. 13 Unadjusted associations between IVP and HIV IVP TypeHIV+/Total(%)OR (95% CI) Insertion73/276 (26.5%)1.3 (1.0–1.9) - Herbs27/102 (26.5%)1.3 (0.9-2.1) - Detergent24/93 (25.8%)1.3 (0.8-2.1) - Lemon 5/29 (17.2%)0.8 (0.3-2.0) - Gels26/93 (27.5%)1.4 (0.9-2.3) - Other8/31 (25.8%)1.3 (0.6-2.9) No insertion307/1,492 (20.6%)1

14. 14 Adjusted associations between IVP and HIV 14 IVP typeUnadjustedAdjusted* Insertion1.3 (1.0–1.9)1.3 (0.9-1.7) Cleansing1.8 (1.2–2.7)1.5 (1.0-2.3) - water only with fingers1.7(1.0-2.8)1.4 (0.8-2.3) - water & soap with fingers1.8 (1.2-2.8)1.5 (1.0-2.4) - cloth1.3 (0.7-2.3) - cotton, paper, other2.8 (1.4-5.9)2.7 (1.2-5.7) No cleansing11 *Age group, employment, and number of sex partners in the last three months as these were independently associated with prevalent HIV

15. 15 Adjusted associations between IVP and HIV 15 IVP typeUnadjustedAdjusted* Cleansing1.8 (1.2–2.7)1.5 (1.0-2.3) - < once daily1.0 (0.4-2.5)0.9 (0.3-2.3) - x1 / day1.5 (0.8-2.6)1.2 (0.7-2.2) - x2 / day1.7 (1.1-2.7)1.5 (0.9-2.3) - x3 / day1.9 (1.2-2.9)1.7 (1.1-2.7) - +4 / day2.0 (1.2-3.4)1.7 (1.0-2.3) No cleansing11 *Age group, employment, and number of sex partners in the last three months. Adjusted p-trend = 0.006

16. 16 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

17. 17 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

18. 18 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

19. 19 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

21. 21 What are intravaginal practices? The WHO Gender, Sexuality and Vaginal Practices Study classification system for vaginal practices: 1. External washing 2. External application 3. Anatomical modification (‘‘cutting’’ and ‘‘pulling’’) 4. Intravaginal cleansing(‘‘washing’’) 5. Intravaginal insertion 6. Oral ingestion

22. 22 North-West Tanzania

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