Up to a third of new female HIV infections could be prevented if scientists could find an effective cure for a mysterious vaginal condition that affects many women in South Africa.
Researchers from the University of Cape Town (UCT) have found that bacterial vaginosis, a change in the dominant bacteria that alters the acidity of the vagina, was ”significantly associated with an increased risk of HIV seroconversion”.
Dr Landon Myer, of the Infectious Diseases Epidemiology Unit in the School of Public Health and Family Medicine at UCT, says that more than half the 5 000 women taking part in the two-year study in Khayelitsha had bacterial vaginosis — and that these high levels could be a key driver of the spread of the HIV epidemic.
Bacterial vaginosis is such a common disorder that some argue it is actually one extreme of the spectrum of normal vaginal environment. Others say it is a pathogenic condition, but do not classify it as a sexually transmitted disease (STD) because it is not caused by a single pathogen, even though it may be spread by sex.
Myer says data from South Africa and the United States indicates that bacterial vaginosis is often correlated with lower socio-economic status, but the reasons and mechanisms behind this are still being unravelled. There are strong links with cleansing activities that affect the interior of the vagina, such as douching or washing internally with soap, or even just water.
Curing bacterial vaginosis requires overcoming three obstacles: getting women to seek healthcare for a problem they might not think they have, having healthcare workers who can diagnose the problem accurately, and finding a long-lasting treatment.
The extent of women’s ignorance about the health of ”down there” is very worrying, says Myer. ”Gynaecologists see women who have terrible vaginal discharge, and yet many women don’t know that it is supposed to be any other way. The study suggests that most women in Khayelitsha have an abnormal vaginal discharge; that’s astounding,” he said.
Some vaginal discharge is normal, but bacterial vaginosis and other infections or diseases commonly cause abnormal discharge.
Too often, women who do seek help are let down by health-care providers. High caseloads, lack of resources — such as microscopes — and lack of training can mean women are often not given an internal examination, but are rather treated on the basis of their answers to a series of questions.
Dr Michelle de Souza, of the School of Public Health and Family Medicine and Department of Obstetrics and Gynaecology at UCT, says she has encountered patients with histories of repeated treatment for vaginal discharge, and yet who have never been examined. In some cases, the women concerned had cervical cancer: easily picked up in an internal examination, easily cured if picked up in time, and lethal if left undiagnosed.
Often women only have gynaecological checkups when they attend an STD or antenatal clinic. In the state sector, South Africa treats sexually transmitted infections (STIs) syndromically — this assumes that if one infection is present, others may be as well, so the patient is given a cocktail of antibiotics as a precaution. This approach alleviates resource constraints because it can be difficult, time-consuming and expensive to identify particular infections, when the woman will in any case need to be treated immediately.
A syndromic approach is relatively easy and effective, especially given the high levels of STIs in South Africa. It allows the healthcare worker to assume the worst from a woman’s answers, to prescribe a cocktail of drugs, and to get on to the next patient. This approach does work with 90% of women, but does not help in cases of bacterial vaginosis, where giving a woman a cocktail of antibiotics can even further damage the vaginal environment.
Bacterial vaginosis can travel up the reproductive tract, and has been implicated in preterm births, infections of the umbilical cord in pregnant women and infections of the cervix and uterus. It can also make it harder to diagnose cervical cancer with a pap smear. The condition may also facilitate the spread of sexually transmitted diseases such as herpes, gonorrhoea or human papillovirus, which is a cause of cervical cancer. STIs are strongly linked with HIV infection, primarily because the open sores they can produce literally open the door for HIV to enter the body.
Traditionally, treatment for bacterial vaginosis has been to give an antibiotic, which rapidly kills the ”bad” bacteria. But the longer-term results have been dismal — of the women in the Khayelitsha study, roughly half had bacterial vaginosis again within six months of treatment.
Now researchers are looking for more effective, long-term treatments, such as pessaries containing ”good” lactobacilli for women to insert themselves. The old wives’ remedy of sitting in yoghurt has been disproved, says Myer. Yoghurt contains the wrong kind of lactobacilli for vaginal health.
Although the results from this Khayelitsha study are striking, Myer acknowledges that the study has limitations, and further research is on going. Not only may bacterial vaginosis be a significant factor in the HIV epidemic, but better understanding the problem and improved treatments will also have a significant impact on women’s reproductive health and overall quality of life.