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Female Genital Cutting and HIV Transmission: Is There an Association?

American Journal of Reproductive Immunology. Article first published online: 13 OCT 2012. DOI: 10.1111/aji.12028

Female Genital Cutting and HIV Transmission: Is There an Association?

Diouf K, Nour N

ABSTRACT

Female Genital Cutting (FGC) refers to the practice of surgically removing all or part of the female external genitalia for non-medical purposes. It is a common practice in many countries in Africa, the Middle East, and to a lesser extent, Asia. Over 130 million women worldwide have undergone this procedure, and over 2 million women and girls are subject to it every year. Various complications have been described, including infection, hemorrhage, genitourinary and obstetric complications, as well as psychological sequelae. Since the beginning of the HIV epidemic, a few reports have also described a potentially elevated risk of HIV transmission among women with FGC. In this report, we aim to review the evidence and identify unanswered questions and research gaps regarding a potential association between FGC and HIV transmission.

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Immunobiology of Genital Tract Trauma: Endocrine Regulation of HIV Acquisition in Women Following Sexual Assault or Genital Tract Mutilation

American Journal of Reproductive Immunology. Article first published online: 4 OCT 2012

Immunobiology of Genital Tract Trauma: Endocrine Regulation of HIV Acquisition in Women Following Sexual Assault or Genital Tract Mutilation

Ghosh M, Rodriguez-Garcia M, Wira CR

ABSTRACT

Studies on HIV acquisition and transmission in women exposed to sexual trauma throughout their life cycle are lacking, but some findings suggest that rates of HIV acquisition through coercive sex are significantly higher than that seen in consensual sex. Sexual trauma can also occur as a result of female genital mutilation, which makes sex extremely painful and can cause increased abrasions, lacerations, and inflammation, which enhances the risk of HIV acquisition. This review presents an overview of the immune system in the human female reproductive tract (FRT) from adolescence, through puberty to pregnancy and menopause. What is clear is that the foundation of information on immune protection in the FRT throughout the life cycle of women is extremely limited and at some stages such as adolescence and menopause are grossly lacking. Against this backdrop, forced or coercive sexual intercourse as well as genital mutilation further complicates our understanding of the biological risk factors that can result in transmission of HIV and other sexually transmitted infections.

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Are there “stages of change” in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia.

Afr J Reprod Health. 2006 Aug;10(2):57-71.

Are there “stages of change” in the practice of female genital cutting?: Qualitative research findings from Senegal and The Gambia.

Shell-Duncan B, Herniund Y.

Department of Anthropology, University of Washington, Box 353100 Seattle, WA 98195-3100, USA. bsd@u.washington.edu

ABSTRACT

In recent years there has been growing interest in developing theoretical models for understanding behaviour change with respect to the practice of female genital cutting (FGC). Drawing on extensive qualitative data collected in Senegal and The Gambia, the research reported here explores whether and how theoretical models of stages of behaviour change can be applied to FGC. Our findings suggest that individual readiness to change the practice of FGC is most dearly seen as operating along a continuum, and that broad stages of change characterise regions or segments of this continuum. Stages identified by previous researchers for other “problems behaviours” such as smoking inadequately describe readiness to change FGC since this decision is often a collective rather than individual one. The data reveal that the concept of stage of change is a complex construct that simultaneously captures behaviour, motivation, and features of the environment in which the decision is being made. Consequently stages identified in this research reflect the multidimensional nature of readiness to change the practice of FGC. Limitations of stage of change models as applied to FGC include the fact that they do not capture important aspects of the dynamics of negotiation between decision-makers, and do not reflect the shifting nature of opinions of individuals or the constellation of decision-makers. Nonetheless, we suggest the application of stage of change theory may provide a useful means of describing readiness for change of individual decisions-makers and at an aggregate level, patterns of readiness for change in a community. How this construct can be employed in quantitative population research requires further investigation.

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Female genital cutting in Kilimanjaro, Tanzania: changing attitudes?

Trop Med Int Health. 2002 FEB; 7 (2): 159-165

Female genital cutting in Kilimanjaro, Tanzania: changing attitudes?

Msuya SE, Mbizvo E, Hussain A, Sundby J, Sam NE, Stray-Pedersen B

ABSTRACT

OBJECTIVES  To study the prevalence, type, social correlates and attitudes towards female genital cutting (FGC) among urban women in Kilimanjaro, Tanzania; and to examine the association between FGC and gynaecological problems, reproductive tract infections (RTIs) and HIV.

METHODS  In 1999, 379 women attending reproductive health care clinics were interviewed and underwent pelvic examination. Specimens for RTI/HIV diagnosis were taken.

RESULTS  Seventeen per cent had undergone FGC, mostly clitoridectomy (97%). Female genital cutting prevalence was significantly lower among educated, Christian and Chagga women. Women aged ≥35 were twice as likely to be cut as those < 25 years. Seventy-six per cent of those who had undergone FGC intend not to perform the procedure on their daughters. Age < 25 years (P < 0.0001) and low parity (P < 0.01) were predictors of that intention. There was no association between RTIs, HIV or hepatitis B and FGC.

CONCLUSION  FGC is still fairly common but there is evidence of a change of attitude towards the practice, especially among young women. The opportunity to educate women who attend reproductive health care facilities on FGC should be taken.

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Knowledge and attitudes about reproductive health and HIV/AIDS among family planning clients

Eastern Mediterranean Health Journal. 1996; 2 (3): 459-469.

Knowledge and attitudes about reproductive health and HIV/AIDS among family planning clients

Megeid AA, El Sheikh S, El Ginedy M, Mohammed M.

ABSTRACT

The knowledge of and attitudes towards reproductive health, and in particular STDs and AIDS, were assessed in 4000 women attending primary health care/family planning facilities in Alexandria, Egypt. In all, 66% did not know the significance of the term reproductive health and 50% considered female circumcision necessary. Of the 69% of women using contraceptives, 93% were using interuterine devices. The majority knew about AIDS but did not know that the use of condoms can prevent transmission of STDs, including HIV. A comprehensive programme should be initiated to increase public awareness of the issues of reproductive health.

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Self-reported and observed female genital cutting in rural Tanzania: associated demographic factors, HIV and sexually transmitted infections.

Trop Med Int Health. 2005 Jan;10(1):105-15.

Self-reported and observed female genital cutting in rural Tanzania: associated demographic factors, HIV and sexually transmitted infections.

Klouman E, Manongi R, Klepp KI.

Department of General Practice and Community Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. elise.klouman@medisin.uio.no

OBJECTIVES: To determine (i) the prevalence and type of female genital cutting (FGC) in a rural multi-ethnic village in Tanzania, (ii) its associated demographic factors, (iii) its possible associations with HIV, sexually transmitted infections (STIs) and infertility and (iv) to assess the consistency between self-reported and clinically observed FGC.

METHOD: The study was part of a larger community-based, cross-sectional survey with an eligible female population of 1993. All were human immunodeficiency virus (HIV)-tested and asked whether they were circumcised (n = 1678; 84.2%). Participants aged 15-44 years were interviewed (n = 636; 79.7%), and 399 (50.0%) were gynaecologically examined to screen for STIs and determine the FGC status.

RESULTS: At a mean age of 9.6 years, 45.2% reported being circumcised. In the age-group 15-44 years, 65.5% reported being cut, while FGC was observed in 72.5% and categorized as clitoridectomy or excision. The strongest predictors of FGC were ethnicity and religion, i.e. being a Protestant or a Muslim. FGC was not associated with HIV infection, other STIs or infertility. A positive, non-significant association between FGC and bacterial vaginosis was found with a crude odds ratio of 4.6. There was a significant decline of FGC over the last generation. An inconsistency between self-reported and clinically determined FGC status was observed in more than one-fifth of the women.

CONCLUSION: The data indicate that both women and clinicians might incorrectly report women’s circumcision status. This reveals methodological problems in determining women’s circumcision status in populations practising the most common type of FGC. The positive association between FGC and bacterial vaginosis warrants further investigation.

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Female genital cutting and HIV/AIDS among Kenyan women.

Stud Fam Plann. 2007 Jun;38(2):73-88.

Female genital cutting and HIV/AIDS among Kenyan women.

Yount KM, Abraham BK.

Department of Sociology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 724, Atlanta, GA 30322, USA. kyount@sph.emory.edu

ABSTRACT

Female genital cutting (FGC) and HIV/AIDS are both highly prevalent in sub-Saharan Africa, and researchers have speculated that the association may be more than coincidental. Data from 3167 women aged 15-49 who participated in the 2003 Kenya Demographic and Health Survey (KDHS) are used to test the direct and indirect associations of FGC with HIV. Our adjusted models suggest that FGC is not associated directly with HIV, but is associated indirectly through several pathways. Cut women are 1.72 times more likely than uncut women to have older partners, and women with older partners are 2.65 times more likely than women with younger partners to test positive for HIV Cut women have 1.94 times higher odds than uncut women of initiating sexual intercourse before they are 20, and women who experience their sexual debut before age 20 have 1.73 times higher odds than those whose sexual debut comes later of testing positive for HIV. Cut women have 27 percent lower odds of having at least one extra-union partner, and women with an extra-union partner have 2.63 times higher odds of testing positive for HIV. Therefore, in Kenya, FGC may be an early life-course event that indirectly alters women’s odds of becoming infected with HIV through protective and harmful practices in adulthood.

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Regarding “male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania”.

Ann Epidemiol. 2007 Nov;17(11):923-5; author reply 928-9. Epub 2007 Aug 28.

Regarding “male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania”.

Adams J, Trinitapoli J, Poulin M.

Letter / Comment on Ann Epidemiol. 2007 Mar;17(3):217-26. SEE

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Disentangling the complex association between female genital cutting and HIV among Kenyan women.

J Biosoc Sci. 2009 Nov;41(6):815-30. Epub 2009 Jul 16.

Disentangling the complex association between female genital cutting and HIV among Kenyan women.

Maslovskaya O, Brown JJ, Padmadas SS.

Division of Social Statistics, School of Social Sciences, University of Southampton, UK.

ABSTRACT

Female genital cutting (FGC) is a widespread cultural practice in Africa and the Middle East, with a number of potential adverse health consequences for women. It was hypothesized by Kun (1997) that FGC increases the risk of HIV transmission through a number of different mechanisms. Using the 2003 data from the Kenyan Demographic and Health Survey (KDHS), this study investigates the potential association between FGC and HIV. The 2003 KDHS provides a unique opportunity to link the HIV test results with a large number of demographic, social, economic and behavioural characteristics of women, including women’s FGC status. It is hypothesized that FGC increases the risk of HIV infection if HIV/AIDS is present in the community. A multilevel binary logistic regression technique is used to model the HIV status of women, controlling for selected individual characteristics of women and interaction effects. The results demonstrate evidence of a statistically significant association between FGC and HIV, after controlling for the hierarchical structure of the data, potential confounding factors and interaction effects. The results show that women who had had FGC and a younger or the same-age first-union partner have higher odds of being HIV positive than women with a younger or same-age first-union partner but without FGC; whereas women who had had FGC and an older first-union partner have lower odds of being HIV positive than women with an older first-union partner but without FGC. The findings suggest the behavioural pathway of association between FGC and HIV as well as an underlying complex interplay of bio-behavioural and social variables being important in disentangling the association between FGC and HIV.

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Intravaginal practices, bacterial vaginosis, and women’s susceptibility to HIV infection: epidemiological evidence and biological mechanisms.

Lancet Infect Dis. 2005 Dec;5(12):786-94.

Intravaginal practices, bacterial vaginosis, and women’s susceptibility to HIV infection: epidemiological evidence and biological mechanisms.

Myer L, Kuhn L, Stein ZA, Wright TC Jr, Denny L

Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. lmyer@cormack.uct.ac.za

ABSTRACT

Intravaginal practices such as “dry sex” and douching have been suggested as a risk factor that may increase women’s susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women’s intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women’s susceptibility to HIV infection. Further research into factors that increase women’s susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

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