Vaginal probiotic adherence and acceptability in Rwandan women with high sexual risk participating in a pilot randomised controlled trial: a mixed-methods approach
Marijn C Verwijs, Stephen Agaba, Marie Michele Umulisa, Mireille Uwineza, Adrien Nivoliez, Elke Lievens, Janneke H H M van de Wijgert, Marijn C Verwijs, Stephen Agaba, Marie Michele Umulisa, Mireille Uwineza, Adrien Nivoliez, Elke Lievens, Janneke H H M van de Wijgert
Abstract
Objectives: To evaluate adherence and acceptability of intermittent vaginal probiotic or antibiotic use to prevent bacterial vaginosis (BV) recurrence.
Design: Repeated adherence and acceptability assessments using mixed methods within a pilot randomised controlled trial.
Setting: Research clinic in Kigali, Rwanda.
Participants: Rwandan women with high sexual risk.
Interventions: Women diagnosed with BV and/or trichomoniasis were randomised to four groups (n=17 each) after completing metronidazole treatment: behavioural counselling only, or behavioural counselling plus 2-month intermittent use of oral metronidazole, Ecologic Femi+ (EF+) vaginal capsule or Gynophilus LP (GynLP) vaginal tablet.
Outcome measures: Adherence and acceptability were assessed by structured face-to-face interviews, semi-structured focus group discussions and in-depth interviews, daily diaries and counting of used/unused study products in randomised women (n=68). Vaginal infection knowledge was assessed by structured face-to-face interviews in randomised women and women attending recruitment sessions (n=131).
Results: Most women (93%) were sex workers, 99.2% were unfamiliar with BV and none had ever used probiotics. All probiotic users (n=32) reported that insertion became easier over time. Triangulated adherence data showed that 17/17 EF+ users and 13/16 GynLP users used ≥80% of required doses (Fisher's exact p=0.103). Younger age (p=0.076), asking many questions at enrolment (p=0.116), having menses (p=0.104) and reporting urogenital symptoms (p=0.103) were non-significantly associated with lower perfect adherence. Women believed that the probiotics reduced BV recurrence, but reported that partners were sometimes unsupportive of study participation. Self-reported vaginal washing practices decreased during follow-up, but sexual risk behaviours did not. Most women (12/15) with an uncircumcised steady partner discussed penile hygiene with him, but many women found this difficult, especially with male clients.
Conclusions: High-risk women require education about vaginal infections. Vaginal probiotic acceptability and adherence were high in this cohort. Our results can be used to inform future product development and to fine-tune counselling messages in prevention programmes.
Trial registration number: NCT02459665.
Keywords: Africa; acceptability; adherence; bacterial vaginosis; vaginal probiotic.
Conflict of interest statement
Competing interests: AN is employed by Biose (owner of trial product GynLP) and EL by Winclove Probiotics BV (owner of trial product EF+). AN has financial and/or intellectual investments in competing products.
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.
Figures
References
- van de Wijgert JHHM, Borgdorff H, Verhelst R, et al. . The vaginal microbiota: what have we learned after a decade of molecular characterization? PLoS One 2014;9:e105998. 10.1371/journal.pone.0105998
- van de Wijgert JHHM, Morrison CS, Cornelisse PGA, et al. . Bacterial vaginosis and vaginal yeast, but not vaginal cleansing, increase HIV-1 acquisition in African women. J Acquir Immune Defic Syndr 2008;48:203–10. 10.1097/QAI.0b013e3181743936
- van de Wijgert JHHM. The vaginal microbiome and sexually transmitted infections are interlinked: consequences for treatment and prevention. PLoS Med 2017;14:e1002478. 10.1371/journal.pmed.1002478
- Li J, McCormick J, Bocking A, et al. . Importance of vaginal microbes in reproductive health. Reprod Sci 2012;19:235–42. 10.1177/1933719111418379
- Nelson DB, Hanlon AL, Wu G, et al. . First trimester levels of BV-associated bacteria and risk of miscarriage among women early in pregnancy. Matern Child Health J 2015;19:2682–7. 10.1007/s10995-015-1790-2
- Hay P. Recurrent bacterial vaginosis. Curr Opin Infect Dis 2009;22:82–6. 10.1097/QCO.0b013e32832180c6
- Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. Expert Rev Anti Infect Ther 2009;7:1109–24. 10.1586/eri.09.87
- Torrone EA, Morrison CS, Chen P-L, et al. . Prevalence of sexually transmitted infections and bacterial vaginosis among women in sub-Saharan Africa: an individual participant data meta-analysis of 18 HIV prevention studies. PLoS Med 2018;15:e1002511. 10.1371/journal.pmed.1002511
- Bradshaw CS, Brotman RM. Making inroads into improving treatment of bacterial vaginosis—striving for long-term cure. BMC Infect Dis 2015;15:292. 10.1186/s12879-015-1027-4
- Anukam KC, Osazuwa E, Osemene GI, et al. . Clinical study comparing probiotic Lactobacillus GR-1 and RC-14 with metronidazole vaginal gel to treat symptomatic bacterial vaginosis. Microbes Infect 2006;8:2772–6. 10.1016/j.micinf.2006.08.008
- Ling Z, Liu X, Chen W, et al. . The restoration of the vaginal microbiota after treatment for bacterial vaginosis with metronidazole or probiotics. Microb Ecol 2013;65:773–80. 10.1007/s00248-012-0154-3
- Ngugi BM, Hemmerling A, Bukusi EA, et al. . Effects of bacterial vaginosis-associated bacteria and sexual intercourse on vaginal colonization with the probiotic Lactobacillus crispatus CTV-05. Sex Transm Dis 2011;38:1020–7. 10.1097/OLQ.0b013e3182267ac4
- Bradshaw CS, Pirotta M, De Guingand D, et al. . Efficacy of oral metronidazole with vaginal clindamycin or vaginal probiotic for bacterial vaginosis: randomised placebo-controlled double-blind trial. PLoS One 2012;7:e34540. 10.1371/journal.pone.0034540
- van der Straten A, Montgomery ET, Cheng H, et al. . High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women. AIDS Behav 2012;16:1775–86. 10.1007/s10461-012-0215-0
- Merkatz RB, Plagianos M, Hoskin E, et al. . Acceptability of the Nestorone®/ethinyl estradiol contraceptive vaginal ring: development of a model; implications for introduction. Contraception 2014;90:514–21. 10.1016/j.contraception.2014.05.015
- Liu CM, Hungate BA, Tobian AAR, et al. . Penile microbiota and female partner bacterial vaginosis in Rakai, Uganda. mBio 2015;6:e00589. 10.1128/mBio.00589-15
- van de Wijgert JHHM, Verwijs MC, Agaba SK, et al. . Intermittent Lactobacilli-containing vaginal probiotic or metronidazole use to prevent bacterial vaginosis recurrence: a pilot study incorporating microscopy and sequencing. Sci Rep 2020;10:3884. 10.1038/s41598-020-60671-6
- Sobel JD, Ferris D, Schwebke J, et al. . Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J Obstet Gynecol 2006;194:1283–9. 10.1016/j.ajog.2005.11.041
- McClelland RS, Richardson BA, Hassan WM, et al. . Improvement of vaginal health for Kenyan women at risk for acquisition of human immunodeficiency virus type 1: results of a randomized trial. J Infect Dis 2008;197:1361–8. 10.1086/587490
- Kestelyn E, Van Nuil JI, Umulisa MM, et al. . High acceptability of a contraceptive vaginal ring among women in Kigali, Rwanda. PLoS One 2018;13:e0199096. 10.1371/journal.pone.0199096
- World Health Organization Guidelines for the management of sexually transmitted infections, 2003. Available: [Accessed 12 Mar 2019].
- Binagwaho A. National guidelines for prevention and management of HIV, STIs & other blood borne infections. Republic of Rwanda—Ministry of Health, 2013. Available: [Accessed 12 Mar 2019].
- McClelland RS, Balkus JE, Lee J, et al. . Randomized trial of periodic presumptive treatment with high-dose intravaginal metronidazole and miconazole to prevent vaginal infections in HIV-negative women. J Infect Dis 2015;211:1875–82. 10.1093/infdis/jiu818
- Veldhuijzen N, Nyinawabega J, Umulisa M, et al. . Preparing for microbicide trials in Rwanda: focus group discussions with Rwandan women and men. Cult Health Sex 2006;8:395–406. 10.1080/13691050600859302
- Low N, Chersich MF, Schmidlin K, et al. . Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. PLoS Med 2011;8:e1000416. 10.1371/journal.pmed.1000416
- Dausset C, Patrier S, Gajer P, et al. . Comparative phase I randomized open-label pilot clinical trial of Gynophilus® (Lcr regenerans®) immediate release capsules versus slow release muco-adhesive tablets. Eur J Clin Microbiol Infect Dis 2018;37:1869–80. 10.1007/s10096-018-3321-8
- Safren SA, Otto MW, Worth JL, et al. . Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring. Behav Res Ther 2001;39:1151–62. 10.1016/S0005-7967(00)00091-7
- van de Wijgert J, Verwijs MC. Lactobacilli-containing vaginal probiotics to cure or prevent bacterial or fungal vaginal dysbiosis: a systematic review and recommendations for future trial designs. BJOG 2020;127:287–99. 10.1111/1471-0528.15870
- Glick P, Sahn DE. Changes in HIV/AIDS knowledge and testing behavior in Africa: how much and for whom? J Popul Econ 2007;20:383–422. 10.1007/s00148-006-0085-8
- Peltzer K, Matseke G, Mzolo T, et al. . Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey. BMC Public Health 2009;9:174. 10.1186/1471-2458-9-174
- Fay H, Baral SD, Trapence G, et al. . Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana. AIDS Behav 2011;15:1088–97. 10.1007/s10461-010-9861-2
Source: PubMed