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com
Sex Transm Inf 2001;77:271275

Original
article

271

Sexually transmitted infections and vaginal

douching in a population of female sex workers in
Nairobi, Kenya
K Fonck, R Kaul, F Keli, J J Bwayo, E N Ngugi, S Moses, M Temmerman

Objective: To assess the association between vaginal douching and sexually transmitted
infections (STI) among a group of female sex workers (FSWs) in Nairobi, Kenya.
Methods: This study was part of a randomised, placebo controlled trial of monthly prophylaxis
with 1 g of azithromycin to prevent STIs and HIV infection in a cohort of Nairobi FSWs. Consenting women were administered a questionnaire and screened for STIs.
Results: The seroprevalence of HIV-1 among 543 FSWs screened was 30%. HIV infection was
significantly associated with bacterial vaginosis (BV), trichomoniasis, gonorrhoea, and the presence of a genital ulcer. Regular douching was reported by 72% of the women, of whom the
majority inserted fluids in the vagina, generally after each sexual intercourse. Water with soap was
the fluid most often used (81%), followed by salty water (18%), water alone (9%), and a
commercial antiseptic (5%). Douching in general and douching with soap and water were significantly associated with bacterial vaginosis (p = 0.05 and p = 0.04 respectively). There was a significant trend for increased frequency of douching and higher prevalence of BV. There was no
direct relation observed between douching and risk for HIV infection or other STIs.
Conclusion: The widespread habit of douching among African female sex workers was
confirmed. The association between vaginal douching and BV is of concern, given the increased
risk of HIV infection with BV, which has now been shown in several studies. It is unclear why we
could not demonstrate a direct association between douching and HIV infection. Further
research is required to better understand the complex relation between douching, risk for bacterial vaginosis, and risk for HIV and other STIs.
(Sex Transm Inf 2001;77:271275)
International Centre
for Reproductive
Health, Department of
Obstetrics and
Gynaecology, Ghent
University, Ghent,
Belgium
K Fonck
M Temmerman
Department of
Medical Microbiology,
University of Nairobi,
Nairobi, Kenya
K Fonck
R Kaul
F Keli
J J Bwayo
Department of
Community Health,
University of Nairobi,
Nairobi, Kenya
E N Ngugi
Departments of
Medical Microbiology,
Community Health
Sciences and
Medicine, University
of Manitoba,
Winnipeg, Canada
S Moses
Correspondence to:
Professor Dr M
Temmerman, ICRH Ghent
University, De Pintelaan 185,
9000 Gent, Belgium
marleen.temmerman@
rug.ac.be
Accepted for publication
18 April 2000

Keywords: vaginal douching; sexually transmitted infections; female sex workers

Introduction
Heterosexual intercourse is the major route of
transmission of HIV in sub-Saharan Africa.
The role of ulcerative and non-ulcerative sexually transmitted infections (STIs) in facilitating
the transmission of HIV is well established.
However, the role of local genital tract factors
in HIV transmission is less clear.
There is some evidence that frequent
vaginal douching may increase womens susceptibility to sexually transmitted agents,
through modification of the vaginal flora. Several studies have suggested that vaginal
douching may increase risk for cervical
infections.14 Others have shown that douching
predisposes women to pelvic inflammatory
disease (PID),58 with a twofold increased risk
of PID associated with douching.6 8 Genital
tract infections such as cervicitis and PID
have, in turn, been identified as a risk factor for
HIV acquisition. Hence, vaginal douching
may indirectly have a facilitating role in the
heterosexual transmission of HIV. In addition,
vaginal douching has been reported to be
associated with reduced fertility.9 Finally,
douching has been suggested as a risk factor
for cervical cancer, although the evidence for
this has been inconsistent.10
The insertion of various substances into the
vagina is a common global practice. Intravaginal substances, largely through their astringent

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properties, are perceived to enhance sexual

pleasure in many areas of sub-Saharan Africa.
In Zimbabwe, 87% of clinic attendees and
nurses interviewed reported this habit.11 The
use of vaginal agents for the treatment of vaginal discharge was reported by 30% of women
in a study in the Central African Republic12 and
is also common in Malawi.13
This study was undertaken to assess the
association between vaginal douching and
sexually transmitted infections among a group
of female sex workers (FSWs) in Nairobi,
Kenya, as part of a large randomised trial of
monthly azithromycin prophylaxis to prevent
STIs and HIV infection in a cohort of Kenyan
sex workers. The study design and baseline and
preliminary findings have been published elsewhere.14 15
Methods
As part of a randomised, placebo controlled
trial of monthly prophylaxis with 1 g of
azithromycin to reduce the incidence of STIs
and HIV infection among female sex workers
in a Nairobi slum area, a structured questionnaire was administered to all women presenting for screening into the study. Written,
informed consent was obtained from all
women. The questionnaire gathered data
regarding vaginal douching, which was defined
as the insertion of any liquid into the vagina,

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272
Table 1

Fonck, Kaul, Keli, et al

Characteristics of HIV positive and HIV negative sex workers

Mean age (years)

Mean number of years lived in Nairobi
Marital status
Never married
Widowed/divorced/separated
Mean age at first sex (years)
Mean duration of prostitution (years)
Mean number of sex partners/day
Mean number of sex partners/week
Mean charge per act (Kenya shillings)
Condom use
Never
Sometimes
Always
Regular partner
Use of oral contraceptives
Sex during menses
Anal intercourse
Alcohol use
History of STIs
History of douching

HIV negative
(n = 373)

HIV positive
(n = 161)

30.4
10.6

30.9
9.9

50%
50%
16.3
6.1
3.9
13.9
118

46%
54%
15.6
6.2
4.0
19.1
93

34 %
47%
19 %
57 %
31 %
23 %
15 %
55 %
28 %
72 %

35 %
55%
10 %
47 %
31 %
26 %
16 %
66 %
27 %
73 %

OR
(95% CI)

p Value
0.4
0.4
0.2

0.9 (0.71.1)
0.005
0.8
0.5
0.08
0.02
1.9 (1.03.6)
2.1 (1.23.9)
1.0 (reference)
0. 8 (0.61.0)
1.0 (0.81.3)
1.1 (0.81.5)
1.1 (0.81.5)
0.7 (0.50.9)
1.0 (0.81.4)
1.0 (0.71.6)

0.04
0.01
NA
0.02
0.5
0.2
0.4
0.01
0.5
0.9

and also included data on demographics,

current sexual behaviour (client numbers,
condom use, and sex practices), and reproductive and medical histories over the past year. A
full physical examination, including speculum
examination and laboratory STI testing, was
performed at the screening visit. Data on the
first 543 women screened are presented here.
The study was approved by ethics review
committees of the University of Nairobi and
the University of Manitoba. A detailed description of the specimens taken and the laboratory tests performed has been published
elsewhere.14
Data were entered into a database in Microsoft ACCESS (OYce 97 format) and analysis
performed after export into SPSS for Windows,
version 8.0 (SPSS Inc, Chicago, IL, USA). In
univariate analysis, the odds ratios and 95%
confidence intervals were used for the
measurement of associations between proportions. Comparisons were made using Pearsons
2, Fishers exact test, and 2 test for trend.
Students t test was used for comparison of
means. Logistic regression models were developed to analyse risk factors for HIV and BV.
These models used input variables that were
associated with HIV or BV in univariate analysis in this cohort, or which have been reported
in other cohorts.
Results
Between May 1998 and August 1999, 543
female sex workers were screened. Three
women declined examination after interview
Table 2

STI prevalence among female sex workers by HIV serostatus*

Bacterial vaginosis
Candida
Trichomoniasis
Chlamydia
Gonorrhoea
Syphilis
Clinical ulcer
CIN

HIV negative

HIV positive

No (%)

No (%)

OR (95% CI)

p Value

138/303 (46)
28/303 (9)
43/369 (12)
30/327 (9)
30/370 (8)
23/369 (6)
2/373 (1)
4/373 (1)

73/129 (57)
11/130 (9)
41/156 (26)
11/124 (9)
22/156 (14)
8/159 (5)
5/161 (3)
5/161 (3)

1.5 (1.02.3)
0.9 (0.41.9)
2.7 (1.74.4)
1.0 (0.52.0)
1.9 (1.03.3)
0.8 (0.31.8)
6.0 (1.131.0)
3.0 (0.811.2)

0.05
0.9
<0.001
1.0
0.04
0.7
0.03
0.2

*Denominators diVer because of missing specimens.

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and were excluded. The mean age was 30 years

(SD 7.8 years). Overall, 161 women (30%)
were HIV-1 seropositive. The prevalence of
bacterial vaginosis was 49%, candidiasis 10%,
trichomoniasis 16%, gonorrhoea 10%, chlamydia 9%, syphilis 6%, clinical ulcer 1%, and CIN
2%. Only one woman presented with genital
warts.
Demographic characteristics, sexual behaviour, and medical history of HIV positive and
HIV negative women are compared in table 1.
There was no association between age, marital
status, duration of prostitution, number of
partners, and HIV serostatus. HIV positive
women had had their first sexual experience at
younger age than HIV negative women,
charged less per sexual act, used condoms less
often, were less likely to report a regular partner, and used alcohol more frequently. Use of
oral contraceptives, douching, sex during
menses, anal intercourse, and history of STIs
were not associated with HIV serostatus. On
multivariate analysis only age at first sex and
alcohol use remained significantly associated
with HIV seropositivity (p = 0.02 and p =
0.05, respectively). STI prevalence at the time
of screening stratified by HIV serostatus is
shown in table 2. Bacterial vaginosis, trichomoniasis, gonorrhoea, and the presence of a
genital ulcer were significantly more common
among HIV positive women. CIN was three
times more prevalent in the HIV seropositive
group.
Of the 543 women interviewed, 392 (72%)
gave a history of douching. Most of the women
who practised douching reported doing so
after each sexual intercourse (91%) and most
of the women douched with water and soap
(81%). Water mixed with salt was used by
18%, water alone by 9%, a commercial
antiseptic by 5%, and washing powder was
used by 1%. The majority of women who
reported douching did so more than once per
day (93%).
There was no diVerence in age, marital status, age at first sexual intercourse, place of
work (home, bar, or club), and duration of
prostitution between women who douched
and those who did not (data not shown).
There was a stepwise association between
condom use and douching: women who sometimes or always used condoms were 1.4 and
2.5 times more likely to douche, respectively,
than women who never used condoms (p =
0.003). Although women who douched had
significantly more partners per day (4.1 v 3.6;
p = 0.01) and practised anal sex more often
(19% v 5%; p<0.001), they were less likely to
report a history of any STI (21% v 45%;
p<0.001), vaginal discharge (11% v 21%;
p=0.003), or abdominal pain (15% v 36%;
p<0.001). On multivariate analysis, condom
use (p = 0.001), a history of anal sex (p =
0.0001), and number of daily partners (p =
0.05) remained significantly associated with
douching.
The relation between genital infections and
diVerent vaginal douching practices is shown in
table 3. Among the small number of women

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273

STI and vaginal douching in a population of female sex workers in Nairobi, Kenya
Table 3

Univariate associations between genital infections and douching

Bacterial vaginosis
Vaginal yeast
Trichomonas vaginalis
Neisseria gonorrhoeae
Chlamydia trachomatis
Syphilis
CIN
HIV

Never
douched

Regular douching,
any product

Ever douche
with water alone

Ever douche
with soap

Ever douche
with salt

No (%)

No (%)

No (%)

No (%)

No (%)

50/121 (41)
9/120 (8)
22/147 (15)
15/147 (10)
10/134 (8)
9/147 (6)
2/150 (1)
44/148 (30)

161/310 (52)*
30/313 (10)
64/381 (17)
37/382 (10)
31/318 (10)
22/381 (6)
7/392 (2)
117/385 (30)

13/26 (50)
1/27 (4)
2/30 (7)
1/30 (3)
1/27 (4)
1/30 (3)
1/31 (3)
3/30 (10)*

125/234 (53)*
23/236 (10)
53/286 (19)
28/287 (10)
27/235 (11)
20/285 (7)
5/293 (2)
92/289 (32)

28/50 (56)**
3/51 (6)
10/62 (16)
6/62 (10)
3/53 (6)
2/63 (3)
2/64 (3)
18/62 (29)

Denominators diVer because of missing specimens.

*p <0.05, versus no douching.
**p = 0.09 versus no douching

who used water alone for vaginal douching, a

significantly lower HIV prevalence was found
(p = 0.02). In multivariate analysis, however,
including variables associated with HIV seropositivity in this or other studies (number of
partners per day, practice of anal sex, history of
STI, history of vaginal discharge, condom use,
presence of bacterial vaginosis, gonorrhoea,
trichomoniasis, and clinical ulcers), the association between HIV and douching with water
disappeared.
A significantly higher prevalence of bacterial
vaginosis was found among women who
douched (OR 1.5, 95% CI 1.02.3, p = 0.05).
This association was also found in the
subgroup of women douching with soap (OR
1.6, 95% CI 1.02.5, p = 0.03). The correlates
of bacterial vaginosis are shown in table 4.
Bacterial vaginosis was more prevalent among
women who used alcohol more often, among
women with trichomoniasis, chlamydial infection, and HIV infection. Bacterial vaginosis
was less prevalent among pregnant women
and women with a history of past vaginal discharge. When the variables associated with
bacterial vaginosis in univariate analysis (p
<0.1) were included in a logistic regression
model, bacterial vaginosis remained significantly associated with any douching (OR 1.6,
Table 4

Characteristics of female sex workers with and without bacterial vaginosis

Mean age (years)

Never married
Mean age at first sex (years)
Mean duration of prostitution (years)
Mean number of sex partners/day
Mean number of sex partners/week
Mean charge per act (Kenya shillings)
Condom use
Never
Sometimes
Always
Regular partner
Use of OC
Any lubricants used
Sex during menses
Anal intercourse
Any alcohol use
Pregnant
History of STI
History of GUD
History of vaginal discharge
History of abdominal pain
Trichomonas vaginalis
Chlamydia trachomatis
HIV

BV negative
(n = 220)

BV positive
(n = 211)

31.0
49%
16.0
6.4
3.8
13.8
110

30.5
45%
15.9
6.2
4.0
14.9
116

35%
49%
16%
57%
26%
23%
22%
14%
53%
6%
31%
3%
19%
22%
10%
5%
26%

34%
45%
18%
56%
32%
25%
26%
16%
63%
2%
29%
3%
12%
23%
21%
13%
35%

OR (95% CI)
0.9 (0.81.1)

0.9 (0.51.5)
0.9 (0.51.5)
1.0 (reference)
1.0 (0.71.5)
1.3 (0.92.0)
1.1 (0.71.7)
1.1 (0.91.4)
1.1 (0.81.4)
1.5 (1.02.2)
0.4 (0.11.0)
0.9 (0.61.4)
1.1 (0.71.8)
0.7 (0.51.0)
1.0 (0.81.3)
2.3 (1.34.1)
3.0 (1.46.5)
1.5 (1.02.3)

p Value
0.5
0.4
0.7
0.8
0.2
0.3
0.5
0.7
0.7
NA
0.8
0.2
0.7
0.5
0.6
0.04
0.06
0.9
0.8
0.06
0.9
0.003
0.003
0.05

www.sextransinf.com

95% CI 1.02.5, p = 0.05) as well as with

douching with soap and water (OR 1.6, 95%
CI 1.02.6, p = 0.04).
Among women who reported douching, the
mean frequency of douching was 13 times per
week. There was a significant trend for
increased frequency of douching and prevalence of bacterial vaginosis: 53% BV prevalence in the group douching more than once
per day, 46% in the group douching once per
day, and 14% among those douching less than
once daily (p = 0.05). More frequent douching
was also associated with higher pH (p = 0.05).
A lack of lactobacilli was detected significantly
more often in women douching with salt (73%
versus 47%, OR 0.3, 95% CI 1.15.0, p =
0.04). There was no diVerence in lactobacilli
detection observed among women douching
with other products.

Discussion
The current study confirms that vaginal
douching is a widespread practice among
African female sex workers, as previously
described. In our study, 72% of the women
reported vaginal douching. Vaginal douching
is also widely practised among pregnant
women and women attending STD clinics in
Africa.13 16 The use of vaginal products for the
treatment of vaginal symptoms as well as the
use of vaginal agents to achieve a tightening
eVect is widespread.13 17 18 The specific preparations used for douching vary according to
local cultural factors. In several African
settings, herbs and dry leaves are used for
treatment of vaginal infections or for a tightening eVect to achieve dry sex.12 19 Although
the question was not specifically asked in our
study, it appears that personal hygiene was the
main reason for douching, as most women did
so after each intercourse. Most women used
water alone or a combination of water and
soap. Commercial products were rarely used.
The women in our study belonged to a low
socioeconomic group, and hence may not have
been able to aVord rather expensive commercial products.
The STD and HIV rates in this population
are similar to other African cohorts, except for
the CIN rate of 2%, which is lower than
reported from most other studies, even in low
risk groups in east Africa.20 Health seeking

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274

Fonck, Kaul, Keli, et al

behaviour and previous screening and treatment of cervical lesions might explain these low
rates of CIN.
We describe a significant association between douching (with soap and water) and an
increased prevalence of bacterial vaginosis.
More frequent douching was also significantly
associated with more prevalent bacterial vaginosis. This is consistent with results from other
studies. A case-control study has shown that
genital hygiene accounts for a twofold increase
in the risk of bacterial vaginosis.21 Although the
cross sectional nature of these studies
precludes the establishment of a cause and
eVect relation (for instance, women with BV
symptoms may douche more often), the
finding in a prospective cohort study that
acquisition of bacterial vaginosis is associated
with douching22 makes a causal relation more
likely.
There is now considerable evidence that the
presence of bacterial vaginosis has a role in the
acquisition of HIV.23 Hence, vaginal douching
may indirectly facilitate the heterosexual
transmission of HIV infection. We did not find
a direct association between douching and
HIV prevalence, but other factors associated
with douching in our cohort may have acted to
reduce HIV risk. Women who reported
douching were more likely to report using
condoms all the time. Vaginal douching
appeared to be used as a form of personal
hygiene, and it seems reasonable that women
more concerned with hygiene might also be
more likely to use condoms. The association
between douching and BV would still be
apparent, but this increased condom use
would bias our ability to detect any eVect of
BV on enhanced HIV acquisition. As has been
seen in previous studies on this subject, there
appears to be a complex relation between HIV
infection and vaginal douching. In a study in
the Central African Republic, Gresenguet et al
found a positive association between HIV and
the use of vaginal agents for the self treatment
of discharge and itching.12 In women without
vaginal symptoms, however, the use of vaginal
agents was not associated with HIV infection.
Dallabeta et al found an increased prevalence
of HIV infection among women using
non-commercial medicines in Malawi.13 The
potential mechanisms whereby vaginal
douching could possibly enhance HIV
transmission are twofold: (1) through
irritation of the vaginal mucosa, thus promoting the proliferation of lymphocytes which are
target cells for HIV24; and (2) through
dehydration of the vaginal mucosa, rendering
the vaginal epithelium more vulnerable to
local trauma.25
In summary, frequent douching seems to be
a common practice among female sex workers
in Africa, and we found a significant association between douching and bacterial vaginosis, but not with other STIs or HIV infection.
The association between vaginal douching and
bacterial vaginosis is of concern, given the
increased risk of HIV infection with BV, which
has now been shown in several studies. It is

www.sextransinf.com

unclear why we could not demonstrate a direct

association between douching and HIV
infection, but this may be due to a complex
interaction with behavioural and other factors
associated with douching. Further research
is required to better understand the
complex relation between douching, risk for
bacterial vaginosis, and risk for HIV and other
STIs.
Grant support: The Rockefeller Foundation, grant no RF 96034
and European Commission, DG VIII/8, contract no 7-RPR-28.
The authors wish to thank the project staV and the staV of the
Nairobi City Council, especially the Langata Health Centre, for
their cooperation and support.
Contributors: KF supervised fieldwork of data entry, data
analysis, writing of the paper; RK supervised fieldwork of data
entry, laboratory procedures, interpretation of data, revision of
draft paper; FK was responsible for fieldwork, revision of draft
paper; JJB supervised the study, supervised laboratory procedures, revision of draft paper; ENN supervised the study,
revision of draft paper; SM was involved with the design of
study, data analysis, revision of draft paper, overall responsibility of the stud; MT was involved with design of study, data
interpretation, and revision of draft paper.

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