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HIV incidence was 3.

Introduction

In Uganda, the cohort study recruited HIV negative and HIV positive women who were either self-identified commercial sex workers CSW or employed in entertainment facilities such as bars, nightclubs, and lodges in the capital city of Kampala. For both cohort studies the women were followed up every three months; follow-up in Tanzania ended after 12 months, and in Uganda is ongoing.

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All participants were asked to only report on practices related to intra vaginal cleansing or insertion. Of these, 39 and 41 completed IDIs respectively see Fig. For the IVP Study in Uganda, women were enrolled by selecting every fourth participant at any follow up visit: nine were enrolled at their three month clinic visit, and the remainder between their 6—15 month visits. A total of 96 participants completed an IDI see Fig. In both countries, women who did not complete an IDI were those that were lost to follow-up. Flow chart of enrolment and numbers of in-depth interviews carried out in the IVP study.

In addition, women were asked about their work, family life, sexual relationships, hygiene during menstruation, and general bathing habits. All IDIs were conducted by female research assistants in a private room at the cohort study clinics. In Tanzania, all IDIs were digitally recorded with the exception of one participant who did not consent to recording and instead notes were taken; and in Uganda, given the concerns over use of recording in this setting, notes were taken with direct quotations noted.

The interviewers were experienced with this approach. At the end of the study, eight FGDs were carried out in Tanzania with female traditional healers 2 , male bar patrons 2 , main cohort participants who reported intravaginal insertion 2 , and main cohort participants who reported intravaginal cleansing 2. Each FGD included 8 to 10 participants, and main cohort participants were selected irrespective of whether they were in the IVP study. The FGDs were led by same-sex research assistants and took place in a private place in a local bar or restaurant during closed hours.

All topic guides included questions on cultural and social norms surrounding IVP and sexual relationships. In Uganda, the IDIs were written up from notes immediately after each interview.

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An initial coding structure based on the study objectives was developed a priori by authors SF and SL. On completion of coding, SL conducted a comparative analysis across the concepts to explore themes related to motivations and drivers of IVP. In both sites, participants were required to give written informed consent.

In Tanzania, women attending the IDI had a mean age of About half of the women had completed primary school, and a few reported never attending school. The majority of the women were Christian with the remainder being Muslim. Just over half of the women worked in bars, hotels and guesthouses, and the other half worked in other facilities such as independent food vendors mamalishe or small grocery stores. Age of first sex ranged from 13 to Most women reported being separated, divorced or single, and relatively few women reported living with a partner.

Characteristics of the Tanzanian and Ugandan IDI participants contributing to the qualitative data analysis. Further characteristics were obtained from the IDI data. Around half the women reported that they earned less than 1 US dollar a day. No data were obtained for the money earned or types of gifts given for transactional sex. The majority of women lived alone in a rented single room or in a compound at their place of work. Most women 71 reported at least one sexual partner. Of these, 32 women had only regular partners defined as more than one year duration , two had both regular and casual partners, and 37 had only casual partners.

Four of the women reported having experienced intimate partner violence from a previous partner. Half the women never went to school or never completed primary school. Most women were Christian. The age of first sex ranged from 8 to Data from the IDI showed that most of the women lived in rented single rooms in the slums. Of the 92 women who reported a sexual partnership: 25 had regular partners, 22 had casual partners, and 45 had both regular and casual partners. As well as physical violence women reported being forced to have unprotected sex. Intravaginal cleansing was reported by all women who attended an IDI, and it was seen as a normative practice routed in ethnic and religious tradition both Christian and Muslim.

In the IDIs, participants reported cleansing daily at different times: during bathing; after toileting; and before and after sex.

The most common type of cleansing was internal washing with a finger and water. Whilst the use of water was desirable, none of the women had access to running water in their homes and instead sourced water from a communal well or tap, or a water vendor. When they were unable to access water, they used a piece of dry cloth or toilet paper. Around half of the women also used soap with water. A variety of soaps were used including body washing soap, antiseptic soap, or powdered or solid bars of laundry soap.

I don't trust other types of soap. It actually says on the wrapper that you wash inside the vagina with that soap, you will remove the bad smell; it will kill the germs. Others stopped following advice from a health professional, including the cohort study clinical staff.

Most of the women were introduced to cleansing during adolescence by a female relative, usually their mother, aunt, sister, or grandmother. Most commonly this was when they started their menses or were given instruction about sex or marriage:.

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She showed me how to use the middle finger to cleanse inside the vagina. Other women reported that they were introduced to cleansing in their twenties by peers.

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A few women also learnt about cleansing through public health messages, either at school or in health centres:. Insertion was less commonly practiced. In IDIs, only nine Tanzanian women and 37 Ugandan women reported inserting a commercial or traditional substance in the previous six weeks. The low frequency of reported insertion in Tanzania may have been due to the stigma that women attach to the practice, and FGDs with the traditional healers in Tanzania suggested that it is far more widely practiced than reported by these women.

Insertion was often taught as part of initiation into womanhood, by traditional healers, or by Ssenga literally paternal aunt in Luganda. However, in Kampala women seeking solutions to physical, sexual or emotional problems also learnt about insertion practices from female peers or through hearsay.

The higher frequency of the practice among the Ugandan women also suggests that it was linked to the demands of commercial sex work see below. Women who reported insertion and traditional healers who supplied medicine in Swahili, dawa reported several different substances used.

The traditional healers in Tanzania described the use of pulverised herbs, leaves and roots. As well as traditional dawa , Tanzanian women reported inserting snuff pulverised tobacco , lemon leaves, cassava leaves, lemon juice, beer, Konyagi a Tanzanian spirit similar to gin , and shabu locally mined alum used to purify water. Substances reported by Ugandan women included traditional herbs, Coca-Cola, Omo laundry detergent , honey, salt, beer or Vaseline. Women either inserted the substance directly in the vagina with a finger, or mixed with ghee clarified butter or Vaseline and inserted with a finger.

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Substances were inserted by the women when experiencing pain, in preparation for sex, or when prescribed by a traditional healer for sexual, relationship or health purposes. Such substances were reported to directly alter the vaginal state e. Women reported that they were willing to stop insertion of commercial substances, particularly when hearing negative stories from other women, or from their own negative experiences:.

Whilst many IVP, such as cleansing, were normative, they were highly secretive and women rarely discussed their own personal practices, even with intimate partners. They suspected that women carry out IVP, particularly cleansing and insertion of substances, to secure and maintain sexual relationships. This secrecy was maintained by traditional healers who emphasised that the herbs they provide for insertion in the vagina were not detectable by men, and these herbs were effective because of the secrecy.

The secrecy surrounding IVP often led to suspicion and distrust between women and men, especially if the women's post-sexual cleansing implied that the man was dirty or infectious:.

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I told him that I feel that my whole body smells, and I feel drier when I bathe and sleep comfortably. He said it is impossible for me to be bathe [at night] … he felt as if I am stigmatizing him or perhaps that I will leave him at any time. During the IDIs, women revealed that IVP were influenced by a number of overlapping motives including hygiene, morality, sexual pleasure, fertility, relationship security, and economic security; thus, one type of IVP may serve more than one motivation at the same time.

Additionally, these motivations were strongly influenced by two drivers: cultural and social norms and subjective well-being see Fig. In this way, IVP embodied norms of womanhood surrounding their moral, sexual, and reproductive roles in society. At the same time, women using IVP were attending to their personal emotional, economic, and physical state, including concerns with the transactional aspect of sex and HIV infection.

Below, each motivation is shown to simultaneously address both drivers. Conceptual diagram of the motivations for intravaginal practices among women who engage in transactional sex in an observational research study in Tanzania and Uganda. IVP were influenced by several overlapping motives including hygiene, morality, sexual pleasure, fertility, relationships and economic security. These motivations were strongly influenced by two factors: cultural and social norms and subjective well-being.

For both the Tanzanian and Ugandan women the main purpose of vaginal cleansing and the insertion of substances was to remove dirt Swahili - Uchafu and Luganda — Obukyafu. Hygiene was also important to women's own sense of well-being, to treat vaginal infection or discomfort or prevent HIV infection. Some women also inserted herbs to treat vaginal symptoms:.

This state embodies women's physical and moral cleanliness:. She makes it narrow, she pulls it, she washes with cold water and it returns to its normal condition. Ugandan women especially reported the use of commercial substances to enhance this virgin-like state. This included inserting shabu , Coca-Cola, or detergents used for washing clothes:. The FGD with Tanzanian male bar patrons highlighted the social pressures on women to ensure a virgin-like state, which the men described as lack of excessive fluid but not too dry, and free from smell and dirt.

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