The dangers of vaginal douching

Dr Sindi van Zyl, General Practitioner

Ever heard of using plain yoghurt, or a mixture of Stoney and Lemon Twist, or

Dr Sindisiwe van Zyl

cinnamon and milk? Well, these are some of the ‘remedies’ that have been recommended to help women douche and get their vaginas to be ‘tight and clean’.

Some people might be shocked by this; but these are just some of the extremes that people go to.

Let’s start off by understanding what douching is.

According to WomensHealth.gov, the word ‘douche’ means to wash or soak. Douching is washing or cleaning out the inside of the vagina with water or other fluids. Most women make their own douching concoctions using water, vinegar, baking soda, yoghurt, cinnamon or iodine.

This last is commonly used by gynaecologists after major surgery.

Douching can lead to infection

The vagina is a self-cleaning organ – it doesn’t need anything to be done to assist it in the cleaning process. When you start douching, you strip the vagina of the bacteria that help it to clean. This leads to infections, the most common being bacterial vaginosis.

The symptoms of bacterial vaginosis are a watery/milky vaginal discharge with a very fishy smell. It smells like tinned pilchards; it’s unmistakeable.

The other infections associated with this practice include vaginal thrush and pelvic inflammatory disease. Women who douche regularly may also have difficulty falling pregnant.

Infections linked to douching

Vaginal Thrush

Vaginal thrush is a common infection caused by an overgrowth of Candida albicans yeast. The yeast lives naturally in the bowel, and in small numbers in the vagina. It is mostly harmless, but symptoms can develop if yeast numbers increase. About 75 per cent of women will have vaginal thrush in their lifetime.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It usually occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries. The Pelvic inflammatory disease often causes no signs or symptoms. As a result, you might not realise you have the condition, and will not get the treatment needed. The condition might only be detected later if you have trouble getting pregnant, or if you develop chronic pelvic pain.

There are a lot of myths regarding vaginal ‘freshness’, and they are passed down from the elders to us. But oh my word, they are not true. Stay away from douching and ‘intimate washes’ – your vagina does not need them. Water will do the trick: yes, the one we get from the tap.

STIs 

Moving on, to another important topic: Sexually Transmitted Infections (STIs). (These were previously called Sexually Transmitted Diseases.) There are different categories of STIs. The trick with STIs is that they must be detected early, and treated accordingly; you need to know what those categories are, so that you can seek treatment timeously. Failure to do so increases the risk of HIV infection. This is why we treat them aggressively.

STIs are passed from one person to another through unprotected sex or genital contact.

Common STIs that affect women in South Africa:

Human papillomavirus 

Human papillomavirus (HPV) is a viral infection that is passed between people through skin-to-skin contact. There are more than 100 varieties of HPV, 40 of which are passed through sexual contact and can affect your genitals, mouth, or throat.

Genital herpes

Genital herpes is a common infection caused by the herpes simplex virus (HSV), which is the same virus that causes cold sores. There are two types of HSV: type 1 and 2. Type 1 causes cold sores on the lip. Type 2 causes genital lesions. Some people develop symptoms of HSV a few days after coming into contact with the virus. Small, painful blisters or sores usually develop, which may cause itching or tingling, or make it painful to urinate.

Gonorrhoea

Gonorrhoea is a bacterial STI easily passed on during sex. About half of women and one in 10 men don’t experience any symptoms, and are unaware that they’re infected. In women, gonorrhoea can cause pain or a burning sensation when urinating, a vaginal discharge (often watery, yellow or green), pain in the lower abdomen during or after sex, and bleeding during or after sex or between periods. It can sometimes cause heavy periods.

Chlamydia

Chlamydia is passed on during sex. Most people don’t experience any symptoms, so they are unaware they’re infected. In women, chlamydia can cause pain or a burning sensation when urinating, vaginal discharge, pain in the lower abdomen during or after sex, and bleeding during or after sex or between periods. It can also cause heavy periods.

These are just a few of the STIs that exist. The World Health Organisation (WHO) estimates that more than one million people get an STI every day. The danger is that most people with sexually transmitted infections do not have any symptoms, and are therefore often unaware of their ability to pass infections on to their sexual partners.

Regular check-ups enable you to know what you have and how best to treat it. There are many risks posed by STIs. If left untreated, they can cause serious health problems including cervical cancer, liver disease, pelvic inflammatory disease (PID), infertility, and pregnancy problems.

The Well Project (thewellproject.org) says having some STIs (such as chancroid, herpes, syphilis, and trichomoniasis) can increase the risk of getting HIV if you are HIV-negative and are exposed to HIV. People living with HIV may also be at greater risk of getting or passing on other STIs.

But there is no need to fear. If you suspect that you might have contracted an STI, you must see your doctor and get it checked out. There are tests that can be performed to ascertain exactly what it is you might have. The tests include:

Blood tests, which can confirm a diagnosis of HIV, or the later stages of syphilis.

Urine samples: some STIs can be confirmed with a urine sample.

Fluid samples: if you have active genital sores, testing of fluid and samples from the sores may be done to diagnose the type of infection. Laboratory tests of material from a genital sore or discharge are used to diagnose some STIs.

Screening: testing for a disease in someone who doesn’t have symptoms is called screening. Most of the time, STI screening is not a routine part of health care; but there are exceptions:

It is advisable for women who are sexually active to test regularly. Once you are sexually active, you must go for PAP smear screening. The PAP smear screens for cervical abnormalities, including inflammation, pre-cancerous changes and cancer, which is often caused by certain strains of human papillomavirus (HPV).

All sexually active women should be tested for chlamydia infection. The chlamydia test uses a sample of urine or vaginal fluid you can collect yourself. Some experts recommend repeating the chlamydia test three months after you’ve had a positive test and been treated; the second test is needed to confirm that the infection is cured, as re-infection by an untreated or undertreated partner is common. A bout of chlamydia doesn’t protect you from future exposure; you can catch the infection again and again, so get retested if you have a new partner.

Screening for gonorrhoea is also recommended for sexually active women. If you happen to find yourself in a new relationship, it is of paramount importance that you both test for STIs.

Going to the clinic can be daunting. Remember that your health comes first! Keep that in mind when you go to seek assistance at any clinic.

Dr Sindisiwe van Zyl is a GP with a special interest in HIV. She is passionate about sharing health-related information, and has used social media extensively for this purpose. Dr Sindi – as she is affectionately known – is in private practice in Johannesburg. Twitter: @sindivanzyl

 

The needs of queer folk in SA

by Thuthukile Mbatha, Spotlight

June 2017 saw the launch of South Africa’s first Lesbian Gay Bisexual Transgender Queer Intersex Asexual Plus (LGBTQIA+) HIV Plan 2017-2022.

Luckyboy Mkhondwana, National Training Co-ordinator at the Treatment Action Campaign

The plan, which was launched under the banner of the South African National AIDS Council, seeks to address some of the many issues affecting the various communities that are part of the LGBTQIA+ community, with all their varied and unique needs. However, nine months have passed, and still there has been no meaningful attempt to implement the plan.

Luckyboy Mkhondwana is the National Training Co-ordinator at the Treatment Action Campaign, and a long-time campaigner and advocate for the rights of the LGBTQIA+ community. He took Spotlight through the gaps that exist in the policy and its implementation.

Do you think that the Sexual and Reproductive Health Rights (SRHR) needs of queer folk are addressed in the public health sector?

No, there are a lot of gaps that need to be addressed. For instance, if a lesbian woman misses her period and goes to a public clinic to find out about the possible cause of the delay, she will be asked about the last time she had sex, and a pregnancy test would be done on her. This is unfair, and disrespectful to her sexual orientation.

Moreover, the judgement received by gay men when they go to public health clinics for screening and treatment of sexually transmitted diseases (STIs) discourages them from going back to the clinic when sick. For instance, if a gay man has warts on the anus, it is not easy to seek medical help, because some healthcare providers will judge him – especially since they are used to seeing warts on the genitals, not on the anus. This has led to many gay men living with untreated STIs. The only clinics that are sensitised to offer non-judgmental health services are the facilities that work with organisations such as the Anova Health Institute; which are not accessible to all gay men, due to where they are located.

Would you say the LGBTQIA+ HIV Plan 2017-2022 addresses the needs of queer folk?

I think the plan is a good document, full of promise – but there is no implementation. It has been nine months, but we have not seen anything on the ground. I am curious to know what they will report on, when it is time for review.

What should be the specific SRHR priorities for queer folk?

The LGBTQIA+I HIV Plan seeks to offer a core package of health services, and it includes confidentiality. However, that is not practised on the ground. If a trans woman visits a clinic, the healthcare providers usually call their peers to stare at the trans woman. They look at her as if she is in a circus, because she is wearing female clothes. There is a good chance that the nurse assisting the trans woman would disclose to his or her colleagues the reason for her visit.

The plan further suggests that the LGBTQIA+ community should have access to HIV-prevention tools; whereas in reality, only a few have access to tools such as Pre-Exposure Prophylaxis (PrEP). If one lives far from the Anova Health Institute centres, one cannot access such services.

There are no lubricants for the trans women and men who have sex with men (MSM) communities. These should be freely available in public health facilities, just as male condoms are easily accessible. A 500ml bottle of lubricant costs R85 or more in a pharmacy, and not all can afford to buy it.

One of the goals of the plan is to reduce HIV prevalence and incidence rates. It continues to highlight the importance of increased access to HIV prevention tools. However, it is very difficult to gain access to dental dams, finger cots and PrEP in the public sector, to protect against new HIV infections.

A dental dam, like a condom, is a barrier method. It is a thin, square piece of rubber which is placed over the labia or anus during oral-vaginal or oral-anal intercourse. Dental dams are most often made of thin latex rubber; however, for those allergic to latex, they are also available in silicone.

A finger cot is a ‘glove’ that covers only one finger. It is basically a ‘finger condom’. Finger cots are often recommended as a safer sex device for fingering.

Access to Human Papilloma Virus and screening is difficult for some lesbian women and trans men who have not gone for gender reassignment. When they go for a Pap smear test, they are asked why they require such services, because they are men. Healthcare providers judge them based on how they look. You may find that some had previously engaged in sexual intercourse with heterosexual men, meaning they too are at risk of contracting the two diseases.

In general, all service providers must be sensitised and taught how to address queer folk. The assumption that we are all either women or men is offensive. Gender non-binary groups are usually the victims of that offense.

An investment in mental health is key to the provision of SRHR, because the two are linked. There is a great demand for psychosocial support among queer folk, since they endure much discrimination at home, in their workplaces, and in their societies in general. A number of them engage in reckless behaviour, including substance abuse and casual sex, to numb the pain. This kind of behaviour poses a threat to their health, since it exposes them to the risk of HIV infection.

Lastly, the plan stresses the importance of recruiting LGBTQIA+ communities through peer educators. However, no recruitment has happened on the ground. Even when it comes to HIV testing, only the non-profit organisations visit LGBTQIA+ spaces to offer the services to them.

Can we say that all queer folk would have similar SRHR needs?

No, [the solutions to] our needs need to be tailor-made to suit each individual. Not every woman wants contraception; queer women need dental dams or finger cots, whereas a trans woman may need a lubricant. Also, the SRHR needs of one trans woman could differ from those of another trans woman, just as heterosexual women may have different preferred contraceptives.

What are the biggest challenges for queer folk trying to access health care in clinics and hospitals?

Stigma and discrimination prevent a lot of people from accessing healthcare services. This is the major barrier for queer folk.

What would you change tomorrow if you had the power, in terms of SRHR for queer folk?

I would ensure that the individual SRHR needs of queer folk are prioritised – I wouldn’t assume that a one-size-fits-all approach will work. I would ensure that healthcare providers are properly sensitised, and that I would be able to go to a clinic and get everything that I need, without fear of being judged.

What is TAC doing to address the SRHR needs of queer folk?

We have an LGBTQIA+ sector in seven provinces. We have been struggling to get funding for LGBTQIA+ advocacy work; however, we have incorporated LGBTQIA+ work in most of our work and campaigns, including treatment literacy programmes. Funders prefer funding service-provider organisations, because they can quantify how many queer folk they have reached, recruited and assisted; whereas advocacy is hard to quantify.

Let our Actions Count: SA National Strategic Plan for HIV, TB & STIs 2017-2020

This is the fourth National Strategic Plan (NSP) that South Africa has adopted to guide its response to HIV, Tuberculosis and sexually
transmitted infections. Viewed together, the plans set out in the NSP provide insight into the path we have travelled as a nation to
overcome one of the most devastating human challenges of our time.
They show how our response to HIV, TB and STIs has evolved over the last two decades as we have come to understand the nature and
impact of the epidemics with regard to the factors that contribute to their spread, and the interventions that work best in reducing
infection, morbidity and mortality.
This NSP is a clear demonstration of the outstanding progress we have made. It is also a stark reminder of how far we still need to go.

Download here

Measuring up to the task of tackling HIV and TB in the new NSP

By Julia Hill

What gets measured gets done and, ideally, gets improved. As the South African National AIDS Council (SANAC) nears completion of the next National Strategic Plan (NSP) on HIV, TB, and STIs (2017-2022), lofty ambitions for positive outcomes are in place. However, what provinces and districts are expected to measure in order to track implementation and incremental steps toward these goals is—at this point—completely absent from the NSP.

Correctly, the NSP aims to achieve substantial reductions in HIV infections to fewer than 100,000 per annum by 2022, and reach UNAIDS 90-90-90 targets by 2020 for HIV testing, retention in care, and viral suppression. Biomedical and social service approaches to HIV prevention are also prominent, including tackling the national epidemic of sexual violence. On the TB front, the NSP similarly seeks to close the gaps in prevention, diagnosis, treatment initiation, and treatment success, and specifically notes the special attention that must be paid toward bringing the drug-resistant TB (DR-TB) epidemic under control.[i] The wish-list of goals in the NSP leaves out very little. But these targets are expected outcomes—and outcomes do not evolve from a programmatic void.

The resulting pie-in-the-sky document makes it difficult for communities most affected by HIV and TB to hold to account AIDS Council governance structures and government departments. National success depends on smaller programmatic successes at district, sub-district, and service provision level. Monitoring and evaluation (M&E) standards must therefore be put in place at these system levels to ensure people are able to access services intended to lead to achievement.

For example, the intention to put half a million adolescents on PrEP by 2022 is overdue and welcome. But where is the breakdown for what districts are expected to contribute to that national total? High-burden districts like King Cetshwayo (formerly uThungulu) in KwaZulu-Natal have HIV incidence rates among adolescent girls that skyrocket to 6.2% by age 19[ii] –far exceeding the WHO threshold for PrEP eligibility. These districts should have very specific targets for the number of adolescents that should start and be retained on PrEP. But districts and sub-districts should also have ambitious targets in place for the proportion of schools offering HIV testing services and referrals to preventative services such as PrEP, or for the proportion of facilities implementing youth-friendly services—such as staying open after-hours on some days of the week. It is through monitoring these types of indicators that we can ensure that districts are offering services that put them on track to meet targets.

At the 21 February 2017 consultation on Draft 1 of the NSP, interested parties were invited to participate in shaping indicators and targets for the provincial implementation plans. A long list of possible indicators was shared with this group. Some indicators were intended to be aggregated at the national level to measure major outcomes—such as the number of people on antiretroviral therapy—but a number of process indicators were also proposed that, if well-designed, could be used to measure programmatic implementation progress down to the sub-district level.

It was not clear if provinces were required to report on any of these process indicators, or if they are merely expected to select those they find interesting or convenient. Outcomes of this meeting were—to our knowledge—never published online or shared, making it extremely difficult for provinces to incorporate programmes and M&E support into their implementation plans.

However, it is not too late for provinces and high-burden districts to be offered guidance on what to prioritize. Not everything must be done everywhere, but certainly a bare minimum must be universally required across the country, and high-burden districts must be required to implement additional interventions beyond the minimum.

So what type of interventions should be prioritized as the essential minimum required from all districts, and implemented with urgency in high-burden districts? At Doctors Without Borders (MSF), our short-list includes the following:

  • Proportion of sub-districts offering a package of school-based services (including HIV testing, TB and STI screening, pregnancy tests, condoms, and referrals for PrEP, VMMC, and referral to further HIV/TB services) in 100% of schools – Target 80% of sub-districts by 2019; ≥90% by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of PrEP courses distributed to adolescents and youth – National target of 200 000 adolescents and 75 000 women age 20-24 initiated on PrEP by 2019; 500 000 adolescents and 200 000 women age 20-24 by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of free HIV self-testing kits distributed in public sector – National target of 3 million tests per year by 2019; 10 million per year by 2022
  • Proportion of sub-districts with primary health care (PHC) facilities (including community health centres (CHC)) offering essential services for sexual violence survivors (forensic examination, PEP, emergency contraception, psychological counseling, social assessment), linked into interdepartmental referral network for more advanced services – Target 100% of designated PEP facilities in all HIV high-burden sub-districts capacitated by 2020; 100% of all sub-districts with minimum one facility by 2022
  • Proportion of CHC/district hospitals and PHC facilities in high-burden settings providing comprehensive DR-TB services (diagnosis, treatment initiation, continued management –Target 100% of PHC facilities in high-burden settings; target minimum one facility per sub-district in lower-burden settings. Total of 800 facilities by 2019; total of 1000 facilities by 2022.
  • Proportion of PHC facilities not providing 3-month ART refills to stable ART patients – Target <5% of facilities by 2019; 0% of facilities by 2022.
  • Proportion of PHC facilities per sub-district achieving ratio of one lay health worker: 800 people within community (with 25% of lay workers facility-based; 75% community-based – Target 80% of facilities by 2019; 100% by 2022.
  • Proportion of treatment sites (including community pick-up points serviced by Central Chronic Medicine Dispensing and Distribution) experiencing stock outs of ARV or TB meds –  Target: <10% by 2019; <5% by 2022.
  • Proportion of PHC facilities in HIV high-burden districts and CHC in all districts offering after-hours/Saturday services for ART initiation and/or ART refill collection – Target 75% by 2019; 90% by 2022.

This approach will require strengthening data capturing and M&E systems, and the public must have access to data if those responsible for action are to be held to account. It is mandatory to invest in requiring and measuring programmes if we are to avoid frittering away the next five years. When sub-districts receive specific guidance, they are inclined to implement it—this is evident in the massive uptick in numbers enrolled on HIV treatment, or registered to receive their medicines at community pick-up points. And if government departments or other stakeholders do not implement programmes, or do not run them well, then a robust M&E system makes it obvious where intensified efforts should be directed to improve the quality and availability of HIV and TB services.

South Africa knows what it wants to accomplish in reducing the national burden of HIV and TB over the next five years. The major question remaining is whether or not it will measure up to the task before it.

Julia Hill is Deputy Head of Mission, Doctors Without Borders/Médecins Sans Frontières South Africa

[i] SANAC. Draft 2: South African National Strategic Plan on HIV, TB and STIs 2017-2022. Accessed 27 March 2017. Available at: http://sanac.org.za/wp-content/uploads/2017/03/NSP-Draft-2_24-February-2017.pdf

[ii] Grebe E, Huerga H, van Cutsem G, Welte A. (2016) “Cross-sectionally estimated age-specific HIV incidence among young women in a rural district of KwaZulu-Natal, South Africa” presented at the 21st International AIDS Conference. July 18-22 (2016), Durban, South Africa.