Kalichman, Seth C. PhD*; Simbayi, Leickness C. DPhil†; Cain, Demetria BS*; Cherry, Charsey MPH*; Jooste, Sean MA†
SOUTH AFRICA HAS ONE OF the fastest growing HIV/AIDS epidemics in the world with an estimated HIV prevalence of 11%; HIV prevalence is 16% among persons aged 15 to 49.1,2 Although there has been speculation that the HIV epidemic in southern Africa can be accounted for mostly by nonsterile medical practices, this hypothesis is not supported.3 Another possible source of rapid HIV transmission may be unreported homosexual and heterosexual anal intercourse, but there is also little support for this hypothesis. It is accepted that HIV is spread in southern Africa primarily through vaginal intercourse.2 Because vaginal intercourse is a generally inefficient route for HIV transmission, cooccurring factors such as circumcision status,4 stage of HIV infection,5,6 and, perhaps most importantly, sexually transmitted infections (STIs), particularly genital ulcer diseases,7 are believed critical in facilitating HIV transmission in sub-Saharan Africa.
Although genital ulcers themselves are clearly important in HIV transmission, bleeding during sexual intercourse (coital bleeding) has been less frequently studied in southern Africa. Bleeding during intercourse can increase the risk for HIV transmission.8–13 For anal intercourse, rectal bleeding is a known independent risk factor for HIV transmission.8–10 For vaginal intercourse, coital bleeding is also associated with increased risk for HIV transmission, at least in the case of female-to-male transmission.11–14 Bleeding as a result of intercourse may increase the risk of HIV transmission by more than 4-fold.11 Padian et al.14 found that the only case of female-to-male HIV transmission in their heterosexual transmission study occurred in a couple with repeated instances of vaginal and penile bleeding during intercourse.
The relative importance of various sources of bleeding during vaginal intercourse such as genital ulcers versus menses, however, remains unclear. Previous research has shown that women may be more vulnerable to STIs during their menstrual period, possibly as a result of cyclic variations in vaginal microflora, changes in cervical mucosa, and changes in local immunity.15–17 Studies have also shown that HIV-1 shedding varies over the menstrual cycle, with viral shedding increasing as menses approaches.18 In a cross-sectional analysis of the European Study of Heterosexual Transmission,13 men who engaged in vaginal intercourse with HIV-positive women during menstruation were more than 3 times as likely to contract HIV compared with men with HIV-positive partners who did not have sex during menses, whereas sex during menses did not influence susceptibility for HIV transmission in women. However, this finding may not have been reliable and was not replicated in a prospective analysis in the same study.19 In a cross-sectional survey of women in the United States that relied on self-reported STIs, Tanfer and Aral15 found that women who reported sex during menses were significantly more likely to also report having been diagnosed with an STI after controlling for numbers of sex partners and frequency of intercourse. Other studies, however, have failed to show a significant association between sex during menses and risks for HIV transmission.17,19,20
In summary, systematic reviews of epidemiologic research have suggested that genital bleeding during vaginal intercourse may increase the per-contact HIV transmission risk to a rate that approximates unprotected anal intercourse.21 However, it is not yet possible to draw conclusions about the relative risks of various sources of coital bleeding such as mucosal trauma and genital ulcers, and the risks of sex during menstruation are particularly unclear.22 Coital bleeding is therefore a potentially important cofactor in heterosexual HIV transmission with unknown relative risks of various sources of bleeding for male-to-female and female-to-male transmission.
We recently reported that as many as one in 3 men and women living a Cape Town township23 and one in 3 adults receiving STI clinic services24 report engaging in vaginal intercourse involving genital bleeding over a 3-month period. Individuals who reported coital bleeding also indicated significantly greater numbers of sex partners, higher rates of vaginal intercourse, and greater rates of STIs, even after controlling for rates of sexual behavior and other potential confounds. These findings mirror rates of sexual intercourse during menses found in a national sample of women in the United States15 and are greater than the rates of sex during menses found among women in Kenya.25 Thus far, studies of coital bleeding in relation to other sexual behaviors in South Africa have not identified the sources of bleeding that likely vary in their relative risks for heterosexual HIV transmission. In addition, coital bleeding in South Africa has only been examined in samples of indigenous Africans (blacks), excluding other racial groups.
The current study was conducted to further examine the prevalence of coital bleeding among South African men and women. We conducted this study in a township in Cape Town, South Africa, that has undergone considerable racial integration in recent years. Thus, the study included Coloured persons* as well as indigenous African men and women. In addition to examining the prevalence of coital bleeding and its association with sexual risk behaviors, the current study sought to identify the sources of coital bleeding among men and women.
Participants and Setting
Participants were 464 men and 531 women residing in a township and its surrounding informal settlements in Cape Town, South Africa. The sample was nearly evenly divided between indigenous African and Coloured races, and the majority of participants were under age 35. Men were significantly more likely to be married and employed than were women (see Table 1).
The township that participated in the current study is located within 20 km of Cape Town's central business district. The township was historically populated by Coloured persons during the apartheid era and is among the first townships to begin racial integration in Cape Town with large numbers of indigenous Africans moving in and around the township. According to the 2001 South African census, the township population is over 60,000 with 73% of residents Coloured and 25% indigenous Africans. The median annual income in the township is R19,000 South African rand (approximately $3100 U.S.).
Measures were administered in English, Xhosa (an African language indigenous to the Eastern Cape region of South Africa), and Afrikaans (a South African national language rooted in Dutch). Measures included demographic characteristics, history of coital bleeding, and sexual behaviors, including unprotected and condom protected acts practiced over the previous 3 months. We also assessed lifetime history of STI diagnoses and STI symptoms. Participants completed measures of substance use, history of relationship violence, and AIDS-related knowledge.
Participants reported their age, race, years of formal education, whether they were employed, and their marital status.
Participants answered 2 sets of questions regarding genital bleeding during sexual intercourse. First, we asked whether participants had sexual intercourse in the previous 3 months that involved genital bleeding. Participants who had engaged in sexual contact involving blood also indicated the frequency of coital bleeding. Second, participants were asked if they had ever in their lifetime had intercourse involving the presence of blood. Participants who indicated having had sexual intercourse involving blood were asked to identify the sources of sexual bleeding, including menstrual bleeding; sexual trauma to the vagina, anus, or penis caused by “friction” during sex; or bleeding caused by genital ulcers, defined for participants as “sores” on the vagina, anus, or penis. Responses could include multiple sources of sexual bleeding.
Sexual Behaviors and Sexual History.
Participants reported their number of male and female sex partners and frequency of sexual events, including vaginal and anal intercourse, in the previous 3 months. Participants were instructed to think back over the past 90 days (3 months) and estimate the number of male and female sex partners they had and the number of occasions in which they practiced vaginal and anal sexual behaviors. Rates of sexual behaviors were recorded using intervals representing the number of times that participants had engaged in each behavior, ranging from zero to 41 or more times. Participants also indicated whether they had ever exchanged sex for money, a place to stay, or material goods.
Sexually Transmitted Infection Histories.
Lifetime history of STI diagnoses and symptoms were assessed by participants reporting whether they had ever been diagnosed with an STI, whether they had ever experienced an open sore on their genitals (genital ulcers), atypical genital discharge, or pain or burning of their genitals. Participants also reported whether they had ever been tested for HIV, and if they had been tested, they were asked to divulge their most recent HIV test result but could decline to indicate their HIV status without penalty.
To assess lifetime history of substance use, participants indicated whether they had ever used alcohol, dagga (marijuana), mandrax (methaqualone, a sedative), cocaine, and other drugs. Participants also indicated if they had ever shared needles to inject illicit drugs and whether they have had a sex partner believed to have injected drugs.
Participants were asked if they had ever been forced to have sexual intercourse when they did not want to. As a marker for domestic violence, participants were also asked if they were ever physically hit by a relationship partner.
HIV Prevention Knowledge.
An 11-item test was used to assess HIV risk and prevention-related knowledge. Items were adapted from a measure reported by Carey et al26 and reflected information about HIV transmission, condom use, and AIDS-related knowledge, responded to as “Yes,” “No,” or “don't know.” The AIDS knowledge test was scored for the number of correct responses, with “don't know” responses scored as incorrect. This scale was internally consistent in the current sample (α = 0.76).
Participants were approached while attending one of 25 venues within the township and its surrounding settlements. Surveys were collected within the commercial center of the township as well as along main thoroughfares running through the township. Venues included a day hospital (7% of surveys), 7 shopping areas (27%), the community center that includes 6 social service facilities (25%), taxi waiting areas (17%), and 9 street junctions that included bus stops, waiting areas, and street vendors (24%). These venues were purposely preselected because they represent public access areas throughout the township and its surrounding areas.
Surveys were administered by a team of 5 indigenous African and 4 Coloured field workers recruited from the township and trained in survey collection procedures, the study protocol, and research ethics, particularly confidentiality. Sampling occurred throughout hours of the day and days of the week. Participants were approached by a field worker of matched race and gender and asked whether they would take a short time to answer an anonymous questionnaire. A total of 1059 people were approached to participate in the survey; 64 refused (45 men and 19 women), representing a 94% response rate. Eighty-five percent of participants self-administered the survey and 15% (N = 151) required assistance. Participants were informed of the sensitive nature of the survey content and were asked to complete the survey without discussing the questions or allowing others to look on. Participants were situated to allow them as much privacy as possible, which varied by venue. These procedures were similar to those used in previous venue and street intercept surveys.23,27,28 Respondents were told that the results of the research would possibly assist the City of Cape Town's Departments of Social Services and Health as well as nongovernmental organizations to develop effective HIV prevention in their community, and that the researchers were contributing a cash prize to the Community Resource Centre and Library in appreciation for the community's participation. Individual cash incentives were not provided in this study at the request of a local community advisory group.
Initial analyses were conducted to describe men and women on demographic characteristics, including age, race, education, employment status, marital status, and history of sexual contacts involving blood and sources of genital bleeding. The main study analyses were conducted to compare individuals who reported engaging in sexual activity in the past 3 months that involved blood with persons who did not report this activity. Logistic regressions compared individuals who did and did not experience coital bleeding in the previous 3 months on demographic characteristics, sexual behaviors in the past 3 months, exchanging sex for money or materials, STI diagnoses, STI symptoms, and HIV testing history. We also compared groups on substance use, relationship violence, and AIDS knowledge. Analyses were conducted separately for men and women.
Finally, we conducted multivariate logistic regressions to examine independent factors associated with coital bleeding. These analyses included all relevant demographic, sexual behavior, STI history, substance use, relationship violence, and AIDS knowledge variables. Multivariate models were conducted separately for men and women as well as for the entire sample. All results report odds ratios (ORs) adjusted for all variables included in analyses as well as 95% confidence intervals (CIs) and associated significance values.
Nearly half of the sample identified themselves as “Coloured” (N = 440 [44%]) and the other half identified as indigenous Africans (N = 482 [49%]), with the remaining 7% (N = 74) identifying themselves as white or Indian. Participants represented a range of ages (see Table 1). In addition, 37% (N = 335) of participants were married, 36% (N = 386) completed at least 12 years of education, and 41% (N = 407) were employed. More than half of participants (N = 556) indicated knowing at least one person living with HIV/AIDS.
Twenty-nine percent of participants reported that they had engaged in sexual activity that involved contact with blood in their lifetime. Both men and women reported that the most common source of coital bleeding was menses. Over 80% of men and women who had experienced coital bleeding indicated menstrual bleeding as the source. It was also common for men (35%) and women (26%) who had sex involving blood to attribute bleeding to vaginal trauma caused by “friction.” Coital bleeding was attributed to genital ulcers by 12% of men and women (see Table 1).
Results also showed that 21% of men and 16% of women had experienced coital bleeding in the previous 3 months, and 10% had done so on 3 or more occasions during that time period (see Table 1). Men were significantly more likely than women to report experiencing coital bleeding in the past 3 months. There were also significant differences between racial groups; 26% of Africans reported coital bleeding in the past 3 months compared with 10% of Coloured persons and individuals of other races (adjusted OR = 1.4, 95% CI = 1.2–1.7, P <0.01). Coital bleeding was not associated with age, marital status, education, or employment status.
Coital Bleeding Among Men
A total of 96 (21%) men reported engaging in sexual intercourse involving blood in the previous 3 months. Bivariate logistic regression analysis showed that coital bleeding for men was associated with African race, having more years of education, having multiple sex partners and higher rates of unprotected, as well as protected vaginal and anal intercourse in the past 3 months. In addition, coital bleeding among men was related to lifetime history of sexual exchange, having been diagnosed with an STI, having genital ulcers and other STI symptoms, involvement in domestic violence, dagga use, using injection drugs, and having sex partners believed to be injection drug users (see Table 2).
In the multivariate analysis for men that included all factors found significant in bivariate analyses as well as additional covariates, coital bleeding among men was significantly associated with having multiple sex partners, higher rates of unprotected vaginal and anal intercourse, and having been diagnosed with an STI (see Table 3).
Coital Bleeding Among Women
Among women, 83 (16%) reported experiencing coital bleeding in the previous 3 months. Analyses for women showed that coital bleeding was associated with being African, having greater numbers of sex partners, higher rates of unprotected and protected intercourse, exchanging sex for money or materials, STI diagnoses and symptoms, injection drug use, believing a sex partner was injecting drugs, history of sexual assault, and history of being hit by a sex partner (see Table 2).
Multivariate analysis for women indicated that African race, greater numbers of sex partners, higher rates unprotected and protected vaginal intercourse, unprotected anal intercourse, having a history of STI, and having been forced to have sex were all independently associated with recent coital bleeding (see Table 3).
Multivariate Model of Coital Bleeding for Entire Sample
A multivariate model was tested for the entire sample with demographic characteristics, including gender, and all risk factors entered as predictors of recent coital bleeding. Results showed that race, numbers of sex partners, rates of unprotected and protected vaginal intercourse, unprotected anal intercourse, STI diagnoses, experiencing genital pain or burning, and dagga use were significantly related to coital bleeding.
Results of the current study should be interpreted in light of its methodological limitations. Our survey instrument was unable to specify the sources of genital ulcers, which were reported by 17% of men and women engaging in sexual contact involving blood. Potential sources of genital ulcers that should be followed up in future research include STI as well as incomplete circumcision healing and mucosal trauma caused by various sex practices (e.g., dry sex and rough sex). Coital bleeding is also likely confounded by such factors as higher rates of sexual behaviors, greater numbers of sex partners, and culturally held gender beliefs. All of the current study findings are also limited by reliance on self-reported sexual behavior and self-reported STIs. Support for the internal validity of the study includes finding rates of coital bleeding that replicate previous research and the fact men and women paralleled each others' rates of coital bleeding. Nevertheless, self-reported behaviors are prone to underreporting biases and, therefore, the behaviors observed here, including coital bleeding, should be considered lower-bound estimates.
A major limitation of the current study was our use of a cross-sectional survey design. Our data can only speak to associations among variables without any inference of causation, and our study does not allow for estimates of coital bleeding as a predictor of HIV transmission. Prospective studies are therefore needed to determine the independent risks of coital bleeding and HIV and other STI transmission. Another study limitation is the potential generalizability of the sample. The socioeconomic characteristics of the sample, particularly its higher education levels, are not typical of more rural areas in South Africa. The higher level of education in our sample may also account for the greater knowledge of AIDS we observed. The survey acceptance and completion rates were also high in this study, most likely because of the use of field workers indigenous to the community, the community incentive that was offered, and the recognized importance of AIDS. Nevertheless, we cannot characterize the 6% of persons who refused participation. Finally, our sample was drawn from a single township in Cape Town, a more racially diverse and more affluent city than other South African cities, and we did not use a random or representative sampling procedure. Additional research is therefore needed to examine the potential role of coital bleeding in southern Africa's HIV epidemic, especially studies using longitudinal designs.
Coital bleeding was prevalent in this racially mixed community in South Africa. We found that more than one in 4 adults had a history of coital bleeding, and it was common for this practice to have occurred recently on more than one occasion. Similar to other research, coital bleeding was related to behavioral risks for HIV transmission, including multiple sex partners and higher rates of unprotected intercourse.15,23,24 People who experienced coital bleeding were more than 3 times as likely to have been diagnosed with an STI, also replicating past research.15 Among women, recent coital bleeding was associated with having been forced to have sex. We found that a significant proportion of sexual exposures to blood involved menses; for both men and women, more than three fourths of all coital bleeding was attributed to menses, which has not been consistently associated with increased HIV transmission risks. Therefore, only one in 4 persons who report coital bleeding is clearly placed at greater risk for HIV transmission by this behavior. Coital bleeding was also associated with race; indigenous Africans were twice as likely to report coital bleeding as Coloureds. Recognizing this racial difference in sexual practices involving blood is important in terms of targeting prevention messages for promoting condom use or perhaps refraining from sex during genital bleeding.
We conclude that there is an urgent need to confirm the current findings in representative samples with prospective study designs and to develop prevention messages to reduce men's and women's sexual exposure to blood as well as more general reductions in risks for HIV infection. Men and women should be encouraged to use condoms consistently to avoid HIV and other STIs regardless of whether genital bleeding occurs. Without detracting from a consistent condom use message, individuals who do not use condoms consistently should be encouraged to use condoms or refrain from intercourse when there is genital bleeding. Although there is not yet definitive evidence for increased HIV transmission risk resulting from some sources of vaginal bleeding such as sex during menses, emphasizing the use of condoms during times of genital bleeding is warranted given the importance of reducing the accumulation of risk factors for sexually transmitted HIV.
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*The overwhelming majority (77%) of the South African population is indigenous in origin and classified as African. A significant racial minority group (9% population) is known as Coloureds and consists mainly of people who are of mixed race or aboriginal in origin classified by the former government as lighter skin nonwhites. The rest of the population, descended from Europe and the Indian subcontinent, is classified as whites (12%) and Indians (2%), respectively. Cited Here...