As for microbicides and other female-controlled STI interventions, it is important to know whether probiotics would be an acceptable product for women, particularly in developing countries. A randomized control trial of L. crispatus vaginal capsule or placebo included an analysis of satisfaction among 232 of the participants. The study found satisfaction and positive beliefs about use of the probiotic capsule were prevalent, especially among women with a clinical and microbiologic response to BV therapy, but even those without response were willing to use the product again.179 In a study of receptivity for probiotic products among 280 premenopausal female students in an African university in Nigeria, 82% of the subjects stated that they would use probiotics orally or as vaginal capsules to improve vaginal health. Over one-third (36%) of women indicated they would be willing to use the probiotics as part of their daily self-care.182 Another study examined a millet-based fermented beverage as a possible culturally appropriate vehicle for probiotic administration in Ghana.183 Several commercial probiotic products for gastrointestinal use have already been introduced in South Africa, but studies have shown poor correlation between the labeled organisms and actual contents.184
The high rate of BV women in general and in African populations in particular, the association between BV and risk of contraction of STIs, the association between BV and loss of hydrogen peroxide-producing lactobacilli, and the increasing acceptance of lactobacilli probiotics for gastrointestinal uses make urogenital use of lactobacilli attractive female-initiated strategy for treatment of BV, and possibly prevention of STIs. The fundamental difficulty with attempting this approach is the lack of knowledge of what the root cause of BV is, and thus whether supplementation with lactobacilli will help. Many confounding issues also remain, such as the exact interrelationship between BV, HIV, and HSV-2. The current incidence of HIV infection in developing countries creates an urgent need for testing novel female-controlled approaches in clinical trials, particularly the ones that have previous evidence of safety.
Previous studies suggest that well characterized lactobacilli that produce substantial amounts of hydrogen peroxide and adhere well to vaginal epithelial cells may be able to colonize the vagina and have the best chance of treating BV and potentially preventing female STI and HIV acquisition. The existing studies on this topic are intriguing but do not yet determine whether probiotic lactobacilli administered vaginally or orally would be better than current antibiotic treatment alone to prevent long-term BV recurrence. A sufficiently powered, well-designed, randomized placebo-controlled trial of a product will be required to measure the efficacy of a probiotic to augment antibiotic treatment to prevent recurrent BV. If results from such a trial demonstrate efficacy, future studies should be designed to determine whether a probiotic could significantly lower the risk for STIs and HIV infection in at-risk female populations. Although still at the experimental stage, development and testing of engineered probiotics that could deliver locally specific molecules to inhibit HIV and other pathogens, should be pursued with careful ethical considerations, as it could provide a simple, cheap and sustainable prevention tool to women in the future. Although significant hurdles in this field remain, ongoing development and testing of probiotics should become a greater priority as a means to mitigate the growing global STI and HIV epidemics.
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