Low prevalence of bacterial vaginosis in Kenyan adolescent girls and rapid incidence after first sex

Abstract

Background: Bacterial vaginosis is a risk factor for sexually transmitted infections, including HIV. Adult African women have a high prevalence of bacterial vaginosis, but it is not known when first bacterial vaginosis occurs.

Objective: This study aimed to describe bacterial vaginosis in younger African women, before and after first sex, and to determine the incidence of bacterial vaginosis and significant correlates of bacterial vaginosis incidence and recurrence.

Study design: In a prospective observational cohort study enrolling adolescents with limited sexual experience, young women aged 16 to 21 years were recruited in Thika, Kenya. Eligible participants were HIV and herpes simplex virus 2 seronegative and reported 0 or 1 lifetime sexual partner. The Nugent score was determined at quarterly visits from vaginal Gram stains. The trends in bacterial vaginosis were described over time; hazard ratios were calculated using Cox regression, and relative risk of bacterial vaginosis was estimated using generalized estimating equations and Poisson regression.

Results: A total of 400 participants with a median age of 18.6 years (interquartile range, 16-21) were enrolled. Of note, 322 participants (80.5%) reported no history of sex, whereas 78 participants (19.5%) reported sex with 1 partner. At enrollment, bacterial vaginosis (Nugent score of ≥7) was uncommon (21/375 [5.6%]). Overall, 144 participants had bacterial vaginosis at least once, for an incidence rate of 16.5 cases per 100 person-years. Before first sex, bacterial vaginosis was present at 2.8% of visits, compared with 13.7% of visits after first sex. An adjusted model of bacterial vaginosis incidence observed that first sex was associated with more than a 2-fold increased bacterial vaginosis risk (adjusted hazard ratio, 2.44; 95% confidence interval, 1.25-4.76; P=.009). Chlamydia diagnosis (adjusted hazard ratio, 1.73; 95% confidence interval, 1.1-2.8; P=.02), and herpes simplex virus 2 seropositivity (adjusted hazard ratio, 2.88; 95% confidence interval, 1.17-7.09; P=.021) were both associated with incident bacterial vaginosis. A multivariate generalized estimating equation model, including all episodes of bacterial vaginosis, demonstrated risk factors, including first sex, sexually transmitted infections, urban residence, recent sex, and no income; the most important risk factor was first sex (adjusted relative risk, 1.92; 95% confidence interval, 1.12-3.31; P=.018). The probability of bacterial vaginosis increased with each subsequent episode; mean Nugent scores increased after each bacterial vaginosis episode.

Conclusion: Using detailed longitudinal observation, this study found that Kenyan adolescents have almost no bacterial vaginosis before first sex and that initiation of sexual activity was the strongest risk factor for both prevalent bacterial vaginosis and incident bacterial vaginosis.

Keywords: Kenya; Nugent score; adolescents; bacterial vaginosis; coitarche; first sex; sexual debut.

FIGURE 1. Cumulative incidence of bacterial vaginosis and of first sexual intercourse over 60 months

A, Cumulative incidence of BV over 60 months, among adolescent girls and young women with no evidence of BV at enrollment visit. B, First sex self-reported or observed over time among adolescent girls who were sexually inexperienced at study enrollment. BV, bacterial vaginosis. Roxby. Bacterial vaginosis prevalence and incidence among Kenyan adolescent girls. Am J Obstet Gynecol 2023.

FIGURE 2. Nugent score results and bacterial vaginosis episodes over 60 months

Each horizontal row represents 1 participant observed for up to 60 months. The results are for 387 participants, 222 who never had a BV diagnosis and 165 who had a BV diagnosis. A Nugent score of 0 to 3 (optimal vaginal microbiota) is represented by a blue circle, a Nugent score of 4 to 6 (intermediate vaginal microbiota) is represented by an orange square, and a Nugent score of 7 to 10 (BV) is represented by a red diamond. A, Participants never diagnosed with BV, showing Nugent scores at time points before reported sexual intercourse. B, Participants never diagnosed with BV, showing Nugent scores at time points after reported sexual intercourse. C, Participants with at least 1 episode of BV, showing Nugent scores at time points before first sexual intercourse. D, Participants with at least 1 episode of BV, showing Nugent scores at time points after first sexual intercourse. BV, bacterial vaginosis. Roxby. Bacterial vaginosis prevalence and incidence among Kenyan adolescent girls. Am J Obstet Gynecol 2023.