The vaginal microbiome, a crucial aspect of women’s reproductive health, has long been overlooked in global health research, despite its profound implications for HIV prevention. In Africa, where HIV prevalence remains high, bacterial vaginosis (BV) – an imbalance of good and bad bacteria —significantly increases vulnerability to HIV in women.
However, much of the research about BV and the vaginal microbiome has been limited by critical gaps in data from Africa. Experts agree that we can unlock new approaches to managing BV and improve women’s health across the continent by integrating insights from existing HIV research, particularly in African contexts.
This urgency is highlighted in the recent review “Ecology meets reproductive medicine in HIV prevention: the case for geography-informed approaches for bacterial vaginosis in Africa”. Prepared in the context of discussions at the recent African Microbiomes in Health and Disease Symposium, the review underscores the link between BV and increased HIV risk among African women and advocates for innovative, geography-informed therapeutics, such as live biotherapeutics. It emphasises the need for Africa-specific research into vaginal microbiomes, pointing to a glaring absence of “missing African microbiomes” in global databases.
“The review significantly includes perspectives from a pan-African network of thought leaders from South Africa, Kenya, and Zambia, underscoring the importance of addressing the ‘missing African microbiomes’ in global databases,” said lead author Dr Jo-Ann Passmore, Professor at the Institute of Infectious Disease and Molecular Medicine (IDM) at the University of Cape Town and Principal Medical Scientist at the National Health Laboratory Services.
“This African-led team of reproductive health experts is well-positioned to advocate for the transformative potential of regionally tailored solutions for global health challenges to advance reproductive health.”
Professor Linda-Gail Bekker, HIV/AIDS expert and Chief Operating Officer of the Desmond Tutu HIV Foundation, echoed this perspective at the African Microbiomes in Health and Disease Symposium in October. This event brought together leading minds in microbiome science from Africa and the world to share their research and insights.
The symposium also marked the launch of the Microbial Interactions Laboratory at the IDM, a cutting-edge facility designed to accelerate microbiome research across Africa. This lab is a vital research facility, supporting scientists investigating the inner workings and interconnectedness of microbial communities to enhance their positive impact on health in Africa
“This is the unspoken elephant in the room,” Bekker emphasised. “In HIV circles, the link between vaginal dysbiosis and women’s health is often overlooked. This reflects a broader denial of women’s health issues. It’s a topic we tend to avoid, even among HIV specialists.”
Bekker highlighted a troubling statistic: every week, approximately 4,000 young women aged 15 to 24 become HIV positive, with 3,100 of them located in Sub-Saharan Africa. She warned, “If we continue to disregard women’s sexual health, mental well-being, and economic equity, we will see increased morbidity and mortality—not just from HIV, but from other health issues as well.”
She also raised concerns about a lack of awareness regarding sexually transmitted infections, noting a rise in diseases like syphilis. “We cannot treat the vaginal microbiome as an afterthought; it must be central to our research inquiries. There is significantly more funding available for HIV research than for this area, so we should leverage that support.”
But what exactly is the vaginal microbiome? At its core, it is the intricate ecosystem of microorganisms residing within the vagina. A well-functioning vaginal microbiome is crucial for preventing infections, supporting reproductive health, and even influencing fertility and the successful birth of healthy infants. However, when this delicate balance is disrupted, women may suffer from conditions such as BV and an associated increased risk of HIV transmission.
Passmore added: “Bacterial vaginosis is a major driver of HIV risk in women. If we don’t address this root cause of genital inflammation, we undermine the effectiveness of powerful HIV prevention tools. In my view, you cannot separate HIV research in women from their reproductive health, particularly the vaginal microbiome.”
Professor Elizabeth Bukusi, Senior Principal Clinical Research Scientist at the Kenya Medical Research Institute (KEMRI), Research Professor at the University of Washington, and senior author of the review adds another layer to this conversation by addressing the significant impact of socioeconomic and cultural factors on vaginal health. “In my experience, these factors make it challenging for women to access appropriate menstrual hygiene products, which predisposes them to genital tract infections and heightens their risk of HIV.”
In Africa, various socio-behavioural and biomedical factors influence the risk of BV, including menstruation, sexual practices, contraceptive use, and hygiene habits. In some regions, vaginal practices, such as the use of commercial or natural intravaginal products, vary widely based on cultural norms. Studies suggest that having multiple sexual partners and engaging in unprotected sex may increase BV risk. Additionally, male circumcision practices and the microbiota of male partners may also influence BV risk.
Prof Bukusi underscores that HIV prevention strategies must prioritise vaginal health: “A normal vaginal microbiome is vital for the reproductive health of women and their partners. Our research must account for this. There’s much we still don’t understand about the differences in vaginal microbiomes across ethnicities and regions, but this knowledge is critical for developing effective prevention technologies.”
She also stressed the importance of ensuring that interventions targeting vaginal microbiota align with women’s lives: “By making sure that new HIV prevention products do not disrupt the normal vaginal microbiota, we can protect women’s health. It’s equally important that these products integrate seamlessly into their daily practices.”
With substantial advocacy from non-profit organisations, activists, and affected communities, HIV research has garnered considerable funding and attention. Breakthroughs in antiretroviral therapies have further accelerated interest in ongoing research. Bekker and her colleagues believe a similar momentum must now be generated around vaginal health.
With the launch of the Microbial Interactions Laboratory at the IDM, and stronger research collaboration between African researchers, there is renewed commitment that Africa will lead efforts to address this critical but overlooked issue, to enhance both HIV prevention strategies and women’s health across the continent.
