Vaginal cleansing

The use of antiseptic or antiviral agents to cleanse the birth canal during labour and delivery has been hypothesized as a possible approach to reducing intrapartum transmission of HIV-1. The use of chlorhexidine lavage to reduce the transmission of group B streptococci was demonstrated in Scandinavian studies²⁹⁹. The concept is attractive for HIV prevention, as it would be an inexpensive intervention, readily achievable in most health care settings, would not require identification of HIV-infected women prior to the intervention and could have other health benefits.

A Malawian quasi-randomized study compared four-hourly aqueous chlorhexidine 0.25% solution by vaginal swabbing after vaginal examinations and a chlorhexidine wash for the baby, with a control group receiving no wash. No overall reduction was shown in the rate of HIV transmission in the study group, however, only 60% of infants were followed up. There was a significant reduction in transmission in mothers who had ruptured membranes for more than four hours²²². Most deliveries in this trial occurred within a short time of the vaginal swabbing procedure. Significant reductions in neonatal and puerperal sepsis were also seen following this intervention³⁰⁰ and use of this procedure may be advantageous for these other health benefits, in addition to any possible role in prevention of mother-to-child transmission of HIV³⁰¹.

Benzalkonium Chloride has been suggested as an alternative antiseptic agent for vaginal lavage, utilizing the antiseptic from 36 weeks gestation in an attempt to maximize the possible benefit (Table 3). The intervention of vaginal cleansing remains a feasible option for resource poor settings and further research work should be undertaken on different concentrations or formulations of agents and methods of application to determine whether the efficacy can be improved.