LemonAIDS  comes of age

 

  The results of our study of vaginal douching with lemon or lime juice by female sex workers in Jos, Nigeria were presented in public for the first time at the Sydney AIDS Conference in July 2007.  The meeting was attended by 6,500 delegates from all around the world.

The striking avenue of illuminated Poster Presentations at the IAS Conference

  The theme of the conference was: HIV Pathogenesis, Treatment and Prevention.  It is a pity that the order could not have been reversed, because as several of the main speakers pointed out, Prevention has always been far more important than Cure, and here we are dealing with a disease for which there is no cure.

  When the Mary Magdalene Project was set up, it was designed specifically to help those who are most at risk of HIV infection, female sex workers in the developing world.  A preliminary survey of  sex workers in Jos, Nigeria (Imade et al (2005) Use of lemon or lime juice douches in women in Jos, Nigeria.  Sexual Health 2, 237-239) showed that many of them routinely wash the vagina with citrus juice before or after sex, in the belief that it protects them from pregnancy and/or sexually transmitted infections.  But they had never been tested for HIV .  Many of them volunteered to take part in a study to evaluate the safety and efficacy of this douching.

  It is remarkable that only 2 years later,  Dr Godwin Imade, Prof Atiene Sagay and Dr Viola Onwuliri could come all the way from Jos to Sydney to tell us the results of the study!  Their findings have already been published in the Abstracts of the Conference Proceedings (www.ias2007.org), and were presented in a lecture and a poster on Tuesday July 24th.  Two full-length papers have also been submitted to medical journals and are under review.

Professor Roger Short (left), Professor Godwin Imade, Matthew Grigg and Professor Solomon Sagay

  The results are a mixture of good news and bad news.  The bad news is that although 398 female sex workers volunteered to take part in the study, of whom 86 regularly douched with lime or lemon juice, the HIV prevalence rate was almost identical in both groups (48% vs 49%) , showing no evidence of any protective effect against HIV infection.  Neither was there any evidence of any protective effect against other sexually transmitted diseases, such as syphilis, gonorrhoea, candida, trichomoniasis and bacterial vaginosis.  But the good news is that the douching did not make the girls any more susceptible to HIV, or any of these other sexually transmitted infections. 

    A more detailed study was made of the vaginal and cervical pathology in 374 of the sex workers, of whom 81 were using citrus douching.  There was no difference in the incidence of genital warts between the two groups, but when Pap smears were taken from the cervix, there was a significant (p=0.03) increase in cervical dysplasia in those who douched with citrus juice, and this needs to be followed up in future.

  The study design had a number of inherent failings.  It was cross-sectional, not prospective, and it was not possible to control for the timing of douching (how long before or after sex), the volume of lime or lemon juice used, or its degree of dilution.  We also do not know how often the male partner used a condom.

  So where do we go from here?  It would be nice to be able to do a longer-term prospective study, but this would be very expensive to conduct, and we do not have the funds available.  Perhaps we could design the optimal way to use the douching immediately before sex, not after, with undiluted juice, not diluted, and a tampon or piece of cotton wool to act as a reservoir.  As the evidence stands at the moment, we are in an awkward no-man?s-land of not having sufficient evidence to either promote or condemn citrus douching.

  What have the volunteers gained from the study?  At least they now know their HIV status, and all those who are HIV positive have been referred to an HIV/AIDS clinic for care, support and antiretroviral treatment.  But if lemon juice is not good enough to protect them, we need to find something much better that they can use.

  We spent many hours in Sydney discussing what to do next.  It was great to be joined by Matthew Grigg, a Final Year University of Melbourne Medical student who had deferred his studies for a year in order to go to Jos and help our Nigerian colleagues.  So the Mary Magdalene Project is just beginning!  We will surely find a better way to protect those girls from HIV infection in the future, and we have a number of really promising leads to follow.  We will keep you informed, and thanks for your support.

                                                                                                                                                                                    Prof Roger Short