12th Prorities in Reproductive Health and HIV Conference Oct 2005, Stellenbosch, South Africa 1 Use of Lemon/Lime Juice Douching by Women To Prevent Infections and Pregnancy in Jos, Nigeria Godwin E. Imade 1*, Atiene S. Sagay 1, Viola A. Onwuliri 1, Daniel Z. Egah 1, Malcolm Potts 2, Roger V. Short 3 1 Faculty of Medical Sciences, University of Jos, Jos, Nigeria 2 University of California, Berkeley, USA 3 University of Melbourne, Melbourne, Australia KEEP CLICKING TO REVEAL MORE INFORMATION

2 Introduction  Women account for 50% of the 42 million people living with HIV World Wide and for 57% of the 25 million infected in sub- Saharan Africa (UNAIDS 2004).  The increasing rate of HIV infection in women in Africa is fuelled by poor socio- economic circumstances and gender inequity.  Older men have sex with younger women  Women can not insist on the use of condom  Cultural practices tend to favour the male

3 Nigeria: National HIV Prevalence trend Nigeria: National HIV Prevalence trend Population: 130 Million %

4 Nigeria: HIV Prevalence Survey 2003 Adamawa Abia Oyo Ogun Lagos Osun Ekiti Ondo Kwara Edo Delta Bayelsa Rivers Akwa Ibom Cross River Imo Anambra Enugu Ebonyi Kogi Benue Nasarawa Niger Plateau Taraba Gombe Bauchi Yobe Borno Kaduna Kebbi Zamfara Sokoto Katsina Kano Jigawa FCT Key ≥ 10% 7.5 – 9.9% 5 – 7.4% 2.5 – 4.9% < 2.5% Prevalence

5 HIV Prevalence in Jos, Nigeria  8-10% in Pregnant women*  25-30% in STI patients  54% among Female Sex Workers and as high as 60% in some parts of Nigeria *Sagay AS, Kapiga S, Imade GE, Sankalé JL, Idoko JA, Kanki P. HIV Infection Among Pregnant Women In Nigeria International Journal of Gynaecology and Obstetrics 2005, 90 (1): 61-67

6 Some Local and Traditional Agents Women Use For Douching To Prevent Sexually Transmitted Infections and Pregnancy Some Local and Traditional Agents Women Use For Douching To Prevent Sexually Transmitted Infections and Pregnancy  Lemon and lime juices  Soft drinks  Others

7 Objectives of Study  To describe the use of lemon/lime juice for douching by female sex workers (FSWs) and family planning clients (FPCs) in Jos, Nigeria.  To determine the mode and rationale for the use of lemon/lime juice for sex.

8 STUDY SITE: JOS, NIGERIA

9 Study Subjects and Methods  Study Subjects: 300 Sexually Active Women.  200 Female Sex Workers  100 Family Planning Clients  A Questionnaire Survey  Period of Interview of study subjects: June 2004  Data collation and analysis were done with File Maker Pro and SPSS Computer Soft wares

10 RESULTS Table 1: Mean ages and users of lemon/lime FCWN=200FPCN=100 Mean Age (Years) 26± ±7.1 Lemon/lime Users 163 (81.5%) 4 (4%)

11 Table 2. The mode, preference and rationale for use of lemon/lime juice by sexually active women (FSWs & FPCs) in Jos, Nigeria Predictorn=167N(%) 95% Confidence Interval (%) A. Do you use lemon or lime LimeLemonMixtureBlank105(62.8)30(18.0)18(10.8)14(8.4) B. In what concentration do you use lemon/lime juice for sex? use lemon/lime juice for sex? Neat (undiluted) Diluted in water Diluted in other Fluids OthersBlank44(26.3)75(44.9)6(3.6)22(13.2)20(12.7) C. How do you know it (lemon/lime) works? 1. It prevents pregnancy 2. It prevents infection 3. It increases sexual pleasure Both 1 and 2 Both 2 and 3 Other reasons 44(26.3)44(26.3) 8(4.8) 8(4.8) 13(7.8) 13(7.8)1(0.6) 54(34.1 ) 54(34.1 )

12 Results Continued  19 % (32/167) of the women found the juice painful.  Duration of use of lemon/lime ranged from <1 to 10 years  They did not know their HIV status.  86% would like to recommend it to others  71% were willing to take part in a study to evaluate its safety and efficacy.

13 Discussion  Lemon/lime juice is widely used in Jos for douching by women at high risk of acquiring HIV with a belief that it prevents pregnancy and STIs including HIV.  The crucial question! Does lemon/lime juice really work? –Literature revealed that women over the years have used lemon/lime juice to prevent pregnancy. E.g. Turkish Women (Norman Himes 1963) –Recent in-vitro studies have shown that lemon/lime juice immobilises spermatozoa and kills HIV. (Clarke, McCoombe & Short, 2005, Short, McCoombe,Maslin, Niam & Crowe 2004) Effects due to Low PH : Citric acid  19% of women experienced pain. Was the pain due to lemon/lime juice or as a result of pre-existing vaginal lesions? –A lesson from the case of Nonoxynol-9

14Conclusion  Lemon/Lime juice is a natural product which is already being used by sexually active women in Nigeria with a belief that it prevents pregnancy and sexually transmitted infections including HIV.  A well designed study to evaluate its safety and efficacy among women volunteers is very urgent to determine whether its use should be promoted or discouraged.  The vulnerable women in sub-Saharan Africa and other developing countries are in desperate need of a cheap, safe, effective and readily available microbicide they can control and use to protect themselves from STIs including HIV and pregnancy.  How soon will this come?

15 Jos Lemon/Lime Study Group Roger Short, University of Melbourne, Australia Malcolm Potts University of California, Berkley, USA Solomon Sagay Godwin Imade Daniel EgahViola Onwuliri Faculty of Medical Sciences, University of Jos, Nigeria

16 Acknowledgement  Mary Magdalene Project, Australian AIDS Fund Inc. Melbourne ( Courtesy: Prof. Roger Short and Brain Haill for providing funds to cover my travel expenses.  The Organisers of 12 th Priorities in Reproductive Health and HIV Conference, Oct 2005, Stellenbosch, South Africa for Bursary award to cover my registration and lodging fees

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