Introduction:The menstrual cup is worn intravaginally, holding blood up to 12 h before emptying and reinserting. It offers protection from sexually transmitted infections and bacterial vaginosis, whilst preserving a Lactobacillus crispatus-dominant vaginal microbiome. The menstrual disc, a type of menstrual cup, is positioned near the cervix and can remain in place during sex, enabling female sex workers (FSWs) to avoid unsafe practices to conceal menstruation during work. In this study, we aim to examine the perceptions and experiences of a convenience sample of FSWs 6 months after they received a menstrual disc, along with client views. Methods:In a qualitative design, our Kenyan study recruited 38 FSWs in 4 focus group discussions (FGDs) and 86 clients in 9 FGDs. Using a semi-structured guide, a Kenyan moderator and note-taker facilitated audio-recorded discussions. Following translation and transcription, the discussions were analysed using deductive thematic analysis. Results:Six themes emerged: Anticipation and reaction to seeing the menstrual cup, Apprehension and determination to use, Benefits, Challenges, Secrecy, and Use during sex. Some FSWs were able to insert the cup on initial attempt, typically others encountered discomfort, pain, or misalignment during insertion or difficulty in removing. By the end of the third month, the majority were using the cup without experiencing any leakage, pain, or concerns. Benefits noted included ease, convenience, reduced leakage, and comfort. Financial advantage over pads and ability to work regularly were also noted. Nearly all FSWs used the cup during sex, despite prior anxiety that a client would detect it and react negatively. In three instances, the FSWs reported that a client "may" have felt the disc, whilst noting just two clients "may" have felt something. None reacted badly. In summing up their experience, the FSWs spoke very positively about the disc, with the intention to keep wearing it in the future. Many clients were supportive of the disc but did not want to know whether an FSW was wearing it. Conclusions:The FSWs quickly adapted to using the disc, finding it a comfortable, reliable menstrual product with financial advantages. With clients remaining mostly unaware of its use, the FSWs enthusiastically embraced the disc with the intention to keep using it. These positive outcomes have implications for future scale-up and roll-out to other vulnerable female populations.
Background Menstrual cups are increasingly promoted in low-resource settings as long-lasting and cost-effective menstrual hygiene solutions. However, no studies have been done among cup users to characterize the bacterial communities found on cups with long-term use when stored. This study sought to comprehensively characterize the bacterial surface profile of the menstrual cup, identify factors associated with putative pathogens, and quantify the vaginal microbiome as potential source for menstrual cup bacterial communities. Methods Over 30 months of follow-up, 369 menstrual cup samples were collected from 172 secondary schoolgirls participating in a randomized controlled trial in western Kenya. Samples were obtained from cups brought to school by girls during study visits. Menstrual cup and vaginal microbiomes were assessed using 16S rRNA gene amplicon sequencing. Mixed effects models were applied to identify factors associated with putative pathogens (Escherichia coli, Staphylococcus aureus, coliform bacteria), and factors associated with vaginal microbiome as potential source environment to bacterial surface profile of the menstrual cup, estimated via fast expectation-maximization for microbial source tracking (FEAST). Results Menstrual cup bacterial surface profile composition was primarily comprised of soil and water bacteria. However, taxa specific to the vaginal microbiome (e.g., Lactobacillus crispatus, L. iners, and Gardnerella vaginalis) were also recovered from cups. The mean relative abundance (presence) of E. coli and S. aureus was 0.09% (36%) and 0.36% (24%), respectively, with higher relative abundance among participants with HSV-2 or non-optimal vaginal community state type 4. Damaged cups were also associated with higher relative abundance of putative pathogens, while antibiotic use was inversely associated with E. coli. On average, 25.1% of cup microbiota originated from the vagina, with lower contributions among older participants and those with damaged cups. No serious adverse events related to the menstrual cup were observed in the cohort. Conclusions Interventions focused on improved cleaning and storage tools and methods, and access to clean water and sanitation infrastructure are required to maximize safety of menstrual cup use in low-resource settings.
Globally, men who have sex with men (MSM) face significant sexual stigma and are at disproportionate risk of HIV and STIs. This cross-sectional study examined differences in HIV/STI-associated psychosocial characteristics and sexual behaviors among men who have sex with both men and women (MSMW) and men who have sex with men exclusively (MSME) in Kenya. MSM were categorized as either MSMW or MSME based on the reported sex of recent sexual partners. Depressive symptoms, alcohol use, and substance use were evaluated using the Patient Health Questionnaire 9 (PHQ-9), Alcohol Use Disorders Identification Test (AUDIT), and Drug Abuse Screening Test (DAST), respectively. Overall, 730 cisgender MSM were included in this analysis (405 MSMW and 325 MSME). MSMW reported twice as many partners as MSME in the last three months, while MSME were more likely to report engaging in receptive anal sex. MSMW were more likely to report hazardous alcohol and substance use. However, MSMW scored lower than MSME on the MSM Sexual Stigma Scale. These findings emphasize the need for socially aware, stigma-informed approaches that recognize how MSM may experience and manage sexual stigma differently, shaping their mental health, substance use, and sexual risk behaviors.
Background Men who have sex with men (MSM) are at high risk for bacterial sexually transmitted infections (STIs), including gonorrhea, chlamydia, and syphilis, in Kenya. Because nucleic acid amplification testing (NAAT) is not widely accessible, most gonorrhea and chlamydia infections go undiagnosed and are treated only if symptomatic. World Health Organization (WHO)–recommended periodic presumptive treatment (PPT) and doxycycline post-exposure prophylaxis (doxyPEP) are both potential interventions to reduce the burden of bacterial STIs in this population. Neither has been rigorously tested among MSM in Africa. Objective This study aims to evaluate the effectiveness of WHO-recommended PPT versus doxyPEP, compared with standard syndromic treatment, in reducing the prevalence of bacterial STIs, including gonorrhea, chlamydia, and syphilis, among MSM in Kenya. Methods We are conducting an open-label randomized controlled trial with 2900 participants assigned in a 2:2:1 ratio to WHO-recommended PPT given every 3 months, doxyPEP taken 24-72 hours after condomless sex, or standard treatment. Sociodemographic, psychosocial, and behavioral data are collected by audio computer-assisted self-interview. Syphilis testing and treatment are provided as part of standard care. Throat and rectal swabs and urine are collected, pooled, and batch tested for gonorrhea and chlamydia by NAAT; these results are not used to guide treatment. The primary trial outcome is the combined prevalence of laboratory-diagnosed gonorrhea, chlamydia, and early syphilis after baseline; secondary outcomes include the prevalence of each pathogen individually and antimicrobial resistance in Neisseria gonorrhoeae. Primary and secondary outcomes will be compared between each intervention and the common control arm by estimating relative risks over follow-up (months 3-18) using a modified Poisson model fitted with generalized estimating equations. We will also assess implementation outcomes, including acceptability, feasibility, and safety of each intervention compared to standard care among providers and patients using a mixed methods approach. Finally, we will evaluate the potential health and economic impact of scaling up WHO-recommended PPT and doxyPEP compared to standard of care on STI control among MSM and their partners in Kenya using a stochastic, network-based model and cost-effectiveness analysis on trial data. Results Enrollment commenced on October 29, 2025. As of November 25, 2025, a total of 357 participants (12.3% of target) have been enrolled, including 133 in Kisumu, 122 in Nairobi, and 102 in Mombasa. Full enrollment is expected to take 6 months, with follow-up occurring over 18 months per participant. Results will be published in 2028. Conclusions Results of this trial will provide critical data needed to inform guidelines to improve STI control among MSM in sub-Saharan Africa and other resource-limited settings where NAAT is not routinely available. Modeled estimates of the health and economic impact of scaling up these two interventions on STI control among MSM and their partners in Kenya will provide critical information to guide policymakers considering adoption of either intervention. Trial Registration ClinicalTrials.gov NCT06468462; https://clinicaltrials.gov/ct2/show/NCT06468462 International Registered Report Identifier (IRRID) PRR1-10.2196/81113
BackgroundLittle is known about female sex worker (FSW) experiences with menstruation and its impact on their economic livelihood and health. To support a future intervention aimed at improving menstrual hygiene management (MHM) for FSW, this study sought to explore FSW's views of MHM, its impact on work, and related practices during client engagement.MethodsThis qualitative study conducted seven focus group discussions among 57 FSWs in Kisumu, western Kenya, between June and September 2023. Semi-structured guides assessed current MHM practices, the impact of menstruation on work and livelihood, and clients' perceptions of sex during menses. The data were analysed using thematic analysis.ResultsOutside of sex work, FSWs primarily reported using disposable sanitary pads, with tampons, reusable pads, cloths, cotton wool and tissue also reported as methods used to absorb menstrual flow. Many FSWs described continuing sex work during menstruation out of financial necessity. Needing to hide menstrual blood flow when engaging in sex work was customary and women resorted to unsafe practices, including intravaginal cleansing or inserting cotton or tissue high into the vagina to stem bleeding. Most FSWs spoke of losing income during their menses from stopping work entirely or reducing the number of clients seen. Women reported a range of client attitudes towards sex during menstruation, from indifference to disgust, with most reporting negative views. FSWs discussed that clients frequently refused services if they became aware of menstruation and that non-payment or physical abuse from clients could occur upon discovering menstruation.ConclusionsThe use of harmful practices to conceal menstrual blood during sex work underscores a critical need for safer menstrual management solutions for this population that can be used discreetly and comfortably during sex, such as menstrual discs that can be worn during sex. Negative perceptions of menstruation contribute to increased financial instability in this population.Clinical Trial Registration: Clinicaltrials.gov NCT05666778; Pan African Clinical Trials Registry 202305912778108.
