Can improvements in breast-feeding practices reduce neonatal mortality in developing countries?
Objective: to review the literature on the relationship between breast-feeding practices in the first month of life and neonatal mortality. Methods: Medline and Cochrane databases were searched using the keywords breastfeeding, and neonatal mortality, supplemented with additional searches using the keywords developing countries, colostrum, infant feeding and infant mortality, hypoglaecemia, hypothermia, breastfeeding practices, and suckling. Findings: breast feeding helps prevent hypothermia and hypoglycaemia in newborn babies, which are contributory causes of early neonatal deaths especially among low birth weight and premature babies. During the late neonatal period, most deaths in developing countries are due to infections such assepsis, acute respiratory tract infection, meningitis, omphalitis and diarrhoea. Feeding colostrum and breast feeding, especially exclusive breast feeding, protects against such deaths. Key conclusions and implications for practice: in most developing countries, nearly all women breast feed in the first month of life, but often breast feeding is delayed beyond the first hour after birth, and exclusive breast feeding is not usually practised. Policies and training of staff of maternity centres and hospitals can encourage early initiation of breast feeding and exclusive breast feeding. Midwives can support community-based efforts to support exclusive breast feeding. Breast feeding plays an important role in reducing neonatal mortality and should be strongly emphasised by programmes attempting to reduce neonatal mortality. (author's)
Survey on the programs of Sanhujori centers in Korea as the traditional postpartum care facilities.
Sanhujori is the term used for the traditional Korean concept of non-professional postpartum care after delivery or abortion. Recently, postpartum care has been transferred to facilities appropriately named Sanhujori centers. This study investigates the programs offered at Sanhujori centers in order to understand the effects of this new type of health care delivery system on postpartum care. A qualitative descriptive study was conducted that included twenty-seven centers. Data were collected via face-to-face interviews followed by telephone interviews conducted from May first until the eighteenth of 2001. The findings permitted description of the general characteristics of Sanhujori centers. Programs for physical recovery, psychosocial recovery, postpartum education, parents-infant bonding, and baby care were analyzed and discussed. (author's)
This study assessed hypotheses that measures of power and control over male condom (MC) use would predict use of the female condom (FC) among women with main partners from two public STD clinics (n = 616). The women (mean age 24 years, 87% African American) were enrolled in an intervention study to promote barrier contraceptive use and were interviewed at baseline and at 6 monthly follow-up visits. Seven baseline predictor variables were assessed: her having requested MC use, his having objected, her having wanted a MC used but not asking, percentage of MC use, perceived control over MC use, anticipated consequences of refusing unprotected sex, and physical violence. In the first Poisson regression analysis, none of the hypothesized predictors was significantly associated with FC use during follow up. In the second regression analysis, which assessed the influence of the hypothesized set of predictors on follow-up FC use in situations when MCs were not used, we found two effects. Either no or inconsistent MC use before study entry was associated with less subsequent FC use; women who reported, at study entry, having more control over MC use were more likely to use FCs during follow up. We found no evidence of adoption of the FC by women in relationships marked by history of conflict over the MC, circumstances in which alternatives are most needed. On the contrary, we found that women with a history of control and consistent use of MCs were the most likely users of FCs when MCs were not used. (author's)
We examined factors associated with women's perceived advantages (pros), perceived disadvantages (cons). and decisional balance (standardized pros score minus standardized cons score) for condom use with main partner. Data from 1,938 young sexually active women who lived in five U.S. cities where the risk for human immunodeficiency virus is high were analyzed by using logistic, ordinal, and multiple linear regression analysis. For the pros scale of condom use, 27% of the women had low scores, and 33% had moderate scores. For the cons scale. 27% had moderate scores, and 5% had high scores. Of the total, 47% had a negative score on the decisional balance measure. Older age, living with a spouse or partner, or binge drinking was associated with lower pros scores and with a negative score on the decisional balance measure. Income from public assistance was associated with higher pros scores. Income from a spouse or partner or a history of sexually transmitted disease was associated with lower pros scores. Multiple sex partners or being at risk for HIV infection (based on perceptions of the main partner's behaviors) was associated with higher cons scores. Income from a job was associated with a positive score on the decisional balance measure. Our analysis identified the characteristics of women who have low pros scores, high cons scores, and negative decisional balance scores. The regression results can inform our work in HIV prevention on whether to focus on the pros, the cons, or both to obtain positive decisional balance scores and increase condom use in situations that warrant protective behaviors. (author's)
Cairo goals for reproductive health: where do we stand at 10 years? [editorial]
Ten years ago, 179 countries—including the United States—agreed on a Programme of Action that revolutionized international population policy. In the Programme adopted at the International Conference on Population and Development in Cairo, the notion of “population control” was replaced with a more comprehensive approach to reproductive health, as a means to achieve development and population stabilization by improving the lives of women and men worldwide [1]. The Programme identified policy goals to be reached by 2015, including: increasing the percentage of deliveries attended by skilled caregivers; decreasing infant and child mortality; improving the social, economic, and educational status of women; increasing access to contraceptive care; and increasing life expectancy. With its broad scope, the Programme engaged forcefully with the intrinsic interconnectedness between reproductive health and other aspects of social and economic development. The ability to delay or space childbearing, for example, can allow women to participate more fully in educational and economic opportunities, and advance women’s roles in society. At the same time, a woman’s status in a relationship may dictate whether she is able to negotiate contraceptive use with her partner in the first place. In addition, delaying or spacing childbearing may be critical to the survival of a family during difficult economic times. Adequate birth spacing also leads to better health outcomes for women and their children, while poor health status due to poverty can increase maternal and child mortality. (excerpt)
Depo-Provera is a highly effective contraceptive, given intramuscularly (150 mg/mL) once every 3 months. It has been in use in the United States for over 10 years. A new lower-dose formulation of Depo-Provera (104 mg/0.65 mL), has been developed that allows subcutaneous injection, potentially increasing the convenience, ease of administration and tolerability of this contraceptive. This prospective, randomized, single-center, single-dose trial evaluates the pharmacokinetics of the lower-dose formulation of Depo-Provera and compares the lower-dose formulation to the original formulation with regard to efficacy and duration of ovulation suppression and the return to ovulation at 12 months. While delivering a 30% lower total dose than the intramuscular formulation, the lower-dose formulation of Depo-Provera suppressed ovulation for more than 13 weeks in all subjects and was not affected by body mass index or race. Median time for return to ovulation was 30 weeks, with a 97.4% cumulative rate of return to ovulation at 12 months. (author's)
Objective: To assess the relationship between venous thromboembolic disease (VTE) and use of low-estrogen dose (<50 µg) combined estrogen-progestin oral contraceptives (OC) and three thrombosis-related gene mutations in a United States population. Design: This case-control study was conducted in 1998–2000 among women ages 15–44 years who were members of the Kaiser Permanente Medical Care Program [KPMCP] (Northern and Southern California). Cases were women with incident VTE; about three times as many women frequency matched for age were randomly selected as controls from the KPMCP membership in the same years. Data were collected in a 1 h face-to-face interview; blood was drawn to extract DNA to test for gene polymorphisms. The analysis data set comprised 196 cases (mean age 35.3 years) and 746 controls (mean age 36.2 years). Results: The adjusted odds ratio (OR) for VTE associated with current OC use was 4.07 (95% confidence interval [CI]: 2.77– 6.00). The OR associated with OC use was higher for women who were obese than in the nonobese (p = 0.01 for likelihood test for interaction) and in women without predisposing medical conditions (p = 0.02 for interaction). The adjusted OR for VTE was 7.10 (95% CI: 2.33–21.61) in women with factor V Leiden (G1691A) mutation, 2.83 (95% CI: 0.70 –11.63) in women with prothrombin G20210A mutation and 0.26 (95% CI: 0.10–0.65) in women with the MTHFR C677T mutation. The OR for VTE in OC users with factor V Leiden mutation (11.32) was elevated more than in OC users without the mutation (3.20) and women with the mutation who were non-OC users (8.42), but confidence intervals overlapped. Conclusions: The risk of VTE is increased in users of low-estrogen OC formulations. Obese women appear to be at greater risk of VTE when using OCs. (author's)
Conventional clinical protocols specify that women initiate depot medroxy progesterone acetate (DMPA) within 7 days of the onset of menses, and product labeling specifies initiation within 5 days. Women outside of this window should wait until next menses to begin, often leaving them with inadequate interim contraceptive protection. An alternative is for women to initiate monthly hormonal contraception immediately, as a bridge to DMPA, with a scheduled follow-up appointment about 4 weeks later. We evaluated bridge preferences and DMPA initiation among 150 women requesting DMPA who were ineligible for their first injection at the time of clinic visit due to menstrual cycle day. Ninety-eight percent (n = 147) rejected the standard protocol of waiting with condoms or abstinence in favor of a hormonal bridge method. Ninety-seven percent follow-up (n = 146) showed that 86% were satisfied with their bridge method. There were no post treatment pregnancies, and 55% (n = 81) of participants had initiated DMPA or another long-term contraceptive within 4 weeks of their initial clinic presentation. (author's)
Objectives: To evaluate symptoms and signs of genital irritation, vaginal leakage and acceptability of polystyrene sulfonate (PSS), which is being studied as a vaginal contraceptive and microbicide. Methods: Forty-nine women applied 2.5 mL of either 5% PSS, 10% PSS, PSS vehicle, or Conceptrol (a marketed spermicidal product containing 4% nonoxynol-9) for 6 consecutive days. Results: All women completed the study except one in the Conceptrol group who experienced vaginal symptoms after her first use and was discontinued. After both the first use and after all uses, irritation was seen among more women in the Conceptrol group than in the PSS groups, reaching statistical significance with regard to any evidence of irritation, signs of irritation and product-related irritation. There were no adverse events that were serious, unexpected and related to product use in any group. The 5% concentration of PSS may be preferable in terms of leakage and acceptability. Conclusion: The results suggest that PSS has a safety profile comparable to that of the marketed nonoxynol-9 product, Conceptrol, and appears to be associated with less genital irritation. (author's)
Women who have had a cesarean section have a risk of uterine rupture when undergoing a second-trimester pregnancy termination. Beyond the first trimester, uterine rupture has been associated with the use of labor-induction agents and, less often, a placenta accreta. Scar dehiscence, a less disruptive form of scar separation, has not been reported with dilation and evacuation abortion. We present two cases of uterine scar dehiscence causing serious bleeding after otherwise uncomplicated dilatation and evacuation procedures. Neither case was associated with uterine contractions, an iatrogenic perforation or placenta accreta. Uterine scar dehiscence, a surreptitious process, can be the cause of hemorrhage after uncomplicated dilatation and evacuation. (author's)
This open-label study evaluated the effects on body fat of the use of a low-dose oral contraceptive (gestodene 75/EE20) in a group of 61 women (OC-U group) as compared to a nonuser group (OC-N group) of 51 women who did not receive an oral contraceptive. Weight, body mass index (BMI), waist-over-hip ratio and body composition data, obtained by bioelectrical impedance [percentages of body fat (%FAT), water (%TBW) and lean mass (%FFM)], were assessed before and after six treatment cycles. Baseline OC-U group weight, BMI, %FAT, %TBW and %FFM did not differ from the OC-N group, either at baseline or at the end of the study, and did not significantly change within each group during the study. Also, there was no modification of fat distribution in either group. Among women in the OC-U group, there was a slight increase in total cholesterol levels and a trend towards higher triglycerides levels. No changes were detected in blood pressure. In conclusion, this low-dose oral contraceptive did not affect weight or body composition. Thus, our data suggest that gestodene 75/EE20 represents an appropriate OC choice and may enhance compliance of women who mistakenly believe that the use of oral contraceptives always leads to weight gain. (author's)
This paper is about how a community in Northern Tanzania experiences and reasons around urinary schistosomiasis and more specifically female genital schistosomiasis or schistosomiasis of the reproductive tract. As a disease, female genital schistosomiasis presents itself with a variety of symptoms which neither the affected woman nor the medical professionals usually recognise as schistosomiasis. The study therefore focused on symptom recognition, the question being whether women living in an endemic area can distinguish symptoms of urinary and genital schistosomiasis from those of other diseases presenting in similar ways. Data were generated using a combination of qualitative methods including observation, individual interviews and focus group discussions with diverse categories of people. All the research participants were aware of the link between water and infection. Because the disease is associated with farming, the main livelihood, there was a strong feeling among the research participants that treatment, whether in hospital or by traditional medicine could not effect permanent cure. Re-infection was considered inevitable and as schistosomiasis was said to be less poisonous than malaria, it was felt there was little choice between being infected and having food. Making sense of the symptoms was considered moreover difficult although women and men said they could tell whether blood in urine was due to urinary schistosomiasis or other conditions such as sexually transmitted diseases which present similar symptoms. The similarity of symptoms was said to be problematic also because of the sensitivity and stigma in sexually transmitted diseases. Urinary schistosomiasis is therefore a complex health problem and for any effective Control there is clearly a need to grasp this complexity. (author's)
This paper has attempted to answer the question why female circumcision persists despite increasing knowledge about its harm to women's health. We argue that the persistence is not due to being deeply rooted in the social and cultural systems where it is practised. Rather, it is the failure to base eradication on an understanding of the meaning of female circumcision, the gender power dynamics within which it is placed, the social normalisation of power and control and the way these are socially constructed and organised. The eradication efforts' have however transformed a practice that among the Kikuyu was a public action controlled and regulated through the public gaze into an individual, secret action. The elaborate and sexual educational ceremony became a simple act of cutting the clitoris, the very aspect that poses threat to women's health. In our view, it is the invisibility that female circumcision has assumed that makes prevention challenging. (excerpt)
Developing a theoretical framework on postpartum care from Tanzanian midwives' views on their role.
Objectives: to describe a theoretical framework developed from the views of midwives in relation to provision of systematic postpartum care. Design: qualitative focus group study using grounded theory approach. Setting: Dares Salaam, Tanzania. Participants: 49 nurse-midwives in five focus group discussions each having 9-11 participants. Findings: the components of the Basic Social Process of 'Becoming a good resource and support person for the postpartum woman' consisted of 'reflection' as an entry point into the process. Integration, networking, balancing, and dealing with reality, emerged as categories related to process activities. The category of 'defining abilities' required that midwives become aware of their competency and their limitations in reflection and all process activities, so that improvement can be part of 'getting ready', a category that describes what needs to be done at individual and health system level to prepare for systematic postpartum care programmes. The 'caring' category was linked to an outcome of the process 'doing things in the right way', which means providing quality postpartum care. The conditional matrix shows the midwife as an individual affected by several micro and macro conditions. Conclusions: the proposed theoretical framework can be used in understanding the dynamics of work situations and in assisting midwives to achieve the goal of being good resource and support persons for postpartum women. Interventions for midwives should focus on the major components of the framework but also on the concepts that relate the proposed framework to other central concepts in midwifery and nursing, issues in the theory-practice gap, empowerment, political awareness, involvement in policy making, decision making and dealing with job stress. (author's)
Gender inequality: still a critical issue in the development of rural KwaZulu-Natal.
There is a two-way relationship between women's involvement and economic development, that is, as economic development takes place there is the likelihood that more women will become involved in economic and socio-political activities. On the other hand, women's involvement in economic and socio-political activities will enhance economic development opportunities. This paper critically examines the current economic and socio-political status of women in KwaZulu- Natal, the possible role of women in development, and policy gaps in promoting development of the region and in promoting women's role in development. It concludes that women's advancement will play a crucial role in the development of the province. (excerpt)
This paper describes the perspectives of men on premarital sex and pregnancy in rural Zimbabwe. It is based on data collected using three qualitative methods including focus group discussions and individual interviews among men and women, and self-generated questions and statements among school youth. The paper illuminates the paradoxes of denial and violence implicit in the way men speak: as relatives on the one hand and as partners on the other regarding pregnancy in girls. The men say they react violently to premarital pregnancy, but neither do they tolerate sexual activity, or allow contraceptive information or service for unmarried daughters and sisters, even though their accounts paradoxically suggest that sexual abuse of young girls is rampant. Despite denying them preventive service and information, men speaking as partners expect girls to have knowledge about sexuality, the menstrual cycle and pregnancy. They blame their girlfriends for getting pregnant, despite indications from the accounts of the girls that it is male partners who pressure the girls into unprotected sexual activity. In such circumstances, the girls say the pregnancy may translate into unsafe, induced abortion. These are complexities at the micro-level that need to be understood for any meaningful programme to improve adolescent sexual and reproductive health. (author's)
The Human Immuno-Deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) have become a major health problem in Zambia. Because of the threat HIV/AIDS poses to the nation, the government of Zambia embarked on a public health campaign aimed at combating the scourge. However, so far this campaign has predominantly been conducted through modern channels of information communication. The overall objective of this study was to explore the role one particular traditional channel of sex information communication, the initiation ceremony of girls, could play in disseminating information to combat HIV/AIDS. Data were collected from five residential areas using systematic random sampling. Overall, the study concludes that although there is no evidence to directly link initiation ceremonies with HIV/AIDS, indirectly today's initiation ceremonies enhance the spread of HIV/AIDS. But it is encouraging to point out that, given the demonstrated willingness of the majority of initiators to learn more about HIV/AIDS, the identified inadequacies in initiation ceremonies can be removed so that this Channel is used effectively in the fight against the disease. (author's)
Objectives: to assess the knowledge, attitudes, practices and the potential role of trained Gambian traditional birth attendants (TBAs) in the prevention, recognition and management of postpartum haemorrhage (PPH). Design: a qualitative, reflective approach using semi-structured interviews followed by group discussions. Setting: poorly-resourced rural villages in The Gambia, West Africa. Participants: 22 trained TBAs and their supervisors from 12 villages. Findings: the TBAs recognised complications such as retained placenta and excessive blood loss and were well aware of the need to refer these women to a health facility quickly. Delay in referral was often due to late call-out of the TBA or lack of transport. Although the TBAs did not know the causes of excessive blood loss, they knew that anaemia was a risk factor for dying from PPH. The TBAs were keen to improve their knowledge and to participate in further training. Key conclusions: although all the TBAs were illiterate, information from training programmes had usually been incorporated into their knowledge and practice. While the local infrastructure remains poor, home deliveries and delayed referrals will continue and interventions for PPH need to be effective at the site of delivery i.e. in the woman's home. These Gambian TBAs have the potential to contribute to the management of PPH in these situations. Implications for practice: these Gambian TBAs could be trained to implement other practices relevant to prevention of PPH in the primary care setting. Linking together and maximising the skills of all health workers is important to reduce PPH mortality in home births in this setting. (author's)
HIV / AIDS in Kenya: moving beyond policy and rhetoric.
Ignorance, poverty, high incidence of sexually transmitted diseases, socio-cultural beliefs and practices, civil strife and deficient public health care systems are the main factors for HIV/Aids spread in Africa. In addition, lack of resources to finance the implementation of cost-effective interventions is a major source of concern for the sub-Saharan region. HIV/Aids-related discrimination and stigmatisation is widespread and occurs in every sector of the society; in schools, in work places through enforced testing and lay-offs; in the markets through ostracism of the identified trader and within families and communities. The fear, ignorance and lack of open dialogue about HIV/Aids and the difficulty of involving all of society, including families and communities in the search for solutions, has placed tremendous pressure on family bonds. The main purpose of this paper is to give an insight into the Kenyan scenario with the primary objective of providing an analysis of the impact of the HIV/Aids pandemic and the capacity of health-care systems .in the provision of care for those living with the disease. It looks at the national and international policies on HIV/Aids with a view of identifying existing gaps in the current situation, and most important, the paper provides views on critical areas if Kenya is to change the current trends in HIV and Aids. (excerpt)
Improving topical microbicide applicators for use in resource-poor settings.
With more than 60 potential microbicides being assessed in preclinical or clinical trials, most attention has been centered on products intended for topical application, with much less research conducted on the applicators that will be used to deliver the microbicides. However, applicator design relates to safety, efficacy, and acceptability. As the foundation for a more systematic approach to evaluating and possibly improving designs for topical microbicide applicators, we conducted a literature review and a series of interviews with microbicide developers, trial investigators, and trial sponsors. Our findings indicate that issues concerning applicator safety, reuse, and cost warrant further investigation. (author's)
Crowding: risk factor or protective factor for lower respiratory disease in young children.
To study the effects of household crowding upon the respiratory health of young children living in the city of São Paulo, Brazil. Case-control study with children aged from 2 to 59 months living within the boundaries of the city of São Paulo. Cases were children recruited from 5 public hospitals in central São Paulo with an acute episode of lower respiratory disease. Children were classified into the following diagnostic categories: acute bronchitis, acute bronchiolitis, pneumonia, asthma, post-bronchiolitis wheezing and wheezing of uncertain aetiology. One control, crudely matched to each case with regard to age (<2, 2 years old or more), was selected among healthy children living in the neighborhood of the case. All buildings were surveyed for the presence of environmental contaminants, type of construction and building material. Plans of all homes, including measurements of floor area, height of walls, windows and solar orientation, was performed. Data were analysed using conditional logistic regression. A total of 313 pairs of children were studied. Over 70% of the cases had a primary or an associated diagnosis of a wheezing illness. Compared with controls, cases tended to live in smaller houses with less adequate sewage disposal. Cases and controls were similar with respect to the number of people and the number of children under five living in the household, as well the number of people sharing the child's bedroom. After controlling for potential confounders, no evidence of an association between number of persons sharing the child's bedroom and lower respiratory disease was identified when all cases were compared with their controls. However, when two categories of cases were distinguished (infections, asthma) and each category compared separately with their controls, crowding appeared to be associated with a 60% reduction in the incidence of asthma but with 2 1/2-fold increase in the incidence of lower respiratory tract infections (p = 0.001). Our findings suggest that household crowding places young children at risk of acute lower respiratory infection but may protect against asthma. This result is consistent with the hygiene hypothesis. (author's)
Mifepristone-induced early abortion and outcome of subsequent wanted pregnancy.
Follow-up information on subsequent pregnancies after mifepristone (RU486)-induced abortion is scarce. The authors examined whether one mifepristone-induced first-trimester abortion affects the outcome of a subsequent wanted pregnancy. In a study conducted in 1998–2001 at antenatal clinics in Beijing, Chengdu, and Shanghai, China, the authors enrolled 4,925 women with no history of induced abortion, 4,931 women with one previous mifepristone-induced abortion, and 4,800 women with one previous surgical abortion and followed them through pregnancy and childbirth. The adjusted odds ratio for preterm delivery in women with one mifepristone abortion compared with women with no abortion was 0.77 (95% confidence interval: 0.61, 0.98). Although the mean birth weight of infants born to women with mifepristone abortion was 33 g (95% confidence interval: 17, 49) higher than that of infants born to women with no abortion, the frequencies of low birth weight and mean lengths of pregnancy were similar. There were no significant differences in risk of preterm delivery, frequency of low birth weight, or mean infant birth weight in the comparisons of women with previous mifepristone abortion and women with surgical abortion. This study suggests that one early abortion induced by mifepristone in nulliparous women has no adverse effects on the outcome of a subsequent pregnancy. (author's)
Traditional birth attendants (TBAs) and village midwives have been employed in many interventions to reduce maternal mortality in developing countries. This study reviews the results of 15 TBA- and midwife-based interventions that aim to improve skilled assistance in delivery and recognition and referral of complications. Outcome measures used to evaluate the impact of the programmes varied. Five of the five programmes reviewed that evaluated their impact on maternal mortality demonstrated a decline in maternal mortality ratios, two of three studies measuring morbidity-related indicators found improvement of some but not all morbidity outcomes, six of seven showed a trend of improved referral rates, and three of three found high levels of knowledge retention among trained TBAs. Programmes with the greatest impact utilised TBAs and village midwives within multisectoral interventions. These findings suggest that TBAs and village midwives contribute to positive programme outcomes. Further investigation is needed to determine the nature of their contribution within larger programmes. (author's)
We investigated how, under various conditions, the risk of mother-to-child transmission of HIV through breastfeeding compares with the risk of death from artificial feeding. We developed a spreadsheet simulation model to predict HIV-free survival during 7 age intervals from 0 to 24 months for 5 different infant feeding scenarios in resource-poor settings. Compared with artificial feeding, breastfeeding during the first 6 months by HIV-positive mothers increases HIV-free survival by 32 per 1000 live births. After 6 months, as the age-specific mortality rate and risk of death caused by replacement feeding both decline, replacement feeding appears to be safer. Under conditions common in countries with high HIV prevalence, replacement feeding by HIV-infected mothers should not be generally encouraged until after the infant is approximately 6 months old. (author's)
Current causes and management of violence against women in Nigeria.
Summary Violence against women is an important health and human rights issue. It carries with it both short- and long-term sequelae for women that can affect both their physical and psychological wellbeing. Every day obstetric providers treat patients who have been assaulted. Timely identification can interrupt the cycle of violence, prevent further injury and initiate the help-seeking process. The objectives of this study were to survey how often Nigerian obstetrician - gynaecologists see these patients in their practice and to describe the demographics and management of their most recent case so as to give an idea of the extent of the problem. This is especially important as abuse is grossly under-reported because the victims are afraid to report it because of male dominance in society and the fear of losing their homes. We used a self-administered questionnaire survey of 138 practicing obstetricians and gynaecologists in Nigeria. Questions were asked about the yearly estimation of cases seen and how recently a case was seen. The type of abuse, risk factors and management of their most recent case was also documented. Most (98.6%) obstetricians surveyed had previously managed a case of violence. The mean estimate of abused women seen was 7.0 per year. Details of the last case managed were recollected by 91.3% of respondents. The majority (51.6%) of patients were pregnant. The assailant was the husband in 69.8% of cases and the most common factor for abuse was as a result of women requesting money for the family needs from their husbands. The most common type of abuse was physical (79.4%), with 34.9% of patients sustaining cuts. Treatment and counselling were the forms of management in most cases. The police were informed in 9.5% of cases and one obstetrician had to give evidence in court. Of the pregnant abused women, 73.8% had live births. Better job opportunities and female empowerment can reduce the risk of violence. Obstetricians should screen routinely for battery, provide education about violence, assess the danger, review safety plans and refer women appropriately. We cannot solve the problem alone, but sensitivity and commitment can begin to make a difference. (author's)
Acceptability of a microbicide among women and their partners in a 4-country phase I trial.
We analyzed qualitative and quantitative data for 98 HIV-negative, low-risk women in Malawi, Zimbabwe, India, and Thailand who participated in a safety and acceptability study of BufferGel, a vaginal microbicide to determine the across-country acceptability of vaginal microbicides among women and their partners. Quantitative survey data were collected at 7 and 14 days after use among enrolled women, and exit interviews were conducted with women and their partners in separate focus group discussions. Acceptability was high in all sites (73% of women approved of the microbicide). Women in Africa, where HIV infection rates are highest, were virtually unanimous in their desire for such a product, suggesting that an individual’s perception of being at risk for HIV will outweigh concerns about side effects, problems applying a product, or other factors, when products are shown to be efficacious. But men and women reported that use, which was kept secret from an intimate partner, would be difficult and might “break the trust” of a relationship. Acceptability research across diverse settings through all stages of microbicide research, development, and postlicensure dissemination can help maximize acceptability and use. (author's)
Trends in maternal mortality due to haemorrhage: two decades of Indian rural observations.
Obstetric haemorrhage continues to be a major cause of maternal mortality. Our analysis of records of over a period of 20 years from April 1982 to March 2002 reveals that it was a contributory cause of maternal mortality in 19.9% of cases. The majority of deaths, (65%) had occurred within 24 hours of admission and in 47.5% of cases there was severe anaemia on admission; 17.5% had died due to an atonic PPH, which was the largest category, followed by ruptured uterus (15%), abruptio placenta (15%) and retained placenta (12.5%). Deaths due to obstetric haemorrhage because of a ruptured uterus, retained placenta and abortion have decreased from 22.22% between 1982 and 1987 to zero in the last 5 years and an increase was seen in deaths due to haemorrhage because of gestational trophoblastic neoplasia and ectopic pregnancy, from 1.69% to 4.87%, unclassified haemorrhage 1.96% to 7.31% and placenta praevia from zero between 1982 and 1987 to 4.87% between 1997 and 2002. (author's)
Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia.
Growing evidence has demonstrated that informal fees for health services comprise a large proportion of total health spending in some countries. In 1999, individual out-of-pocket payments for health in Cambodia were estimated at US$27 per person, with a proportion paid as under-the-table fees at public facilities. By formalizing such payments and implementing resource management systems within a comprehensive health financing scheme, Takeo Referral Hospital controlled out-of-pocket patient expenditures, ensured patients of fixed prices, protected patients from the unpredictability of hospital fees and promoted financial sustainability. Utilization levels increased by more than 50% for inpatient and surgical services, and cost recovery from user fees averaged 33%. Furthermore, the hospital phased out external donor support gradually over 4 years and achieved financial sustainability. (author's)
The progestogen component of oral contraceptives (OCs) has undergone changes since it was recognized that their chemical structure can influence the spectrum of minor adverse and beneficial effects. The objective of this review was to evaluate currently available low-dose OCs containing ethinylestradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates. The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases were searched. Randomized trials reporting clinical outcomes were considered for inclusion and were assessed for methodological quality and validity. Twenty–two trials were included in the review. Eighteen were sponsored by pharmaceutical companies and in only 5 there was an attempt for blinding. Most comparisons between different interventions included one to three trials, involving usually less than 500 women. Discontinuation was less with second-generation progestogens compared to first–generation (RR 0.79; 95% CI 0.69–0.91). Cycle control appeared to be better with second-compared to first generation progestogens for both, mono-and triphasic preparations (RR 0.69; 95% CI 0.52–0.91) and (RR 0.61; 95% CI 0.43–0.85), respectively. Intermenstrual bleeding was less with third compared to second-generation pills (RR 0.71; 95% CI 0.55–0.91). Contraceptive effectiveness of gestodene (GSD) was comparable to that of levonorgestrel (LNG), and had similar pattern of spotting, breakthrough bleeding and absence of withdrawal bleeding). Drospirenone (DRSP) was similar compared to desogestrel (DSG) regarding contraceptive effectiveness, cycle control and side effects. The third- and second-generation progestogens are preferred over first generation in all indices of acceptability. Current evidence suggests that GSD is comparable to LNG in terms of contraceptive effectiveness and for most cycle control indices. GSD is also comparable to DSG. DRSP is comparable to DSG. Future research should focus on independently conducted well designed randomized trials comparing particularly the third-with second-generation progestogens. (author's)
This paper considers evidence of the effectiveness of a non-governmental organization (NGO) primary health care programme in rural Bangladesh. It is based on data from the programme’s management information system reported by 27 partner NGOs from 1996–2002. The data indicate relatively high coverage has been achieved for reproductive and child health services, as well as lower infant and child mortality. On the basis of a crude indicator of socio-economic status, the programme is poverty-focused. There is good service coverage among the poorest one-third and others, and the infant and child mortality differential has been eliminated over recent years. A rapid decline in infant mortality among the poorest from 1999–2002 reflects a reduction in neonatal mortality of about 50%. Allowing for some under-reporting and possible misclassification of deaths to the stillbirths category, neonatal mortality is relatively low in the NGO areas. The lower child and maternal mortality for the NGO areas combined, compared with estimates for Bangladesh in recent years, may at least in part be due to high coverage of reproductive and child health services. Other development programmes implemented by many of the NGOs could also have contributed. Despite the limited resources available, and the lower infant and child mortality already achieved, there appears to be scope for further prevention of deaths, particularly those due to birth asphyxia, acute respiratory infection, diarrhoeal disease and accidents. Maternal mortality in the NGO areas was lower in 2000–02 than the most recent estimate for Bangladesh. Further reduction is likely to depend on improved access to qualified community midwives and essential obstetric care at government referral facilities. (author's)
Prevalence of Chlamydia trachomatis infection among women in a Middle Eastern community.
Common vaginal infections that manifest in women are usually easily diagnosed. However, Chlamydia infection is often asymptomatic, leading to infertility before it is detected. If it occurs in pregnancy, it could lead to significant neonatal morbidity. It may also play a role with other viral infections for e.g. Human Papilloma Virus in the development of cervical cancer. The objective of this study was to determine the prevalence of Chlamydia infection in women undergoing screening for cervical abnormalities as a part of a research project in primary and secondary care institutions in the United Arab Emirates. In this cross sectional study married women attending primary and secondary care participating in a large nationwide cervical abnormalities screening survey were offered Chlamydia testing using a commercially available test kit. This kit uses a rapid immunoassay for the direct detection of Chlamydia trachomatis antigen in endocervical swab specimens. As this study was performed in a traditional Islamic country, unmarried women were excluded from testing, as the management of any positive cases would create legal and social problems. All married women consenting to take part in the study were included irrespective of age. Of 1039 women approached over a period of eight months 919 (88.5%) agreed to participate. The number of women in the 16 to 19 years was small (0.01%) and 30% were aged over 40 years. The prevalence of Chlamydia infection in this study was 2.6% (95% confidence interval 1.2–3.3%), which was marginally higher in women screened in secondary care (p = 0.05). This is one of the few reports on the prevalence of Chlamydia infection in women from the Middle East. Due to cultural and social constraints this study excluded a large proportion of women aged less than 19 years of age. Hence no direct comparisons on prevalence could be made with studies from the West, which all included younger women at high risk of Chlamydia. However this study emphasizes the importance of cultural factors while interpreting results of studies from different cultures and communities. (author's)
Previous analyses derived the relative risk (RR) of dying as a result of low weight-for-age and calculated the proportion of child deaths worldwide attributable to underweight. The objectives were to examine whether the risk of dying because of underweight varies by cause of death and to estimate the fraction of deaths by cause attributable to underweight. Data were obtained from investigators of 10 cohort studies with both weight-for-age category (<-3 SDs,-3 to<-2 SDs,-2 to <-1 SD, and >-1 SD) and cause of death information. All 10 studies contributed information on weight-for-age and risk of diarrhea, pneumonia, and all-cause mortality; however, only 6 studies contributed information on deaths because of measles, and only 3 studies contributed information on deaths because of malaria or fever. With use of weighted random effects models, we related the log mortality rate by cause and anthropometric status in each study to derive cause-specific RRs of dying because of undernutrition. Prevalences of each weight-for-age category were obtained from analyses of 310 national nutrition surveys. With use of the RR and prevalence information, we then calculated the fraction of deaths by cause attributable to undernutrition. The RR of mortality because of low weight-for-age was elevated for each cause of death and for all-cause mortality. Overall, 52.5% of all deaths in young children were attributable to undernutrition, varying from 44.8% for deaths because of measles to 60.7% for deaths because of diarrhea. A significant proportion of deaths in young children worldwide is attributable to low weight-for-age, and efforts to reduce malnutrition should be a policy priority. (author's)
Multiple micronutrient deficiencies may contribute to low birth weight, which is a major global determinant of mortality. We assessed the effect of prenatal multimicronutrient supplementation on gestational length and birth size. We conducted a randomized, placebo-controlled, double-blind effectiveness trial among antenatal care attendees in Harare, Zimbabwe. Pregnant women (22–35 wk of gestation) were randomly allocated to receive a multimicronutrient or placebo supplement daily until delivery. Supplementation with iron and folic acid was part of antenatal care. Of 1669 women, birth data were available from 1106 (66%), of whom 360 (33%) had HIV infection. The mean gestational length was 39.1 wk, and 16.6% of the women had a gestational length <37 wk. The mean birth weight was 3030 g, and 10.5% of the infants had a birth weight < 2500 g. Multimicronutrient supplementation was associated with tendencies for increased gestational length (0.3 wk;95%CI:-0.04, 0.6 wk;P=0.06), birth weight (49 g;-6, 104 g; P = 0.08), and head circumference (0.2 cm; -0.02, 0.4 cm; P = 0.07) but was not associated with low birth weight (birth weight < 2500 g) (relative risk: 0.84; 0.59, 1.18; P = 0.31). The effect of multimicronutrient supplementation on birth weight was not significantly different between HIV-uninfected (26 g; -38, 91 g) and HIV-infected (101 g; -3, 205 g) subjects (interaction, P > 0.10). Antenatal multimicronutrient supplementation may be one strategy to increase birth size. (author's)
Reproductive health research challenges.
Welcome to the journal 'Reproductive Health'. The Journal adopts the broad definition of reproductive health as endorsed by the International Conference on Population and Development in Cairo in 1994. Reproductive health is defined as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Good reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Men and women should be informed about and have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth. Reproductive health includes a much wider area than only physical wellbeing. Topics such as sexual- and gender-related, social and ethical issues are discussed and researched more than before. Recently, a series of papers pointed out the inequalities in access to reproductive health services as a major contributor to maternal morbidity and mortality. There is a need for more research into inequities in the access and utilization of reproductive health services and information. (excerpt)
We are writing in reference to the recent article by Shell-Duncan and McDade. We share the authors’ interest in the development and application of a field-friendly screening method for detecting iron deficiency in community settings. The authors reported a community-based survey based on the measurement of soluble transferrin receptor (sTfR) using a modified whole-blood spot method, a method which required a single finger prick blood sample placed onto a spot of filter paper. We feel it is also necessary to bring to your attention some inaccuracies and limitations of the method used. Firstly, the authors claimed that their method for measuring sTfR on whole blood spot samples can be performed with the commercially available Ramco kit. We disagree with this important comment because the standards and sample diluents used for the assay were not part of the commercial kit, but were “home-made” in the laboratory of the authors. This would mean that even with the Ramco kit, the dilution buffer and standards would be inconsistent among laboratories with potentially different results. (excerpt)
We welcome the attempt by Spacek et al. to develop a practical, accurate, and less expensive alternative to universal CD4 lymphocyte testing to guide the initiation of potent antiretroviral therapy in resource-limited settings. In South Africa the government has recently announced its intention to provide antiretroviral treatment for individuals with HIV and AIDS. We are aware that the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa calls for the initiation of antiretroviral treatment based on clinical assessment and CD4 lymphocyte count. However, universal CD4 lymphocyte testing in South Africa will require substantial upgrading of the current nationwide capacity. Therefore, we investigated the utility of the algorithm of Spacek et al. in our own clinic setting. As flow cytometry is available in South Africa, we chose to apply method II in their paper. Using this algorithm, patients with total lymphocyte counts of less than 1200 cells/mm/3 are predicted to have CD4 lymphocyte counts of less than 200 cells/mm/3; patients with total lymphocyte counts of 1200 cells/mm/3 or greater and hemoglobin levels less than 12 g/dl require CD4 lymphocyte testing; and patients with total lymphocyte counts of 1200 cells/mm/3 or greater and hemoglobin levels of 12 g/dl or greater are considered to have CD4 lymphocyte counts of 200 cells/mm/3 or greater. We conducted a retrospective review of patients’ charts at the King Edward VIII Hospital Family Clinic, a public sector, tertiary care referral HIV/AIDS Clinic in Durban, KwaZulu, Natal, where potent antiretroviral therapy is still inaccessible to the majority, but where CD4 lymphocyte counts and full blood counts are performed routinely. (excerpt)
Health care reform and the crisis of HIV and AIDS in South Africa.
South Africa’s transition to a democracy — characterized by a liberal constitution, a bill of rights, and attempts to pursue reconciliation rather than revenge — has been widely admired as a paradigm shift in human relationships from seemingly inevitable conflict to a negotiated peace. The challenge of narrowing racial disparities in health care is a formidable one for the new government. 1,2 The high rates of infection with the human immunodeficiency virus (HIV) and full-blown AIDS add another layer of complexity. In this review I evaluate health care reform and responses to the pandemic of HIV and AIDS during the first decade of the new democracy. (author's)
Community pharmacy in Ghana: enhancing the contribution to primary health care.
It is widely believed that pharmacists could make a greater contribution to the provision of primary health care, especially in developing countries. Particular strengths of pharmacy services commonly cited include their accessibility within many communities and the opportunities for advising on the management of health problems. The potential for pharmacy to respond to health care needs and contribute to specific health policy objectives is receiving greater prominence both internationally and in individual countries. However, despite this widely acknowledged potential, developments have been limited. Pharmacy is concerned with promoting the safe and appropriate use of drugs. Drug use in developing countries has frequently been described as irrational. It is influenced by a wide range of factors, including health and drugs policy, the organization and provision of health care, the availability of objective information, and health beliefs and cultural perspectives regarding health and drug therapy. The practices of pharmacy retailers, which are conducted in the context of wider structures and processes of health care provision, have also been questioned. The aim of this paper is to consider possible directions for community pharmacy service development in Ghana. The paper draws on the literature relating to health care, drug use and pharmacy in Ghana to describe the background against which pharmacy services operate. In the context of current directions in pharmacy practice and policy, potential opportunities and barriers regarding the development of services are then addressed. (author's)
Successful cervical cancer prevention depends on reaching, screening and treating women with pre-invasive disease. We aimed to evaluate the effectiveness of two media interventions—a photo-comic and a radio-drama—in increasing cervical screening uptake. A randomized controlled trial compared a photo-comic on cervical cancer screening with a placebo comic. One month after the comics were distributed a radio drama paralleling the photo-comic was broadcast on the community radio station and a retrospective evaluation was carried out. The trial was set in Khayelitsha, a peri-urban squatter community near Cape Town, South Africa. A random sample consisted of 658 women between the ages of 35 and 65 years, from a stratified sample of census areas. The main outcome measure was self-reported cervical screening uptake 6 months after distribution of the comics. Seven percent (18 of 269) of women who received the intervention photo comic reported cervical screening during the 6 months follow-up, compared with 6% (25 of 389) of controls (P 5 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (nine of 53, 17%) than those who did not (19 of 429, 4%; P < 0.001). We conclude that the photo-comic was ineffective in increasing cervical screening uptake in this population. The radio-drama may have had more impact, but only a minority of women recalled being exposed to it. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action. (author's)
Analysis of generic antiretroviral formulations manufactured in India.
Highly active antiretroviral therapy has significantly modified the natural history of HIV infection, decreasing mortality and the incidence of opportunistic infections. However, 90% of infected individuals worldwide do not have access to these drugs, because their cost is too high for the developing countries that are most affected by the AIDS epidemic. India is a major producer of generic antiretroviral drugs that are widely used in developing countries because they are less expensive than those produced elsewhere. There have, however, been reports of generic medications, including antiretroviral agents, which contain little or no active ingredients. It is therefore important that generic antiretroviral medications be analysed for drug content. Data describing the integrity of these drugs are not publicly available except for a report by Penzak et al. on nevirapine. We analysed the content of six commonly used nucleoside and nonnucleoside reverse transcriptase inhibitors alone and in combination, from three Indian sources (Aurobindo Pharma, Ranbaxy and Cipla) and compared the values with proprietary medications manufactured in the United States. (excerpt)
Household decision-making on child health care in developing countries: the case of Nepal.
Quantitative studies on health care utilization often overlook the importance of capturing the ‘pathway’ of household decision-making processes. This paper offers a four-step construct which maps out a hierarchical scale of household decision-making regarding child health care. The construct begins with the perception of illness, moves on to choice of care and provider, and finally ends with health care expenditure. The construct is substantiated by means of a descriptive analysis of nationally representative data from the 1996 round of the Nepal Living Standards Survey. About 10% of the total population reported illness, 69% of whom sought care, and depending upon the provider they chose, spent between 2.5 to 4.3% of their per capita household total annual expenditure on health care. Bivariate analysis detected age and gender biases in the perception of illness, but if a child was reported ill, all subsequent steps were found to be free from such differences. Further analysis, that took into account the changing effects of income and mother’s education, indicated that there may be conceptually different household dynamics that underlie boys’ and girls’ illness perception; this ultimately determines whether or not health care is sought. The authors put forward a hypothesis to be tested by future studies. They argue that gender role significantly affects the perception of illness, but not necessarily the subsequent care-seeking. The relevance of this hypothesis to explaining the typical South Asian characteristic of differential child mortality rates is discussed. (author's)
A randomized trial of multivitamin supplements and HIV disease progression and mortality.
Results from observational studies suggest that micronutrient status is a determinant of the progression of human immunodeficiency virus (HIV) disease. We enrolled 1078 pregnant women infected with HIV in a double-blind, placebo-controlled trial in Dar es Salaam, Tanzania, to examine the effects of daily supplements of vitamin A (preformed vitamin A and beta carotene), multivitamins (vitamins B, C, and E), or both on progression of HIV disease, using survival models. The median follow-up with respect to survival was 71 months (interquartile range, 46 to 80). Of 271 women who received multivitamins, 67 had progression to World Health Organization (WHO) stage 4 disease or died — the primary outcome — as compared with 83 of 267 women who received placebo (24.7 percent vs. 31.1 percent; relative risk, 0.71; 95 percent confidence interval, 0.51 to 0.98; P=0.04). This regimen was also associated with reductions in the relative risk of death related to the acquired immunodeficiency syndrome (0.73; 95 percent confidence interval, 0.51 to 1.04; P=0.09), progression to WHO stage 4 (0.50; 95 percent confidence interval, 0.28 to 0.90; P=0.02), or progression to stage 3 or higher (0.72; 95 percent confidence interval, 0.58 to 0.90; P=0.003). Multivitamins also resulted in significantly higher CD4+ and CD8+ cell counts and significantly lower viral loads. The effects of receiving vitamin A alone were smaller and for the most part not significantly different from those produced by placebo. Adding vitamin A to the multivitamin regimen reduced the benefit with regard to some of the end points examined. Multivitamin supplements delay the progression of HIV disease and provide an effective, low-cost means of delaying the initiation of antiretroviral therapy in HIV-infected women. (author's)
Multivitamins, nutrition, and antiretroviral therapy for HIV disease in Africa.
Readers could be forgiven for being confused by the literature on micronutrients and the pathogenesis of human immunodeficiency virus (HIV) disease. Micronutrients play important roles in maintaining immune function and neutralizing the reactive oxygen intermediates produced by activated macrophages and neutrophils in their response to microorganisms. Serum and plasma measurements of vitamins and trace elements, which are imperfect indicators of body stores, have shown that deficiencies are common among HIV infected persons, especially those who are underprivileged, such as women in developing countries, and injection-drug users. A vicious cycle has been envisaged in which undernourished HIV infected persons have micronutrient deficiencies, leading to further immunosuppression and oxidative stress and subsequent acceleration of HIV replication and CD4+ T-cell depletion. 1 It has been difficult, however, to show causal associations between specific deficiencies and adverse clinical outcomes in HIV-infected persons, and data linking replacement or supplementation of specific micronutrients with a clinical benefit have been sparse and inconsistent. In this issue of the Journal, Fawzi and colleagues report the results of a controlled trial of multivitamin supplementation among HIV-infected pregnant women in Tanzania. 2 Their report prompts important questions about the plausibility of the findings but also raises broader issues concerning the role of nutrition in the public health response to HIV infection and AIDS in Africa in this era of increasing access to antiretroviral therapy. (excerpt)
Regression equations to estimate percentage body fat in African prepubertal children aged 9 years.
The regression equations of Slaughter and Dezenberg, which are based on mixed ethnic samples, are currently recommended for predicting body fat from skin-fold-thickness measures in prepubescent children of African ancestry. These equations contain methodologic problems that could make them inappropriate for African children. The objective was to apply the Slaughter and Dezenberg equations to predict body fat in African prepubertal children and to compare the results with body fat measured by dual-energy X-ray absorptiometry (DXA). If significantly different outcomes were observed, then the objective was to develop new prediction equations and validate them on African children. The Slaughter and Dezenberg equations were applied to a cross-sectional sample of 214 prepubescent (Tanner stage 1) African children (118 boys). Body fat was determined by DXA, and subcutaneous fat at triceps, biceps, subscapular, suprailiac, thigh, and calf sites was measured with use of Holtain calipers. A randomly selected sample of 134 participants (78 boys) was used to generate new prediction equations that were validated on the remaining 80 participants (40 boys). The Slaughter and Dezenberg equations significantly underestimated (P<0.001) body fat compared with DXA in both boys and girls. The best combination of skin-fold thicknesses to predict body fat in African prepubertal boys, controlling for chronologic age, was triceps, biceps, subscapular, suprailiac, and thigh (SEE = 2.87), and for girls it was biceps, subscapular, suprailiac, thigh, and calf (SEE = 3.51). The Slaughter and Dezenberg equations are unsuitable for predicting body fat in 9-y-old African prepubertal children. New equations that are based on skin-fold-thickness combinations from African children provide more accurate estimates. (author's)
10 best resources in ... cost analysis for HIV / AIDS programmes in low and middle income countries.
Cost analysis is a powerful tool; programmes can use the data to develop realistic budgets, calculate the most efficient use of resources, and understand the demands of scale-up or replication. To provide programme managers and decision makers with a guide to costing in HIV/AIDS, we review the best resources in this area. A cost analysis identifies all inputs or resources that a programme uses and their costs. A cost-effectiveness analysis goes one step further, measuring the impact a programme has on the HIV/AIDS epidemic relative to its cost. Programme planners can use these findings to make informed decisions about how and where to channel resources. For detailed information on costing methodology, we recommend Costing guidelines for HIV prevention strategies and for templates to help guide data collection, we refer you to online worksheets on the UNAIDS website. Only a handful of published HIV/AIDS cost studies exist outside of sub-Saharan Africa, and even within sub-Saharan Africa, there are few studies relative to the many existing interventions. In line with much of the literature, we have classified the evidence according to the level of impact of the costs: (1) provider, (2) patient, and (3) national or international. The best place to keep track of such studies is at the website of the International AIDS Economics Network. (excerpt)
Increased morbidity and mortality due to the HIV/AIDS epidemic in South Africa necessitates the examination of policies for the protection and support of school age children. At a colloquium held in Durban participants from government and non-government health and education sectors briefed delegates on key policies and programmes for promoting the health and mental health of school age children. Researchers gave evaluative accounts of the impacts of these measures and presented an overview of South African children’s health and mental health needs. In the discussions that followed four critical issues emerged: intersectoral collaboration, accountability, retraining middle management, and a more comprehensive strategy to support pupils and teachers infected and affected by HIV/AIDS. (author's)
Use of volunteer medical brigades to assess growth in Honduras.
We endeavored to determine whether a visiting volunteer medical group could effectively measure growth status among children in a developing country, identify predictors of poor growth, and thus participate in nutritional surveillance. Cross-sectional measurements of growth and diagnosis of current clinical conditions were made. A sample of 3284 Honduran children aged 2–11 years who sought care from volunteer medical brigades between January 2000 and May 2001 were included in the study. Main outcome measures were height-, weight- and body mass index-for-age z scores. Compared with standard reference data, 10 per cent of children were moderately underweight and 3.3 per cent severely underweight, while 13.7 per cent were moderately stunted and 6.4 per cent were severely stunted. After simultaneous adjustment for demographics, clinical conditions, and village characteristics, nutritional complaints were associated with lower body mass index- and weight-for-age, while children seen in villages with clean water and higher levels of development had higher body mass index- and weight-for-age. Older children had poorer growth for all parameters. It was concluded that Honduran children seeking care from a volunteer medical brigade were underweight and stunted compared with a reference population. This study demonstrates that a visiting volunteer group can collect quality growth data that may assist in nutritional surveillance, identify predictors of poor growth, and provide information useful for local public health initiatives. (author's)
Low-dose mifepristone for contraception: a weekly versus planned postcoital randomized pilot study.
In this randomized pilot study, we compared the contraceptive efficacy, safety and side effect profiles of weekly versus planned postcoital regimens of low-dose mifepristone. Forty participants were randomized to receive mifepristone 10 mg weekly or planned postcoitally (to be used no more frequently than once every 5 days), for 12 consecutive months. Participants were evaluated monthly to determine pregnancy, ovulation status and acceptability of physical side effects. We ended this pilot study prematurely due to low efficacy and predetermined stopping rules. Three pregnancies during 56 woman-months occurred in the weekly group and three pregnancies during 68 woman-months occurred in the planned postcoital group. Almost half of the participants ovulated monthly on either regimen. The majority of the participants found the physical side effects of these regimens acceptable. Participants in the planned postcoital group, however, found adhering to the regimen more difficult than those in the weekly group. Mifepristone 10 mg used weekly or planned postcoitally did not adequately prevent pregnancy in our pilot study population. Although the concept of intermittent low-dose mifepristone is appealing, the contraceptive effectiveness was disappointing. (author's)
Misoprostol overdose during the first trimester of pregnancy.
Misoprostol is a synthetic prostaglandin E1 used during the first trimester of pregnancy as an adjacent to RU486 for medical termination of pregnancy. We present a case of a healthy 23-year-old woman who was admitted due to misoprostol overdose, used to induce an illegal abortion. Manifestations of toxicity included abdominal pain, vomiting, diarrhea and confusion. Treatment was supportive and included gastric lavage and administration of activated charcoal. Recovery was completed within a few hours, and the patient was scheduled for a dilatation and curettage the following day. (author's)
The Lothian Emergency Contraception Project (LECP)—a primary care-based intervention to offer advance supplies of emergency contraception (EC) to women aged 16–29 was not associated with a reduction in abortion rates. We undertook case studies, utilizing qualitative and quantitative methods, to evaluate the intervention. In this article we present findings from qualitative interviews with 44 primary care professionals working at case study sites and 22 women who had received advance supplies to explain this failure. Professionals reported that women rarely asked for advance supplies of EC and they were reluctant to offer supplies to women because of concerns about contradictory sexual health messages implied by the offer, a perceived association of EC use with chaotic behavior by women, views about the sort of women suitable for advance supplies and practical difficulties making the offer. Women were reluctant to ask for advance supplies because of misgivings about the appropriateness of offering advance supplies to everybody and concerns about being judged by health professionals as morally inadequate. If advance provision of EC is to be successful in reducing abortion rates, professionals must address their concerns about EC and develop imaginative ways of encouraging women most at risk of unwanted pregnancy to take supplies home. (author's)
Despite the ready availability of effective contraception, termination of pregnancy continues to be a substantial health care need. In Britain, the Abortion Act allows pregnancy to be terminated provided that two medical practitioners agree that the specific criteria of the act have been met. A range of methods are available including medical termination using mifepristone followed 48 h later by prostaglandin and surgical termination under general anaesthesia, local anaesthesia or conscious sedation. The method choices and safety are greatest when termination is carried out before 10 weeks gestation. Unfortunately women continue to meet negative judgmental attitudes both in primary and secondary care, delaying referral and stifling choice. (author's)
Children in northern Nigeria and elsewhere in the hot, arid western Sahel, are at risk of having their lung function compromised by a variety of factors, including undernutrition, environmental factors (e.g. airborne pollutants such as dust and smoke from wood fires), chronic upper-respiratory tract infections, and low socioeconomic class. We were interested in using spirometry to compare the pulmonary function of Nigerian children and adolescents aged 6–18 years who were living in urban and rural settings with the corresponding standards for African-American children. A total of 183 boys and girls in the rural village of Sabon Fobur on the Jos Plateau and another 128 boys and girls in the city of Jos were tested to determine their forced vital capacity (FVC), FVC at 1 s (FVC1), and peak expiratory flow (PEF). The nutritional status of the subjects was determined by measuring the body mass index (BMI), triceps skin-fold thickness, and mid-arm circumference, and fatfree mass (FFM) and fat mass (FM) by bioelectrical impedance analysis. According to the results of anthropometry, the subjects in Sabon Fobur and Jos were lean but generally adequately nourished. The mean FVC, FVC1 and PEF values for the rural males were 1.85l, 1.76l, and 3.52l, and for the urban males they were 1.97l, 1.79l, and 3.47l, respectively. The corresponding values for the rural females were 1.79l, 1.70l, and 3.37l, and for the urban females they were 1.76l, 1.67l, and 3.09l. These values were approximately 100 per cent of the corresponding values for African-American children. In general, strong correlations were found between each of the three lung function parameters and age, weight, height (only for the males), BMI,MAC, and FFM. These results show that: (1) the lung function of Nigerian children and adolescents living in either rural or urban areas were similar and compared favorably with African-American standards, and (2) weight was as important as height in determining pulmonary function. The inclusion of FFM as an explanatory variable did not further increase the accuracy of the prediction, even in a population where malnutrition may be prevalent. Therefore, we conclude that measurements of height and weight are all that are required for the assessment of lung function using spirometry in Nigerian children. (author's)
Effect of intermittent treatment with mifepristone on bleeding patterns in Norplant implant users.
A double-blind, placebo-controlled, randomized trial, was carried out in 120 Norplant users to evaluate the effect of mifepristone, 100 mg/day administered for 2 consecutive days every 30 days, on the vaginal bleeding pattern. Treatment was given from months 2–7 of implant use. Volunteers recorded bleeding and spotting days, during treatment and for the ensuing 6-month period. During treatment, women on mifepristone recorded the same frequency of bleeding/spotting episodes but significantly less prolonged bleeding episodes than placebo controls (mean ± SD: 11 ± 3 vs. 22 ± 23 days) and their total number of bleeding days was 35% lower than in the placebo group. After the end of mifepristone use, bleeding patterns were similar in both groups. One pregnancy occurred in the mifepristone-treated group, in month 6 of treatment, the outcome was a healthy male baby. We conclude that intermittent administration of mifepristone can offer a clinically significant improvement of the vaginal bleeding pattern in Norplant users. (author's)
Guided by the conceptual framework of the Health Belief Model, this study aimed to identify factors associated with pregnant women’s expressed willingness to accept voluntary counselling and HIV-testing (VCT). A cross-sectional interview survey of 500 pregnant women, complemented by focus group discussions, was conducted in the Kilimanjaro region of Tanzania. Constructs derived from the Health Belief Model explained 41.7% of women’s willingness to accept VCT. Perceived high personal susceptibility to HIV/AIDS, barriers related to confidentiality and partner involvement, self efficacy regarding alternative feeding methods and religion were all shown to be associated with willingness to accept VCT. The women’s acceptance of VCT seems to depend upon their perceiving that VCT and alternative feeding strategies provide clear benefits, primarily for the child. Whether a positive attitude to VCT and alternative feeding strategies are transformed into actual behaviour depends on a set of complicated decisions in which several potential psychological consequences are assessed. Sharing the diagnosis with partners may not have the intended effect if there is a lack of sensitivity to the women’s fear of blame and rejection. If pregnant women are to fully participate in and benefit from mother-to-child-transmission prevention efforts, their partners must be committed and involved in the process. (author's)
HIV prevalence and risk factors among fishermen in Sihanouk Ville, Cambodia.
We assessed HIV antibody and risk exposures in a cross-sectional sample of 446 fishermen in Sihanouk Ville, a port and fishing area in Cambodia, where high HIV prevalence has been found in sentinel surveillance studies. HIV prevalence was 16.1%, and was highest among unmarried men (17.3%) compared with married (14.6%). Men who stayed in port over one day had a significantly higher prevalence of HIV (31.7%) than those in port for = day (14.6%). Men who had sex exclusively with their wife or girlfriend in the previous three months were significantly less likely to be HIV-infected than those who reported no sexual relations during the same time period (11% vs 23.7%, respectively). HIV infection in Cambodian fishermen was more than double that estimated in the general Khmer population. Although a large-scale condom promotion programme has been implemented in Sihanouk Ville, additional prevention programmes are needed to prevent further spread of HIV. (author's)
It is generally agreed that social environments influence the success of health education but there is less agreement about what constitutes a health-enabling community context. Focuses on the processes underlying successful peer education. Outlines a case study conducted by the author of a schools-based peer education and condom distribution programme for HIV prevention in a school setting. Identifies a number of obstacles to the development of new peer norms, youth empowerment and critical thinking that are essential preconditions for programmes success. Notes that the research conducted that one important reason for the failure of HIV-prevention programmes lies in the over-optimism of those who believe that peer education programmes can change behaviour in marginalized communities in the absence of appropriate partnerships. Programme success is unlikely without parallel efforts to create supportive social environments, through building alliances between peer educators and more influential groups. (author's)
Running on empty: sexual co-factors are insufficient to fuel Africa's turbocharged HIV epidemic.
The hypothesis that heterosexual transmission drives sub-Saharan Africa’s HIV epidemics requires much faster transmission dynamics in Africa than in the US and Europe, where heterosexual transmission is arguably insufficient to maintain existing levels of HIV prevalence. Initially, experts surmised that Africans had more sexual partners; however, studies of sexual behaviour circa 1990 undermined this assumption. Next, it was supposed that the high burden of bacterial sexually transmitted disease (STD) in Africa explained greater HIV transmission efficiency; however, during the 1990s, community studies in Africa showed that STD had much less than expected impact on HIV transmission. Current attempts to explain HIV as a primarily sexual epidemic in Africa propose multiple factors, including herpes simplex virus type 2, lack of male circumcision, concurrency, and others. These factors also fail for various reasons to account for Africa’s HIV epidemics: they are present also in the US and/or Europe; they do not correlate with differences in HIV prevalence across Africa; etc. While behavioural and biological variables influence personal risk for HIV acquisition, the available evidence suggests that they do not differentiate African from US and European epidemics, nor do they determine the differential HIV epidemic trajectories noted across Africa. (author's)
Correlates of condom breakage and slippage among university undergraduates.
An anonymous questionnaire was used to explore relationships between condom breakage, slippage and possible correlates in a sample of 428 single, never married college men and women. Specific condom use errors and problems that could lead to breakage and slippage were also examined. A three-month recall period was used. Breakage/slippage was found to be associated with never receiving instruction on correct condom use (P=0.001), more than one sex partner (P=0.001), more frequent use of condoms (P=0.001), and partner(s) being less than highly motivated to use condoms (P=0.02). Those reporting that condoms had contacted a sharp object were three times as likely to report breakage (P=0.001). Those using condoms without proper lubrication (P=0.006) and those experiencing loss of erection during sex (P=0.001) were more likely to report slippage. Further research should investigate the efficacy of instruction addressing specific factors that may reduce the incidence of breakage/slippage, thereby enhancing condom effectiveness. (author's)
I've spent the past week struggling with what you might call a contraceptive conundrum because, as regular readers may remember, for the April 2004 issue of the Journal I was asked to conduct and write up a qualitative survey of European women’s attitudes to sex education. I duly reported on what one might call the basics: how the women had learned about gender differences, the fact of sex, the values surrounding the act and how to make it pleasurable and meaningful, and so on. The message that came through was clear. Sex education had been largely accurate, informative and positive – but it had also been somewhat emotionally charged. Many women throughout Europe, particularly in more Catholic countries, had spent their early years squirming with embarrassment. The current cry from the heart was not for different content in sex education but for better delivery, more relaxed and sympathetic presentation and, above all, the teaching of more emotional literacy around sexuality. (excerpt)
IUD insertion following medical TOP [letter]
We found the FFPRHC Guidance on ‘The copper intrauterine device as long-term contraception’ most informative but were surprised by the lack of data relating to intrauterine device (IUD) insertion following medical termination of pregnancy (TOP). Our district general hospital performs more than 300 medical TOPs annually up to 83 days’ gestation. All women are screened for sexually transmitted infections and there is a 96% complete miscarriage rate. In a proportion of cases abortion occurs or completes at home in the first few days following the administration of misoprostol. If abortion occurs in hospital, contraception such as oral contraceptives or DepoProvera is commenced immediately by the nursing staff. Women are then reviewed in a weekly specialist family planning clinic approximately 7–10 days after their termination procedure. This review ensures that the termination is complete and allows the patient’s physical and emotional status to be assessed. IUDs or implants are inserted at this visit. Occasionally at this review appointment bleeding is still continuing and further misoprostol is required to expel all products of conception. Another appointment is then made 1 week later for the IUD fitting. (excerpt)
Declining HIV rates in Uganda: due to cleaner needles, not abstinence or condoms.
Public health and political authorities have ascribed the apparent decline in Ugandan HIV or AIDS rates to increased rates of sexual abstinence or condom use. However, what appears to be special about Uganda is that in the middle to late 1980s there was a growing public awareness of health care risks. Given the lack of evidence for transmission of HIV to healthy persons by penile–vaginal intercourse, the improvement in injection safety is the best candidate for declining HIV and AIDS rates. (author's)
Does selected ecological evidence give a true picture of HIV transmission in Africa?
Current reconsideration of the contributions of various modes of transmission to HIV epidemics in sub-Saharan Africa has important implications for HIV prevention. In recent reviews, we argue that accumulated evidence supports the hypothesis that unsafe health care fuels Africa’s HIV epidemics. In response, critics have presented selected ecological evidence—age and sex distribution of HIV infections and geographic distribution of hepatitis C virus infections—to support the conventional hypothesis that sexual contact accounts for most HIV infections. In this communication, we examine critics’ evidence and arguments. Critics ignore or reject important evidence including, for example, large numbers of unexplained HIV infections in children, strong associations between incident HIV and injections, and genetically-linked infections in persons with no known sexual contact. We urge that research projects in Africa disclose unpublished relevant evidence on risks for incident HIV. In any case, because each iatrogenic infection causes subsequent linked infections, the impact of HIV transmission through health care has been underestimated. We commend the emerging consensus to improve the safety of health care delivery. In countries with generalized HIV epidemics, we urge public education about the risks for HIV acquisition from unsterile health care. (author's)
The 6th International AIDS Impact Conference was held on 7_/10 July 2003, in Milan, Italy. As the epidemic evolves, treatments improve, access is debated and psychosocial ramifications are underscored, the importance and relevance of such a meeting was immense. The conference linked the psychological, social and socio-political, together with the biomedical aspects of HIV and AIDS and emphasized the fact that in order to fight this epidemic, a comprehensive approach is needed. The broad themes of the 2003 conference were: 1. Living with HIV/AIDS, with the sub-themes: quality of life; adherence to, complications of and reasons for discontinuation of HAART; disclosure; sexual behaviour and dysfunction; prevention issues; care and treatment issues, especially in disadvantaged populations (migrants, the homeless, drug users). 2. Prevention of HIV, addressing the challenges and advances in different target groups (gay men, drug users, sex workers, adolescents, women and men), as well as discussing the need for new preventive technologies, such as vaccines and microbicides. 3. The social, socio-political and socio-economical aspects of the epidemic: law, human rights and ethics (disclosure; infecting others, while not disclosing known serostatus; migrant populations). Access to and cost of treatment and other interventions. 4. Tomorrow’s generation, addressing transmission in pregnancy, parenthood, children, policy, stigma and the integration of approaches. (excerpt)
The acceptability of the female and male condom: a randomized crossover trial.
Although studies have assessed the acceptability of male and female condoms, comparative trial data are lacking. A sample of 108 women in stable relationships recruited from an urban, reproductive health clinic were randomly assigned to use 10 male or female condoms, followed by use of 10 of the other type. A nurse provided instruction in correct method use. Demographic information was collected in a baseline questionnaire; acceptability data were collected in follow-up and exit questionnaires and coital logs. Nonparametric and chi-square statistics were used to analyze measures of the methods' relative acceptability. Bowker's test of symmetry was adapted to test the null hypothesis of no difference in acceptability between condom types. Participants used 678 female and 700 male condoms. Although neither method scored high on user satisfaction measures, the 63 women completing the study protocol preferred the male condom to the female condom for ease of application or insertion, ease of removal, general fit, feel of the condom during intercourse and ease of penetration. Participants reported that their partner also favored the male condom, although women generally appeared to like this method more than their partner did. In a direct comparison between the methods at the end of the study, women generally judged male condoms superior on specified preference criteria. Across a range of criteria, the female condom was less acceptable than the male condom to most women and their partners. Although both types had low acceptability, they are needed and valid methods of pregnancy and disease prevention. That neither rated high on user satisfaction measures underscores the need for more barrier methods that women and men can use. (author's)
Identifying the psychosocial correlates of condom use by female sex workers in Hong Kong.
This study examined factors affecting condom use by Hong Kong female sex workers when they have sex with their clients and steady partners. Our respondents consisted of 109 active female sex workers, mainly streetwalkers or sex workers who worked in villas. During a 30-minute interview, respondents were interviewed individually and were asked questions regarding their condom use practice. These questions were designed to measure various factors affecting their condom use practice, including attitudes toward condom use, normative pressure, perceived behavioural control, perceived AIDS risks, past condom use behaviour, and future condom use intentions with respect to the two types of partners. Multiple regression analyses reveal that perceived behavioural control is the most important factor associated with these respondents’ future condom use across the two types of partners. Perceived AIDS risk is the additional predictor for condom use with clients, while normative pressure is the additional predictor for condom use with steady partners. Past condom use behaviour also provided significant additional prediction for both types of partners, implying the habitual nature of condom use among our respondents. These results have significant implications for designing intervention programmes targeting at increasing condom use by female sex workers in Hong Kong. (author's)
"Throwing the dice": pregnancy decision-making among HIV-positive women in four U.S. cities.
Although AIDS-related deaths among U.S. women have decreased, the number of HIV-positive women, especially of reproductive age, has increased. A better understanding of the interaction between HIV and family planning is needed, especially as antiretroviral medications allow HIV-positive women to live longer, healthier lives. Qualitative methods were used to examine pregnancy decision-making among 56 HIV-positive women in four U.S. cities. Biomedical, individual and sociocultural themes were analyzed in groups of women, categorized by their pregnancy experiences and intentions. Regardless of women's pregnancy experiences or intentions, reproductive decision-making themes included the perceived risk of vertical transmission, which was often overestimated; beliefs about vertical transmission risk reduction strategies; desire for motherhood; stigma; religious values; attitudes of partners and health care providers; and the impact of the mother's health and longevity on the child. Most women who did not want children after their diagnosis cited vertical transmission risk as the reason, and most of these women already had children. Those who became pregnant or desired children after their diagnosis seemed more confident in the efficacy of risk reduction strategies and often did not already have children. Future studies may help clarify the relationship between factors that influence pregnancy decision-making among HIV-positive women. HIV-positive and at-risk women of childbearing age may benefit from counseling interventions sensitive to factors that influence infected women's pregnancy decisions. (author's)
Teenage pregnancy and associated risk behaviors among sexually abused adolescents.
Previous research suggests a link between adolescent pregnancy and sexual abuse history, but most studies have used clinical samples of females only and single measures of abuse. Associations between pregnancy involvement, risk behaviors and sexual abuse were examined in sexually experienced teenagers from the Minnesota Student Surveys of 1992 (N=29,187) and 1998 (N=25,002). Chi-square tests assessed differences in pregnancy involvement and related risk behaviors among four groups of adolescents, categorized by type of abuse experienced: none, incest only, nonfamilial only or both. Odds ratios for pregnancy involvement and risk behaviors, adjusted for grade level and race, were calculated for each gender by using logistic regression analysis. Sexual abuse was reported by 6% of males and 27% of females in 1992, and by 9% and 22% in 1998. Reports of pregnancy involvement were significantly more common among abused adolescents (13-26% of females and 22-61% of males, depending on type of abuse) than among nonabused adolescents (8-10%). Abused adolescents were more likely than others to report risk behaviors, and teenagers reporting both abuse types had the highest odds of pregnancy involvement and risk behaviors. The differential in the odds of pregnancy involvement and most behaviors was larger between nonabused and abused males than between nonabused and abused females. Teenage pregnancy risk is strongly linked to sexual abuse, especially for males and those who have experienced both incest and nonfamilial abuse. To further reduce the U.S. teenage pregnancy rate, the pregnancy prevention needs of these groups must be adequately addressed. (author's)
The future of the female condom.
Despite both successes and disappointments, the female condom remains important to promote, especially in the face of heterosexually acquired HIV infection rates that are soaring globally. It is unfortunate, therefore, that a discourse has emerged recently that marginalizes the female condom as a viable prevention option, out of concerns about its high cost and the need for women to obtain their partner's cooperation in order to use it. Such a conclusion is premature, as the picture is far more complex. In this viewpoint, we review what has been learned about the female condom over the past decade, and argue for a renewed commitment to behavioral intervention research and the implementation and evaluation of large-scale female condom programs. (excerpt)
Behavioural responses of South African youth to the HIV / AIDS epidemic: a nationwide survey.
South Africa is reported to have the largest number of people living with HIV/AIDS in the world. The present study investigated the behavioural responses of South African youth to the HIV/AIDS epidemic. A multi-stage stratified cluster sample of 2,430 youths aged 15_/24 was selected, 46.9% of them males and 53.1% females. Nurses administered questionnaires to consenting youths, measuring behavioural risks and also took an oral fluid specimen for HIV antibody testing. It was found that the median age of sexual debut for both sexes was 16.5 years; most of the youths were sexually experienced with no variation by sex; sexual experience was highest among Africans living in informal urban areas; partner turnover was low and multiple partners were more common among African males living in urban informal settings; sexual frequency among sexually active youth was relatively low; secondary abstinence during the past 12 months was 24%; condom use at last sexual intercourse was high, at 52.8% for males and 47.6% for females, especially among Africans living in urban informal settings; and the majority of youths (74%) indicated that they had discussed HIV prevention with their partners during the past 12 months. These results suggest that South African youth are heeding the message to abstain, be faithful and use a condom; messages that are at the core of South Africa’s HIV/AIDS prevention programme. (author's)
We previously reported an HIV prevalence of 24% among rural adolescent girls living in the Shire Valley, southern Malawi. Voluntary HIV counselling and testing (VCT) could help prevent HIV among adolescents by encouraging informed decision-making and behavioural change. The Malawian National AIDS Control Programme has prioritized VCT as an HIV prevention strategy, but it is unclear whether adolescents in rural areas are informed about VCT, and how acceptable HIV testing would be to adolescents and parents. We undertook a study to assess the role of drama as a tool to promote knowledge of, and positive attitudes towards, VCT. The study was undertaken in 2003 in seven villages in Chikwawa District, within a 12 km radius of Montfort Hospital. VCT services were available at Montfort although only 7% of clients in the previous year were adolescents. Two counsellors were interviewed about issues faced by adolescents going for VCT, and these formed the basis for the drama script. The drama, which was translated into Chichewa, comprised songs giving information on HIV/VCT, a 30-minute drama and an epilogue, and was performed by two drama groups (hospital and youth). In each village, on the day of the drama, 25 adolescents (15–19 years) and 25 adults who had an adolescent child, were asked to complete a questionnaire before, and after the performance. In two villages the questionnaire was re-administered four weeks later to assess knowledge retention. The study was approved by Ethics Committees in Liverpool and Malawi. (excerpt)
The female condom has received much attention for its potential to empower users in negotiating safer sex. Studies demonstrate that the process used to introduce the method can influence subsequent use rates, resulting in calls for comprehensive documentation of introduction activities. This paper details an intervention study introducing the female condom to Vietnamese sex workers in Cambodia. Part of a wider community mobilization approach to reducing HIV/AIDS transmission, the intervention emphasized informed debate, group skills building and collective support. Research methods included both quantitative and qualitative data collection to evaluate the introduction’s effect on sex workers’ negotiation skills and social support networks. The findings show that approximately 16% of sex workers tried the female condom. Ever-use was significantly associated with participation in intervention workshops, and with indicators of both individual and community empowerment. Sex workers who incorporated the female condom into their work were also more likely to feel a sense of community identity. Introduced through an appropriate process, the female condom can serve as an ‘entry point’ to building community capacity. It can support sex workers in achieving protected sex and developing cooperative relationships, even in severely restrictive settings. (author's)
Traditional beliefs about the cause of AIDS and AIDS-related stigma in South Africa.
AIDS-related stigmas are pervasive in some segments of South African society and stigmas can impede efforts to promote voluntary counselling and testing and other HIV-AIDS prevention efforts. The current study examined associations among the belief that AIDS is caused by spirits and supernatural forces, AIDS-related knowledge and AIDS-related stigmas. A street intercept survey with 487 men and women living in a Black township in Cape Town, South Africa showed that 11% (n=54) believed that AIDS is caused by spirits and supernatural forces, 21% (n=105) were unsure if AIDS is caused by spirits and the supernatural, and 68% (n=355) did not believe that AIDS is caused by spirits and supernatural forces. Multiple logistic regression analyses controlling for participant age, gender, years of education and survey venue showed that people who believed HIV-AIDS is caused by spirits and the supernatural demonstrated significantly more misinformation about AIDS and were significantly more likely to endorse repulsion and social sanction stigmatizing beliefs against people living with HIV-AIDS. However, nearly all associations between beliefs that AIDS is caused by spirits and AIDS stigmas were non-significant when logistic regressions were repeated with AIDS-related knowledge included as a control variable. This finding suggests that relationships between traditional beliefs about the cause of HIV-AIDS and AIDS stigmas are mediated by AIDS-related knowledge. AIDS education efforts are urgently needed to reach people who hold traditional beliefs about AIDS to remedy AIDS stigmas. (author's)
We evaluated the effect of school closure on the occurrence of respiratory infection among children ages 6–12 years and its impact on health care services. During this period, there were significant decreases in the diagnoses of respiratory infections (42%), visits to physician (28%) and emergency departments (28%) and medication purchases (35%). The present study provides quantitative data to support school closure during an influenza pandemic. (author's)
Invasive pneumococcal infections among hospitalized children in Bamako, Mali.
Prevention of invasive pneumococcal disease (IPD) in children is a global public health priority, and determination of the most common serotypes is crucial for vaccine development and implementation. We performed prospective surveillance for IPD in hospitalized children in Bamako, Mali. All febrile children and others suspected to have invasive bacterial disease had an admission blood culture and cultures of additional anatomic sites when indicated. Standard microbiologic methods were used to identify, serotype and determine antibiograms for pneumococcal isolates. Of 2049 children enrolled, 106 (5%) had an IPD, including 47 cases of meningitis and 44 bacteremic pneumonias. The incidence was highest in infants (84/100,000/year). The overall IPD case fatality rate was 24%. Only 2 of 96 isolates were nonsusceptible to penicillin. The serotypes isolated were 5 (54%), 2 (14%), 7F (10%), 19F (8%), 6A/B (3%), 9V (3%), 1 (2%) and 14 (1%). IPD is common and frequently fatal among hospitalized children in Mali, but surprisingly little resistance has occurred. Notably, 91% of the serotypes causing IPD in Bamako children are found in the 11-valent pneumococcal conjugate vaccine. (author's)
Global health impact of soil-transmitted nematodes.
Infection with soil-transmitted nematodes (STNs), including Ascaris lumbricoides, Trichuris trichiura and hookworms (Ancylostoma duodenale, Ancylostoma ceylanicum and Necator americanus), remain among the most common diseases of humans, affecting up to one-fourth of the world’s population. At least part of the explanation for this is the strong association with rural poverty. With new quantitative methods to assess impact of chronic diseases of low to moderate morbidity, there is renewed appreciation of the impact of STN infection on global health. STN infections may account for up to 12% of total disease burden among children in resource-poor countries. WHO recently estimated that STN infections and schistosomiasis account for up to 40% of the total disease burden in tropical countries, excluding malaria. This impact on health has led to novel strategies to reduce the cumulative health effect of STN infections in the world’s most vulnerable populations. (excerpt)
Little is known about the prevalence of human papillomavirus (HPV) infection in young adults in Asia. We invited female and male students in Busan, South Korea, to participate in a survey that included, for females, self-collection of vaginal cells and, for males, physician-performed collection of exfoliated genital cells. The prevalences of 25 HPV types were evaluated, by a polymerase chain reaction–based assay, in 672 female students (median age, 19 years) and in 381 male students (median age, 22 years). HPV DNA was detected more frequently in female students (15.2%) than in male students (8.7%); in both sexes, high-risk HPV types were predominant. Among sexually active students, HPV prevalence was 38.8% in females and 10.6% in males. In female students, currently smoking cigarettes and having multiple lifetime sex partners were the strongest risk factors for HPV infection; in male students, associations between HPV prevalence and sexual habits were similar to those in female students but never attained statistical significance. Young women in South Korea start having penetrative sexual intercourse relatively late (median age, 18 years), but, once they begin, HPV prevalence quickly rises to levels comparable with those found in university students in the United States and in northern Europe. The high rate of participation in our study suggests that trials of new vaccines against HPV may be feasible among university students in South Korea. (author's)
Syphilis control -- a continuing challenge.
Syphilis. The name of this widespread and ancient disease is familiar to health care providers worldwide. This name recognition, however, belies the complexity of the disease, as well as the diagnostic and therapeutic challenges that continue to affect global efforts to control syphilis. Early (primary or secondary) syphilis is typically marked by ulcerative lesions that occur initially at the site of inoculation, followed several months later by widespread cutaneous, mucosal, and even systemic manifestations of the dissemination of the causal agent, Treponema pallidum. Even without treatment, both primary and secondary lesions resolve, and the infection enters a “latent” stage. During this stage, there are no clinical manifestations of disease, yet the infection may still be passed to children born to infected mothers; it may also progress, resulting in late (tertiary) manifestations, including late neurosyphilis, cardiovascular disease, and space-occupying inflammatory lesions (gumma). The ill effects of syphilis, however, go far beyond the disease’s effect on individual infected persons. Early syphilis is associated with the infection of sexual partners and an increased risk of acquisition or transmission of human immunodeficiency virus (HIV). The transmission of syphilis to infants of untreated mothers may occur at any stage of infection. (excerpt)
Transmission of herpes simplex virus type 2 among factory workers in Ethiopia.
The herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV) epidemics are believed to fuel each other, especially in sub-Saharan countries. In Ethiopia during 1997–2002, a retrospective study was conducted to examine risk factors for infection and transmission of HSV-2, in a cohort of 1612 factory workers. Prevalence of HSV-2 seropositivity at enrollment was 40.9%, and incidence of seroconversion was 1.8 seroconversions/100 person-years (PY), which decreased over time. Independent risk factors for seropositivity were having an HSV-2–seropositive partner, female sex, HIV antibodies, positive Treponema pallidum particle agglutination assay result, older age, low education level, and orthodox religion. These same factors were independent risk factors for HSV-2 seroconversion, with the exception of the latter 3. Most HSV-2– infected persons did not report symptoms. Among 41 monogamous HSV-2–serodiscordant heterosexual couples, incidence of HSV-2 seroconversion was 20.75 seroconversions/100 PY for women and 4.93 seroconversions/ 100 PY for men. The high burden of both HSV-2 and HIV infection in Ethiopia warrants stringent control measures. (author's)
HIV and AIDS in the former Soviet Bloc.
As compared with most nations affected by the human immunodeficiency virus (HIV) and AIDS, the countries of the former Soviet Bloc encountered the disease rather late. The first public announcement of cases of HIV infection in the former Soviet Union came in the mid-1980s and was greeted with denial and derision: many believed that AIDS could not happen there and that it must therefore be limited to homosexuals, drug addicts, and other “deviants,” as well as black Africans and foreign tourists. Some believed that HIV was developed by the United States as part of the Cold War, to be “tested” on marginalized persons who led a disorderly sexual life. The epidemic may have taken a long time to reach this region because of the strict controls once placed on the movement of people and contacts with foreigners. With the collapse of the Soviet Union in 1991, the barriers between its republics and the rest of the world tumbled down, facilitating the propagation of the virus. Today, this region has some of the fastest-growing rates of HIV infection in the world, according to the United Nations Development Program (UNDP). (excerpt)
Sub-Saharan Africa suffers from an excessively high endemicity of hepatitis B virus (HBV), but little is known about the prevalent genotypes. In this study, we investigated the PreS1/PreS2/S genes of 127 viruses obtained from 12 locations in Mali, Burkina Faso, Togo, Benin, Nigeria, Cameroon, and the Democratic Republic of Congo. Except for those obtained from the Cameroon HIV cohort (18/22 HBV genotype A), 96 of 105 sequences belonged to HBV genotype E (HBV/E), and viral DNA was very similar (1.67% diversity) throughout this vast HBV/E crescent, which spans 6000 km across Africa. The low diversity suggests that HBV/E may have a short evolutionary history. Considering a typical mutation rate of DNA viruses, it would take only 200 years for the strain diversity of HBV/E viruses to develop from a single introductory event. The relatively recent introduction of HBV/E into humans would also explain its conspicuous absence in the Americas, despite the forced immigration of slaves from west Africa, until the early 19th century. Infection during infancy is mostly associated with chronic carrier status, and this combination can account for the explosive spread of virtually identical viruses within a community, but whether other routes of long-range transmissions must be considered becomes an important question. (author's)
As the AIDS pandemic enters its 24th year, the number of people living with human immunodeficiency virus (HIV) infection continues to increase steadily (see Figure). Two thirds of infected persons are in Africa, where the epidemic exploded during the 1990s, and one fifth are in Asia, where the epidemic has been growing rapidly in recent years. As of the end of 2003, an estimated 34.6 million to 42.3 million people throughout the world were living with HIV infection, and more than 20 million had died of AIDS. In that year alone, about 4.8 million people became infected with HIV, and about 2.9 million died of AIDS. The challenge of the epidemic is that despite the increases in funding, global attention, and political will, more infections and more deaths continue to occur. The participants in the 15th International AIDS Conference, which begins in Bangkok, Thailand, on July 11, will once again consider the daunting task of reversing these trends. In preparation for the meeting, the Joint United Nations Program on HIV/AIDS (UNAIDS) has updated its global statistics (see Table). On the basis of better data than have previously been available from many countries, the estimation of the number of people living with HIV infection as of the end of 2003 has been revised downward — to a point estimate of 37.8 million from an earlier estimate of about 40 million. The estimated number of deaths due to AIDS has also been revised downward. Nonetheless, the statistics are merely estimates that reflect many assumptions and uncertainties; the situation in particular countries, such as those where accurate data are hardest to obtain, may be better or worse. Of all people between 15 and 49 years of age worldwide, 1.1 percent are now infected with HIV. (excerpt)
Work with women belonging to indigenous groups in Latin America needs to take into account both their identity as women and their identity as indigenous people, and the interplay between these identities. Indigenous women do not reject their culture, but want to change certain traditions in order to promote justice. Novib and Hivos, two Dutch development organisations, organised a workshop with local experts to discuss how to support indigenous women. Two important dilemmas were identified: the tension between collective and individual rights, and the need to link and address social and economic exclusion with cultural discrimination. Holistic solutions are needed. Changing power relations is a long-term process, which also needs to deal with fighting gender-based violence. NGOs need to change their attitude towards their target groups, and think and work for the long term. This is a challenge, given the current emphasis on short-term, measurable results. (author's)
Carboxyhemoglobin levels in Kenyan children with Plasmodium falciparum malaria.
Heme oxygenase (HO) is thought to be induced in severe malaria, but the pathophysiologic consequences have not been examined. It is induced by hemolysis, oxidative stress, and inflammation. It degrades heme, producing carbon monoxide (CO), which causes elevated levels of carboxyhemoglobin (COHb). In a prospective study of 1,520 children admitted to a Kenyan district hospital, COHb levels were no higher in children with malaria than with other infections. The COHb levels in children with severe malarial anemia were higher than in other children with malaria, but significantly lower than in children with other causes of severe anemia such as sickle cell disease. Levels of COHb were not significantly higher in children with cerebral malaria or in those dying of malaria. These results do not support a systemic increase in HO activity in malaria compared with other infectious diseases, but the roles of HO and CO in malaria require further study. (author's)
This article examines diversity in the women’s movement in Zimbabwe, focusing on the Women’s Coalition, which was set up in 1999. It traces the development of the women’s movement in relation to political developments in Zimbabwe, and highlights how the depoliticised language of development can obscure inequality between women, as well as between women and men, ethnic groups, and rural and urban people. The Women’s Coalition emerged from an awareness that coalition building is necessary if civil society is to be a strong political force. But diversity of values and core beliefs must be acknowledged if coalitions are to operate effectively, and we must understand coalitions as political institutions which face internal and external challenges. How well a coalition navigates this political terrain influences its survival. (author's)
We show that Ugandan adults coinfected with Schistosoma mansoni and human immunodeficiency virus type 1 (HIV-1) are able to mount S. mansoni–specific immune responses but that few such responses increase after treatment with praziquantel (PZQ). Levels of soluble wormantigen (SWA)–specific immunoglobulin (Ig) G1, IgG2, IgG3, IgG4, interleukin (IL)– 4, and IL-5 increased significantly in HIV-negative participants after treatment with PZQ, whereas most soluble egg antigen– specific antibody responses and levels of interferon-g were unaltered. Only levels of SWA-specific IL-5 increased in HIV- 1–coinfected participants after treatment. These deficiencies in immune responses may account for the previously reported increased susceptibility to infection and reinfection with S. mansoni in individuals coinfected with HIV-1. (author's)
Patterns of sexual behaviour among secondary school students in Swaziland, southern Africa.
Among the many sub-Saharan African countries hardest hit by HIV/AIDS is the Kingdom of Swaziland. In an effort to reduce the spread of HIV, young people are an important group to reach with prevention messages. However, before developing such programmes, it is essential to understand young people’s sexual risk behaviours. Students (n=941) from four coeducational secondary schools in Swaziland participated in a crosssectional survey of sexual behaviours. Results indicate that considerable proportions of young people in this study were sexually experienced, irrespective of gender. Findings also suggest unacceptable high levels of sexual coercion, irrespective of age or gender. While boys may be less likely than girls to experience sexual coercion, being a male in this setting was not a protective factor. No significant differences were found on these variables in relation to location of the schools (rural vs. urban). Implications for developing and implementing HIV prevention programmes are suggested. (author's)
Gender, identity, and diversity: learning from insights gained in transformative gender training.
This article aims to stimulate critical thinking around gender, identity, and power in development organisations. It focuses on two insights from gender and development training: first, an individual’s identities are always multiple and interconnected, so that you cannot talk about gender in isolation; and second, all identities are gendered. There are power dynamics between different identities, and these give privileges to some and make others vulnerable. The aim of transformative gender and diversity training is to acknowledge these power dynamics, to demystify them, and to find strategies that will promote equality for all involved. I discuss four insights from training that have important implications for organisational transformation in relation to gender and diversity. (author's)
Iron deficiency and malaria among children living on the coast of Kenya.
Both iron deficiency and malaria are common in much of sub-Saharan Africa, and the interaction between these conditions is complex. To investigate the association between nutritional iron status, immunoglobulins, and clinical Plasmodium falciparum malaria, we determined the incidence of malaria in a cohort of children between the ages of 8 months and 8 years who were living on the Kenyan coast. Biochemical iron status and malaria-specific immune responses were determined during 2 cross-sectional surveys. We found that the incidence of clinical malaria was significantly lower among iron-deficient children (incidence-rate ratio [IRR], 0.70; 95% confidence interval [CI], 0.51-0.99; P<.05), that the incidence of malaria was significantly associated with plasma ferritin concentration (IRR for log ferritin concentration, 1.48; 95% CI, 1.01-2.17; P<.05), and that iron status was strongly associated with a range of malaria-specific immunoglobulins. We conclude that iron deficiency was associated with protection from mild clinical malaria in our cohort of children in coastal Kenya and discuss possible mechanisms for this protection. (author's)
Organisational strategy in India and diverse identities of women: bridging the gap.
Some differences among Indian women are well known – for example, those based on class, ethnicity, caste, and religion