Eritrea lies along the Red Sea coast in the Horn of Africa, at the northernmost limit of malaria transmission in the region. About two-thirds of its 3.5 million people live in malaria endemic or epidemic-prone areas, and malaria accounts for approximately 30% of clinic visits and hospital admissions. Eritrea has made a strong commitment to malaria control. The National Malaria Control Program (NMCP) is implementing a Five Year Plan with technical and financial support from Roll Back Malaria (RBM) partners, including WHO, the World Bank and USAID. The NMCP has earned recognition for its success in increasing the availability of insecticide-treated bednets, revising policy to assure the use of effective antimalarial drugs, and regularly evaluating its progress using standardized indicators. (excerpt)
On 26-28 May 1999, a meeting was held at UNAIDS, Geneva, with the following theme: “Care within the context of HIV/AIDS-related research in developing countries.” The objective of the meeting was to develop a framework of care that guarantees that the health needs of participants in HIV-related research in developing countries are given precedence, and that their personal and social integrity are fully protected. The meeting also sought to clarify the appropriate roles and responsibilities of research partners with respect to the care of participants in HIV/AIDS-related research. The meeting was guided by the general ethical principles expressed in the Declaration of Helsinki (World Medical Association) (1996) and the International Ethical Guidelines for Biomedical Research Involving Human Subjects (Council for International Organizations of Medical Sciences)(1993). The meeting was attended by representatives of community and patient organizations, research organizations, research sponsors, ethics committees, governmental and inter-governmental organizations, and academia. Those at the meeting confirmed that respect for the individual and the community should be at the core of HIV-related research in developing countries, and that participants must be provided with a context of care that fully addresses their dignity and responds to their physical and psycho-social health needs. The meeting confirmed that the health and well-being of participants must be the primary concerns during HIV-related research and that they should prevail over any other concerns, including the interests of science. (excerpt)
At the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, in June 2001, governments from 189 countries committed themselves to a comprehensive programme of international and national action to fight the HIV/AIDS pandemic by adopting the Declaration of Commitment on HIV/AIDS. The Declaration established a number of goals for the achievement of specific quantified and time-bound targets, including reductions in HIV infection among infants and young adults; improvements in HIV/AIDS education, health care and treatment; and improvements in orphan support. The Declaration of Commitment also included a pledge, on the part of the United Nations General Assembly, that it would itself devote at least one full day per annum to reviewing the progress achieved in realizing the goals established. To facilitate this ongoing review process, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and its partners have developed a set of core indicators that permit monitoring of measurable aspects of the various international and national actions, national programme outcomes, and national impact objectives envisaged in the Declaration of Commitment. Information obtained on these indicators will also be incorporated into reports and publications produced for broader dissemination and debate. The purpose of the current guidelines is to provide countries with technical guidance on the detailed specification of the indicators, on the information required and the basis of their construction, and on their interpretation. These guidelines aim to maximize the validity, internal consistency and comparability across countries and over time of the indicator estimates obtained, and to ensure consistency in the types of data and methods of calculation employed. (excerpt)
National AIDS councils. Monitoring and evaluation operations manual.
HIV/AIDS is the leading cause of death in sub-Saharan Africa. More than 18 million Africans have died, more than 12 million African children have been orphaned because of AIDS, and another 28 million Africans are living with the virus today, the vast majority of them in the prime of their lives as workers and parents. Life expectancy is dropping, family incomes are being decimated, and agricultural and industrial efficiency is declining because of the epidemic. African nations and the international community have recognized how disastrous the epidemic is to the African continent, and have concluded that past efforts to wage war against the virus have failed because: (i) there was insufficient commitment and leadership to fight the epidemic among nations both inside and outside the continent; (ii) the war was being waged with too few human and financial resources; (iii) those programmes that were effective, often undertaken by civil society organizations, were rarely scaled up; (iv) resources were not reaching communities; and (v) programmes were too narrowly focused on the health sector. (excerpt)
The HIV/AIDS epidemic in Kenya has moved beyond public health crisis to a personal, community, and national development catastrophe. Because the epidemic acts at all these levels, efforts to contain it must also act at individual, community, and national levels. One important way of addressing the epidemic at these points is by developing systems, strategies, and capacities to provide care for people living with HIV/AIDS (PLWHAs) within their own homes and communities. Home-based care represents a partnership in care that has many advantages for the PLWHA, for the PLWHA's family, for the community, and for the health-care system. Home-based care is not only an important mechanism for extending the continuum of care by providing at home the basic nursing care and treatment necessary for many of the afflictions that strike PLWHAs. It also promotes community awareness of HIV/AIDS, provides powerful examples to motivate behaviour change and decrease the stigma attached to the disease, and enables PLWHAs to maintain their family and community roles. Home-based care is cost effective as well. It frees up hospital beds and medical personnel for the acutely ill and thus relieves the burden on the health care system. (excerpt)
Paediatric HIV infection and AIDS. UNAIDS point of view.
More than 1500 children become infected with HIV every day. The vast majority (more than 90%) acquire the infection from their mother. Children may acquire HIV during pregnancy, labour, delivery or, after birth, through breastfeeding. Among infected infants who are not breastfed, about two-thirds of cases of mother-to-child transmission occur around the time of delivery and the rest during pregnancy. In 2001, more than 2.6 million pregnant women had HIV infection and more than half a million transmitted the virus to their infants. Children may also become infected with HIV through contaminated blood transfusion and or blood products, the use of contaminated needles and syringes, and sexual abuse or exploitation. Since the beginning of the pandemic, of the over 5 million infants who have been infected with HIV, 90% were born in Africa. However, the number of cases in Central Asia, Eastern Europe, India and South-East Asia is rising. HIV infection is a major contributing factor to childhood disease and mortality. In developing countries, it is threatening gains made in infant and child survival and health over recent decades. (excerpt)
The treatment of bednets and curtains with insecticides has been shown to be a cost-effective and efficacious approach to malaria vector control in many situations, and as such provides significant public health benefits. Along with these benefits, however, the use of these treated materials and their re-treatment with insecticides creates tangible risks to human health and the environment throughout the life cycle of the insecticide products. This assessment finds that the public health benefits of these products justify the apparently modest risks. Nonetheless, the risks associated with the use of insecticide-treated materials (ITMs), including bednets and curtains, should be minimized through such steps as proper pesticide product selection, appropriate labeling, and user educational campaigns. Programs should also actively monitor for adverse health and environmental effects, to assure that risks are adequately understood and to allow appropriate and timely interventions to reduce risks. The use of ITMs can significantly reduce malaria transmission, with estimates of six lives saved per 1,000 children protected by insecticide-treated nets. ITMs are cost-effective and environmentally friendly as compared with alternative vector control measures that use pesticides (with the exception, perhaps, of some low-toxicity biopesticides used in larviciding); a relatively small amount of pesticide is needed to treat nets and other materials, as compared with indoor residual house spraying, space spraying, and larviciding. The products currently used to treat ITMs are also more environmentally sound than other vector control pesticides, such as DDT. (excerpt)
Remember the children [letter]
On May 27, the President signed into law the U.S. Leadership Against HIV/AIDS Tuberculosis and Malaria Act of 2003. This is an achievement that few, perhaps, would have expected from this Administration. And yet President Bush acted decisively on this issue: in just four months, we saw an idea move from a cameo appearance in his State of the Union address to a five-year, $15 billion authorization to fight these critical diseases of poverty. That this took place during a time of increased budget pressures makes the achievement all the more significant. As we move from authorization to implementation, however, it also makes the global health community extremely wary. With the federal budget spiraling into record deficits, there is already enormous pressure to rob Peter to pay Paul - to fund the AIDS initiative at the expense of programs that support primary health-care systems, infectious disease control, maternal and child health, and broader development goals. (excerpt)
A collective battle in the TB war.
Life in South Africa's rural areas - despite its deep traditions, familial ties, and a hard-fast faith in humanity - is challenging. The Eastern Cape Province, which has given the world some of its greatest leaders in Nelson Mandela and Steve Biko, suffered greatly at the hands of the apartheid regime. Today, the Eastern Cape's rural villages are disproportionately affected by tuberculosis (TB) and HIV/AIDS, diseases whose societal impact is exacerbated by widespread poverty. The odds of effectively combating TB are currently stacked against many communities. Breakdowns in TB support, implementation and community systems all contribute to high treatment interruption, low cure rates, and inefficient case findings. In the Eastern Cape Province, half of all TB patients do not complete their treatment and cure rates are currently below 50 percent, dipping even lower in some of the poorest areas. These statistics are among the worst on the continent; only Nigeria and Ethiopia have worse TB infection rates. (excerpt)
Mobilizing communities for obstetric and neonatal emergencies.
Dedicated to the women of her community in rural Nicaragua, traditional birth attendant Felipa Arteta has learned new skills for assessing a complicated birth. Artera's training in emergency obstetric and neonatal care is part of a program designed by the PRIME II Project and local partners to strengthen community responses to obstetric and neonatal emergencies in the mountainous Jinotega region. The maternal mortality ratio in Jinotega, estimated at 150 per 100,000 live births in 2002, is the highest in Nicaragua and one of the highest in Latin America. PRIME II's initiative for safer motherhood and improved newborn care in the region is part of the Project's global effort, funded by USAID, to strengthen the performance of primary-care providers as they strive to improve family planning and reproductive health services in their communities. (excerpt)
This study tested whether a redesign methodology would improve the quality of medical records in the obstetric services of four Ecuadorian hospitals. Quality teams in each hospital implemented a redesign methodology, working in cooperation with local quality assurance (QA) experts from the QA Project and following a predetermined sequence of steps. Eight quality standards for medical records were defined: (1) complete set of forms, (2) correct chart headers, (3) complete discharge summary, (4) complete delivery form, (5) patient consent, (6) identification number on admission and discharge forms, (7) legibility, and (8) coherency and consistency. Pre- and post-samples of medical records (448 before and 459 after) were audited to determine compliance with the eight standards. The average increase in the eight indicators for the four-hospital pooled sample was 27 percentage points, up from 41 percent compliant in the pre-sample to 68 percent in the post-sample. Five of the indicators showed highly significant gains of 25 percentage points or more, with four of them attaining post-intervention compliance of 80 percent or more. Across the four hospitals, pre-intervention average compliance ranged from 27 to 49 percent; the average gain ranged from 24 to 31 percentage points. The gain at each hospital was statistically significant, but the differences among the hospitals were not. A secondary purpose of the study was to test and improve the redesign methodology. The study was carried out sequentially, one hospital at a time: participants made recommendations for improving the methodology, those recommendations were used to modify the methodology, and the modified version was used at the next hospital. In effect, although small modifications were made to the redesign methodology as the study progressed, there was no evidence that these modifications improved compliance with the standards. Prior to redesign, the quality of the obstetric medical records was very poor, well under 50 percent compliance. Such poor documentation is not suitable for use in quality assessment or for proper management of patients. The systematic and participatory redesign methodology applied in this study was very successful in increasing the quality of the medical records, especially for the indicators of completeness, legibility, and coherency, but less so for indicators related to patient signature and patient identification number. Future research is needed to test whether the improved quality of these records is adequate to monitor changes in the quality of obstetric care. (author's)
Report of activities, 2001, [UNAIDS] Inter-Country Team for West and Central Africa.
Strengthening of national responses through inter-country initiatives for reducing vulnerability and risks associated with HIV/AIDS in the context of population mobility. The Inter-Country Team, with the support of the World Bank, has since 1996 concentrated its efforts on issues related to population mobility in the context of the HIV/AIDS epidemic. In this respect, it supports the development of technical resources networks and research-actions; it manages an electronic network for exchange of information and discussions; it also supports interventions on areas, routes and sites where populations interact with each other with a view to reducing incidents of HIV/AIDS among the populations concerned, and thereby reduce the effects of the epidemic. Development of partnerships between governments, implementing agencies, NGOs and all the actors concerned, such as transport unions, was retained as an essential strategy for reducing risks and vulnerability associated with HIV/AIDS among mobile, migrant and displaced populations. (excerpt)
Faith-based communities partnering to combat mother-to-child transmission of HIV.
Though the scourge of HIV/AIDS is felt all over the developing world, few people feel the threat of the disease more acutely than expectant mothers. Catholic Medical Mission Board (CMMB) is providing services for the prevention of mother-to-child transmission (PMTCT) of HIV with Born to Live, a multi-year initiative to address PMTCT through partnerships with in-country faith-based institutions. Currently CMMB has PMTCT faith-based partnerships in southern and East Africa, Latin America and the Caribbean. Because faith-based institutions often serve as trusted havens, faith-based hospitals and clinics have provided for the health-care needs of local communities for years. In addition, faith- based facilities offer a substantial percentage of health-care services to those in need, particularly in rural areas. (excerpt)
Resource requirements to fight HIV / AIDS in Latin America and the Caribbean.
Economists and epidemiologists from ten countries in Latin America and the Caribbean (LAC) reviewed the methods used to develop estimates for resource requirements to address HIV/AIDS prevention and care in low- and middle-income countries. They applied their country-specific knowledge to re-estimate costs, coverage, and capacity of their health and education systems to expand HIV/AIDS interventions by 2005. The reasonably small discrepancy between the model estimates and those of country specialists totaling US$ 173 million provides some confidence in the overall consistency and reliability of the estimating procedures. The most important difference between the model estimates and those of the country specialists was in the estimated future price of HAART. In essence, the estimates of the model reflect the efficiency gains that could result from purchasing arrangements that lead LAC countries to lower prices for ARVs. This preliminary exercise with ten LAC countries confirmed the validity of the use of these estimates as tools at the international level – both to guide the allocation of resources across diseases and countries, and for advocacy and resource mobilization. With the country revisions, these estimates have also been shown to be key tools for country-level strategic planning. (excerpt)
Spacing births, saving lives. Ways to turn the latest birth spacing recommendation into results.
For many years, family planning experts believed that a 24-month birth interval (the amount of time between the birth date of one child and the birth date of the next child) was adequate to ensure healthy mothers and healthy children. However, recent findings by Shea Rutstein, Ph.D. indicate that spacing births at least 36 months (three years) apart is even more beneficial. In his analysis, Rutstein examined the association between birth intervals and various child health and nutrition outcomes, including perinatal, infant, and under-five mortality. The analysis was conducted using MEASURE DHS+ data from 17 less-developed countries. As a result of Rutstein’s study, international experts now recognize the need to promote birth intervals that are at least three years long. (excerpt)
The private sector responds to the epidemic: Debswana—a global benchmark. UNAIDS case study.
In many respects, Botswana is Africa’s success story. It is a peaceful, democratic and prosperous country, with a standard of living and quality of life that have improved steadily in recent decades, largely as a result of good governance and sound public finance. At independence, Botswana was one of the world’s poorest countries but, over the past 30 years, its economic growth rate has been one of the highest worldwide. This rapid growth was initially driven by minerals (with the diamond mines remaining central to the economy) but there has also been diversification of economic activity. By 2000, most children were receiving primary- and secondary-level education, and literacy rates were above 70%. Nearly 90% of the population were within reach of State health facilities, and 98% of one-year-olds were fully immunized against BCG. The approximately 1.6 million citizens enjoyed a per capita income of US$3240. Despite these achievements, Botswana has the worst HIV/AIDS epidemic in the world. According to the Report on the global HIV/AIDS epidemic, June 2000, the adult HIV prevalence rate was 35.8%—over 10% higher than the next-highest country, Swaziland, which has a HIV rate of 25.25%. The latest government sentinel surveillance does not show any improvement in the situation. (excerpt)
Final annual report, FY 2002: Latin America and Caribbean Regional HIV / AIDS Initiative (LACRI).
This Annual Report summarizes the activities conducted between October 1, 2001 and September 30, 2002 (FY02) for the Latin America and Caribbean Regional HIV/AIDS Initiative (LACRI), as implemented by the Synergy Project of the TvT Division, Social and Scientific Systems for USAID/LAC/RSD-PHN. This initiative responds to Strategic Objective (SO) 3: More effective delivery of selected health services and policy interventions of LAC/RSD-PHN Accordingly, LACRI has the following SO-level statement: To increase awareness among policy makers and program managers of best practices, research results and experiences in the region. The Intermediate Results (IR) for the Initiative are the following: IR1: Existing Information is disseminated through a website and information clearinghouse. IR2: Regional exchanges between HIV/AIDS policy makers and program managers are facilitated. IR3: Regional technical assistance in HIV/AIDS (south-to-south and north-south) is enabled. IR4: Regional guidelines and tools are available for validation. (excerpt)
Empowering women with the female condom.
"The female condom is suitable for all women because, whether you are married, single or having lots of partners, you are in control. You are the one who has to insert it, so if anyone does not want to use it, then they can leave [without having sex]," said a 35-year-old married woman from the Western Cape. Female-controlled barrier methods are being advocated in South Africa to reduce unwanted pregnancies and high rates of sexually transmitted infections like HIV, since male condom use is low and inconsistent, and few women are empowered to insist on their use. To increase the options available to South African women, the South African Department of Health (DOH) introduced the female condom (FC) at selected primary health clinics and Planned Parenthood Association of South Africa (PPASA) sites across the country. This program, which began in June 1998, was initiated by the National Department of Health (NDOH), and designed and implemented by the Reproductive Health Research Unit (RHRU) of Chris Hani Baragwanath Hospital, with technical assistance from Family Health International (FHI). The Society for Family Health (SFH) has been responsible for implementing the social marketing component, selling female condoms mostly via pharmaceutical wholesalers. (excerpt)
Countering the feminization of AIDS with microbicides.
Although HIV infections among men who have sex with men dominated the headlines in the epidemic's infancy, as early as 1983 an AIDS epidemic within the heterosexual population was emerging in Africa. While this prompted the Centers for Disease Control to add the female sexual partners of infected men to its list of 'risk groups' in the United States, a more precise understanding of women's risk has been slow to come. Not until 1996 did UNAIDS have what it considered a reliable tally of global HIV/AIDS incidence and prevalence among women - in that year finding that women accounted for 42 percent of new HIV infections worldwide. By the end of 2002, that percentage had risen to 50 percent. In sub-Saharan Africa, women account for 58 percent of adults living with HIV/AIDS, and females between the ages of 15 and 29 are two-and-a-half times more likely than men in their same age group to be infected. The feminization of HIV/AIDS is not confined to sub-Saharan Africa: unless action is taken, women worldwide - particularly those in countries on the brink of epidemic explosions, like India and China - will be disproportionately infected and affected by HIV/AIDS. (excerpt)
Twenty-three years of war and conflict has largely destroyed Afghanistan's health infrastructure, making the health status of the country's men, women and children one of the worst in the world. Afghanistan's Deputy Minister of Public Health, Dr. Ferozudeen Feroz, visited the United States as part of a month-long tour of donor countries to promote the ministry's plans for rebuilding Afghanistan's health system. Dr. Feroz presented the preliminary results of the first nationwide survey of health infrastructure, the Afghanistan National Health Resources Assessment (ANHRA). He sat down with Management Sciences for Health's CEO, Dr. Ron O'Connor, for an exclusive interview about the current reality of the health care system, its challenges, and a hopeful future for the Afghan people. Q: What are the main health problems facing Afghans? A: There are many, of course, as in any developing country that is just emerging from two decades of war and conflict - especially diseases that affect children under five years, like acute respiratory infections and diarrhea, and those that affect all age groups, like TB and malaria. For these, we need inexpensive solutions like basic antibiotics, bednets to prevent malaria, and an expanded DOTS program to treat TB patients. Our particular concern is the health problems that affect mothers, such as complications from pregnancy. Our priority is to deal first with those problems where we can do something quickly, effectively and inexpensively. A good example is oral rehydration for treating diarrhea in children. Another is bringing down our maternal mortality rates - which are the highest in the world at 1,600 per 100,000 live births - through better capacity building, such as the training of community health care providers and midwives, more female staff in basic primary health care clinics, and more staff and equipment available to provide caesarean sections in hospitals. (excerpt)
Using evidence to improve reproductive health quality along the Thailand-Burma border.
The Mae Tao Clinic, located on the Thailand-Burma border, has provided health services for illegal migrant workers in Thailand and internally displaced people from Burma since 1989. In 2001, the clinic launched a project with the primary aim of improving reproductive health services and the secondary aim of building clinic capacity in monitoring and evaluation (M&E). This paper first presents the project's methods and key results. The team used observation of antenatal care and family planning sessions and client exit interviews at baseline and follow-up, approximately 13 months apart, to assess performance on six elements of quality of care. Findings indicated that improving programme readiness contributed to some improvement in the quality of services, though inconsistencies in findings across the methods require further research. The paper then identifies lessons learned from introducing M&E in a resource-constrained setting. One key lesson was that a participatory approach to M&E increased people's feelings of ownership of the project and motivated staff to collect and use data for programme decision-making to improve quality. (author's)
Equitable access to HIV treatment for women and girls.
Recent international initiatives to provide antiretroviral (ARV) treatment in resource-poor countries have changed the landscape of the HIV/AIDS debate and signal an unprecedented new phase in the struggle against HIV/AIDS. With an estimated 40 million people living with HIV/AIDS and 14,000 new infections every day, access to treatment is a challenge of global proportions. In sub-Saharan Africa alone, almost 4.5 million people need antiretroviral treatment, yet only 100,000 are currently receiving it. To develop effective treatment programs, national governments, international donors and community stakeholders should ensure equitable access to HIV treatment and care, particularly for vulnerable populations such as women and girls. Integrating a gender approach in the rollout of treatment programs is a matter of urgency. In the worst affected countries of sub-Saharan Africa, women and girls account for 58 percent of those living with HIV/AIDS, and girls aged 15-19 are infected at rates up to four-to-seven times higher than boys, a disparity linked to sexual abuse, coercion, discrimination and impoverishment. In addition, gender-related barriers to health care are compounded by HIV/AIDS. The threats that HIV-positive women face upon disclosing their status - especially if they are the first to be identified as being HIV-positive and are blamed for bringing the virus into the household - in turn heighten their risk of violence, abandonment, and other forms of stigma and discrimination. Treatment initiatives provide an opportunity to address the violence and inequities that put women and girls at particular risk of HIV transmission, and thereby help to break the cycle that has led to the disproportionate impact on women and girls. (excerpt)
AIDS and war: women in the crossfire.
Women account for nearly 50 percent of AIDS cases worldwide. Out of 18.5 million women living with AIDS. 18 million of them live in developing countries. 15 million of whom are in sub-Saharan Africa. Equally alarming has been the increase in armed conflict, especially in developing countries, since the end of the Cold War. Disruption of services and the forced movement of people during armed conflict make conflict zones a ripe environment for the spread of STIS, especially HIV. Indeed, evidence suggests that civil wars and the subsequent movement of both troops and refugees contributed to the spread of HIV in Uganda, Mozambique and Angola. Why are women in conflict zones at particular risk for contracting HIV? And what are the programmatic responses necessary to address women who live in or near conflict zones? (excerpt)
AIDS Agenda, the new campaign of the international development charity VSO, aims to focus attention on the need for more equality between women and men as part of an effective response to HIV and AIDS. VSO's new position paper, "Gendering AIDS: Women, Men, Mobilization, Empowerment" - the result of research undertaken in South Africa, India, Namibia and Cambodia - examines how inequalities between women and men have contributed to the spread of HIV and AIDS, and how these inequalities are exacerbated by the epidemic. Knowing that since the start of the epidemic, deep-rooted gender and economic inequalities have meant that women are less able than men to discuss sex, and less likely to have the economic means to protect themselves or to alleviate the burden of infection, AIDS Agenda recommends the following three-pronged advocacy approach: Increase the constructive involvement of men in activities and interventions designed to reduce gender inequalities and minimize the impact of HIV and AIDS; Address the immediate needs of women affected by HIV and AIDS, for example, as caregivers within the family and community; as people suffering from gender violence; and as individuals requiring treatment and attention for HIV and AIDS; and Continue to focus on directly empowering women to attain equality in the family, the workplace and the community by ensuring, in particular, that existing policies and commitments supporting women's rights are implemented. (excerpt)
Philippa Lawson: changing policies by and for positive women.
When Philippa Lawson found out she was living with HIV in 1986, she followed the medical advice given and told her loved ones she was dying of cancer. HIV had yet to be identified as the cause of AIDS (it was then known as HTLV-3), and there was a great deal of ignorance and fear about the disease even inside the medical community. "I had no pre- or post-test counseling, just a female doctor who began to cry when she told me that I had the AIDS virus, and that I probably had six months to live. I was 23 years old then," Lawson recalled. Not only did doctors urge her not to tell anyone, including her family, but they also advised her to carry bleach with her, to disinfect the silverware, dishes and toilets that she used. But after the sixth month of her death sentence came and went, Lawson knew that she needed to learn how to live with the disease. Unfortunately, the only support group she could find in Chicago was for gay men. Lawson joked, "I told them, I'm willing to pretend." Still, despite her ability to face adversity with humor, Lawson knew she wasn't the only infected woman who needed a supportive environment. (excerpt)
Sexy schoolgirls and other images of disdain.
"See that hotel with the green sign?" My colleague, a Lao expert in HIV/AIDS and migration, gestured across the river. If the Mekong had dried up, the Thai hotel with its huge bank of beckoning neon would have been an easy walk from the Savannakhet café where we sat. "Chinese businessmen on sex junkets call across the river and, in two hours, pimps on this side deliver a fresh bunch of Lao schoolgirls to their hotel room doors. In their uniforms. And they have to be virgins, or the Chinese won't pay." The pigtailed, flirtatiously "knock- kneed" schoolgirl, whose short plaid skirt barely conceals her buttocks, is not just an old pornographic cliché; these days the literature of women and AIDS is also rife with stories of molested innocents who were introduced to the school of hard knocks at the same time as they were learning their ABCs. Adopting the schoolgirl as an icon of the predicament of women in the world of AIDS might not be a bad idea, expressing as it does the deep sense of "gender conflict" - the outright misogyny - underlying the rapid spread of HIV in all corners of the world. (excerpt)
Objective: To assess risk factors and mycobacterial agents in mycobacterial adenitis. Design: Cross sectional involving comparison analysis of high-risk groups. Setting: Seven hospitals in rural and semi-rural districts of Arusha. Subjects: The study comprised of 457 patients of clinically diagnosed mycobacterial adenitis. Interventions: Biopsy materials were cultured and identification of mycobacterial isolates, and HIV infection testing were performed using standard methods. A questionnaire was used to establish information for assessing risk factors. Main outcome measures: Proportions of mycobacterial isolates, risk factors and odds ratios. Results: Of the 457 specimens, 65(14.2%) were culture positive. Isolates identified were M. bovis, 7(10.8%) M. tuberculosis, 27(41.5%) and non-tuberculous mycobacteria 31(47.7%). HIV infection and ingestion of raw milk were linked with increased risk of M. bovis infection by OR of 13.6 (95% CI, 1.7 - 109.9) and 15.28 (3.26 - 71.7), respectively. On multivariate analysis, an OR of 16.2 (1.3 - 201.3) for having M. bovis adenitis was linked to HIV infection, raw milk and houses with poor ventilation. An OR of 5.2 (1.2 - 20.6) for non-tuberculous mycobacterial adenitis was linked to history of TB in the family, HIV infection, raw milk, raw animal products and poor knowledge on transmission of tuberculosis. Conclusions: M. bovis caused one out of ten cases of culture positive mycobacterial adenitis. Non-tuberculous mycobacteria were more common than M. tuberculosis (50% and 40% of the cases, respectively). HIV infection and raw animal products are among the risk factors identified for M. bovis and non-tuberculous mycobacterial adenitis. (author's)
Objective: To compare the efficacy of vaginal and oral misoprostol for the induction of labour in women with intra-uterine foetal death (IUFD). Design: A prospective randomised clinical trial, comparing 200µg oral and 200µg vaginal misoprostol, six hourly for a minimum of four doses for the induction of labour in women with IUFD. Setting: Ga-Rankuwa hospital (Department of Obstetrics and Gynaecology), Pretoria, South Africa. It is a tertiary institution serving predominantly black indigenous population. Main outcome measures: The primary outcome measure was the induction to delivery time, and secondary outcome measures were the number of patients requiring augmentation with oxytocin and all complications were noted. Results: Twenty women were randomised to the vaginal route and 18 to the oral route. The induction to delivery time was shorter with vaginal misoprostol (13.5 +/- 8.3 hrs) compared to oral misoprostol (21.4 +/- 13.9 hrs; p< 0.05). There was no significant difference in the amount of misoprostol needed to achieve successful induction in the two groups. More women (10/18) who received oral misoprostol required oxytocin augmentation to complete the induction of labour compared with 4/20 women in the vaginal group (p<0.05; Odds Ratio 2.8; 95% CI 1.36 - 4.24). There were no cases of failed induction. The systemic side effects (shivering, diarrhoea, vomiting and pyrexia) were more common with oral misoprostol (44.5%) compared to vaginal misoprostol (20%). This difference gives an overall Odds Ratio of 2.2 at 95% CI of 1.6-2.8(p<0.05). Conclusion: Vaginal misoprostol achieved successful induction of labour in women with IUFD in a shorter time than oral misoprostol with significantly less side effects. (author's)
Have we all forgotten the female condom? [letter]
While I welcome the recent press release about the need for female-controlled prevention methods, the increased vulnerabilities of women and girls to HIV infection and the launching of a new Global Coalition on Women and AIDS, I must admit it left me saddened - and not only because of women's vulnerabilities to HIV and the advance of the epidemic. How can we discuss the need for new female-initiated prevention methods, the lack of negotiation skills women tend to have, the risk of violence against women and increases in HIV infection driven by gender vulnerabilities, and actually fail to mention the female condom? The female condom is the only new prevention technology invented during this epidemic; and, at present, it is the only female-initiated one. Statements such as "a lack of existing female-controlled HIV prevention methods" only serve to damage the work we are trying to do to strengthen the resources for women and men to use female condoms. I welcome with open arms the need for more female-initiated methods, but believe that this should be in a context of complementing existing methods. The history of contraception shows that the more options for birth control that exist, the more people will use birth control - providing diversity and choice is a good thing, in terms of public health. (excerpt)
HIV efforts are failing women and girls.
Mrs. Akinyi's husband died of AIDS in 1990. She believes her husband infected her with HIV - he had a history of extramarital affairs. When he died, her in-laws denied her property inheritance. In her words, "Immediately after the burial, I was chased away from home with my children." Mrs. Nyakumabor's husband died of AIDS in 1998, and left her HIV-positive with five children. Her in-laws grabbed household items and took over the house and land she had helped pay for. Soon after her husband's death, Mrs. Nyakumabor's father-in-law called a family meeting, told her to choose an inheritor, and ordered her to be cleansed by having sex with a fisherman. Mrs. Nyakumabor refused, causing an uproar. She now struggles to meet her family's needs, and her slum landlord has threatened to evict her because she cannot always pay rent on time. These women's stories (their names have been changed) are two of the hundreds collected by Human Rights Watch and other organizations, documenting the stripping of property rights in the wake of AIDS among some of the most vulnerable people on earth. (excerpt)
Hepatitis C virus seroprevalence among mothers delivering at the Korle-Bu Teaching Hospital, Ghana.
The objectives were to determine the Hepatitis C virus (HCV) carrier rate among mothers, and to determine if selected sociodemographic characteristics are associated with HCV seropositivity. The design was a Maternity Unit of the Korle-Bu Teaching Hospital (KBTH). The setting was a cross-sectional serological survey of mothers delivering at the KBTH. Women who had singleton live births and fresh stillbirths in the two labour wards of the KBTH were randomly selected for screening from 1st March to 30th September, 2001. A structured pre-tested questionnaire was used by trained research assistants to collect and record data on medical and sociodemographic characteristics of the subjects. Maternal blood samples were taken and stored at the Public Health Reference Laboratory. The second generation Murex diagnostics ELISA kit was used to test the maternal sera for HCV antibodies. Sixteen (2.5%, 95% CI, 1.5-4.1%) of the 638 subjects were HCV seropositive. None of the medical and sociodemographic characteristics examined showed any association with HCV seropositivity. No subject or her sexual partner was a drug injector. The carrier rate of 2.5% of HCV infection found in this study is near the top end of the range found in unselected pregnant populations from other parts of the world. Knowing the prevalence rate of HCV infection in our pregnant population will help policy-makers on the cost effectiveness of available intervention measures. (author's)
Curbing Cambodian sex workers' HIV rates.
Phnom Penh, Cambodia - There is no sign outside to reveal what lies within the ramshackle building on an unpaved road in a scruffy neighborhood on the outskirts of the Cambodian capital. The chain and padlock on the front doors do not encourage visitors. But any man knocking on this door knows exactly where he is. An unfriendly, suspicious face appears and, after a brief conversation, he unlocks the doors and leads a small group through a maze to the back of the building. The noise of the visitors rouses a bevy of giggling girls, mostly young, mostly Vietnamese, from their mid-afternoon torpor. This is a brothel in Svay Pak, the infamous red-light district of Phnom Penh, and it offers young girls to foreign and Cambodian men. In Cambodia, sex is not hard to find - it is available in brothels, massage clubs, karaoke bars, beer gardens and on the street. While it is tragic that so many girls and young women are forced into such a high-risk lifestyle, there is hope. Although HIV prevalence in Cambodia is still the highest in Asia, it appears to be declining among commercial sex workers (CSWs), as well as within the general population. Among "direct" (brothel-based) CSWs, HIV has dropped from 42.6 percent in 1998 to 28.8 percent in 2002. Among the general population, it has fallen from 3.3 percent in 1998 to 2.6 percent in 2002 (Data source: HSS). Sexually transmitted infections (STIs) are also on the decline. (excerpt)
Gender power: an AIDS oxymoron?
The global face of HIV is changing and the reasons for this change are not surprising. Perhaps they are more of an indictment of opportunities missed, chances not taken and lessons not applied. This shift in the international image of HIV does provide the catalyst - if that is indeed what is still needed in 2004 - to address in a far more comprehensive, urgent and practical manner many of the underlying systemic factors of the epidemic. These overarching factors - unless addressed with real resolve and commitment by the political leaders and international agencies - will ensure that, despite our best intentions and strategic initiatives, HIV will continue to spread. Over the past five years, the all too obvious and worrying shift in the epidemic has simultaneously placed both the burdens of disease and care on the shoulders of women. But this shift might actually have its roots sewn in a much more intricate and complex tapestry: an AIDS tapestry that indicates how much still remains to be done if we are to make tangible inroads. (excerpt)
Making women central to family care.
A mother in Africa shares the concerns of any mother in any country around the world. Will my child be safe? Will my child be healthy? Will she get a good education? Will she be happy? Today, faced with the ravages of the HIV/AIDS pandemic that has hit the continent harder than anywhere else, a mother in Africa faces these issues with increased urgency. Added to her concerns is the realization that she may not live long enough to look after her children, or to teach them how to look after themselves. With a weakened immune system and a CD4 cell count of just one shortly after she gave birth to her second daughter, Margaret, 38, feared she did not have long to live. "I had lost hope," she says. "I had given up [and thought] that I was going to die." At Mulago Hospital in Kampala, Uganda, doctors urged Margaret to enroll in MTCT-Plus, a recently- established program at the hospital that would give her access to life-saving drugs, along with specialized care. Six months later, Margaret's CD4 cell count had risen to 147, and her energy returned. The improvement in her health came not a moment too soon. Having passed the virus onto her daughter, Margaret needed all the strength she could gather to care for her ailing family. (excerpt)
Objective: To determine the prevalence of hepatitis A, B, C and HIV seropositivity among patients with acute icteric hepatitis. Design: Cross-sectional descriptive survey. Setting: Kenyatta National Hospital, Nairobi. Subjects: Eighty four patients aged above six months with a history of jaundice not exceeding six months were recruited. There were 47 males and 17 females with an age range of eight months to 67 years and a median age of 25 years. Methods: History was obtained physical examination done and blood taken for determination of bilirubin, ALT, AST and ALP levels. Sera that had disproportionately greater transaminase than ALP elevation were assayed for IgM anti-HAV, IgM anti-HBc, HbsAg, anti-HCV and anti-HIV antibodies. Results: Evidence of hepatitis A, B, and C was round in 41.7%, 26.2%, and 7.1% of the patients respectively, 13.1% of the patients were HbsAg carriers while 30.1% of all patients were HIV positive. Thirty two patients did not have evidence of hepatitis A, B, or C infection and this group was significantly associated with HIV infection (p=0.003). Conclusion: Hepatitis A was the commonest overall type of acute icteric hepatitis seen at the KNH, and among patients aged 15 years and below. Hepatitis B was the leading identified cause of acute hepatitis among those aged over 15 years. Hepatitis C accounted for 7.1% of acute icteric hepatitis 30.1% of all patients and 50% of those admitted with acute hepatitis were also HIV positive. (author's)
CDC researchers also reported results of a study of human papillomavirus type 16 (HPV-16), the first study to provide national data on the infection’s prevalence in the U.S. population. At any one time, an estimated 20 million people in the U.S. have genital HPV infections that can be transmitted to others, and every year, about 5.5 million people become infected. There are 30 types of HPV that can infect the genital area. HPV can lead to cervical, penile and anal cancer, and HPV-16 accounts for 50 percent of all cervical cancer cases. “HPV is likely the most common STD among young, sexually active people,” concluded the study’s authors. “Given the health consequences of this infection, there is a tremendous need for us to better understand how to prevent HPV infection and why it either persists or is cleared up by the body’s immune system, so people don’t go on to develop life-threatening complications like cervical cancer.” (excerpt)
Commentary: Fortifying oral contraceptives with folic acid.
The following is a statement from AWHONN to the Food and Drug Administration’s Advisory Committee for Reproductive Health Drugs presented in live testimony on December 15, 2003, in Washington, D.C., by Claudia Reid Ravin, CNM, MSN, associate director of women’s health programs for AWHONN. Significant evidence exists to demonstrate the benefits to women of reproductive age in consuming folic acid for the prevention of significant birth defects. Neural tube defects (NTDs) are among the most serious, common and preventable birth defects that occur in the U.S. Each year an estimated 2,500 babies are born with these defects, and many additional affected pregnancies result in miscarriage or stillbirth. Up to 70 percent of NTDs can be prevented by consuming 400 micrograms of folic acid every day, beginning before pregnancy. This recommendation is supported by the Institute of Medicine, which advises that all women of childbearing age take 400 micrograms of synthetic folic acid daily, from supplements and/or fortified foods, to reduce NTD risk. (excerpt)
The objective was to compare the growth and illness pattern of infants who were exclusively breast fed for six months with those of infants commenced on complementary feeding before the age of six months and ascertain reasons for the early introduction of complementary feeding. The design was a comparative prospective study. The setting was an Urban Comprehensive Health Centre (UCHC), Obafemi Awolowo University Teaching Hospitals Complex, Ile-lfe. Three hundred and fifty-two mothers and their normal birth weight babies, weighing 2.500kg or more, and aged less than 14 days were serially recruited into the study. Mean/median monthly weights in the first six months of life, history/outpatient presentation for illnesses. Of the 352 mother-infant pairs recruited into the study, 345 (98%) were successfully followed-up for the first six months of life. At six months, 264 (76.5%) were exclusively breast-fed, 45 (13.1%) were started on complementary feeding, between the ages of four and six months while 36 (10.4%) commenced complementary feeding before the age of four months. Infants who were exclusively breast-fed for six months had median weights above the 50th percentiles of the WHO/NCHS reference that is currently used in the national "road to health" (growth monitoring) cards. Furthermore, the mean weight of these babies at age six months was above those of babies who started complementary foods before six months. They also reported fewer symptoms and had fewer illness episodes (0.1 episodes per child) compared to those who started complementary feeding before six months. Infants who commenced complementary feeding before four months reported more symptoms and had more illness episodes (1.4 episodes per child) compared to those that commenced complementary feeding between four and six months (1.2 episodes per child). Common symptom/illnesses seen or reported during the study among the groups were fever, diarrhoea and cough. Reasons given for early introduction of complementary foods include insufficient breast milk, thirst and convenience. It is concluded that exclusive breast-feeding supported adequate growth during the first six months of life for most of the infants studied. Early introduction of complementary foods did not provide any advantages in terms of weight gain in our environment, it was frequently associated with illness episodes and growth faltering. Many mothers however require support, encouragement and access to health care providers to breastfeed exclusively for the first six months of life. (author's)
College-Bound Sisters: exploring one pregnancy prevention program.
We were several years into an intervention program to prevent second pregnancies among adolescent mothers when we noted that the younger sisters of the women in our community frequently followed in the footsteps of their older siblings and joined the ranks of very young mothers. A search of the nursing and related literature revealed that, although the problem was well-recognized, this group of at-risk mothers had largely been ignored by the research community. East and Felice (1992) had reviewed the handful of studies done to date and confirmed that in the U.S., younger sisters of adolescent mothers were about twice as likely as other girls to become pregnant. The need for intervention was obvious, and we committed ourselves to designing and intervention that would help reduce the incidence of pregnancy among this high-risk group of teen girls. (excerpt)
Obstetric performance of women aged over forty years.
Background: Advanced age and parity constitute two major factors in the outcome of pregnancy and labour management both in the developed and developing countries. Objective: To examine pregnancy outcomes in women aged 40 years and above with the view of proffering solution to some of the problems encountered. Design: A case control retrospective study. Setting: Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria from 1st January, 1995 to 31st December, 1999. Subjects: Three hundred and three women who delivered at 40 years of age or above. The control group comprised of 303 women who delivered between 20 and 29 years during the five years period. Main outcome measures: Gestational age at delivery, birth weight, mode and type of delivery, pregnancy and birth outcome. Results: This showed a significant increase in prematurity, low birth weight, medical complications, operative deliveries (Caesarean section, vacuum and forceps), birth asphyxia and perinatal deaths all at P<0.05. Conclusion: There is a poor pregnancy outcome at fourty years and above. Patients need to be counselled for care in a specialised centre. (author's)
Abortion surveillance: trends, characteristics and the necessity of data collection.
In 1969, the Centers for Disease Control and Prevention (CDC) began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions. The data have been published every year since 1970 and recently was released in the November 28 issue of the CDC’s “Morbidity and Mortality Weekly Report” (MMWR). The report, entitled “Abortion Surveillance— U.S., 2000,” reveals that the total number of legal induced abortions performed in the U.S. for 2000 was down from 1999, and has been on the decline for a decade. It’s important for health care professionals to understand the collection of this information, and where it can be obtained, as well as to monitor these trends so that we can better understand the differing aspects and evolving patterns of this elective pregnancy outcome. It’s equally important to recognize the necessity of having such data resources available for health care professionals and advocates. (excerpt)
In what ways does gender facilitate HIV transmission, and how can sexual health promoters take account of this in designing and managing HIV-prevention programmes? This profile examines these issues in the context of the Mothusimpilo Project, a recently initiated HIV intervention in Carletonville, a gold mining community of 250 000 people near Johannesburg. As is the case in many parts of Southern Africa, levels of HIV amongst Carletonville residents are high, and condom use with casual partners is low, despite the fact that people are generally well-informed about the causes of HIV and how to prevent its transmission. About 75 000 of the Carletonville residents are male migrant workers who travel from within South Africa and neighbouring countries to work on the gold mines. The majority of these workers are housed in single sex hostels some distance from their families, and within this context a thriving commercial sex industry has sprung up, with large numbers of impoverished women flocking to the mines to make a living selling sex. The gold mines have been praised for the speed at which they implemented HIV prevention programmes for mineworkers, both through condom provision as well as good quality Sexually Transmitted Diseases (STD) services and information-based health education to all workers. However these programmes have not been as successful as was hoped. While they have succeeded in raising peoples' levels of factual knowledge of the risks of HIV infection, levels of HIV continue to rise, and unprotected sex is still common in casual or commercial sexual encounters. This poses a challenge to those concerned with HIV prevention: if factual knowledge is such a weak determinant of sexual behaviour, what are the other co-determinants, and what are the implications of these for the design of HIV intervention programmes? (excerpt)
The links between gender violence and HIV / AIDS.
South Africa has the fastest growing rate of HIV transmission of anywhere in the world, and most of the people infected are women. Until August 12, 1998, there was no visible nor active link made between these two very disturbing facts: not only are women prone to be the victims of gender violence, there is also a very high risk of women being infected with HIV. On August 12, 1998, however, a groundbreaking forum was organised by the Tshwaranang Legal Advocacy Centre to End Violence Against Women and the Aids Law Project, two non-governmental organisations (NGOs) based in Johannesburg. Held at the office of the Commission for Gender Equality (CGE), the forum was attended by representatives from over 30 organisations, including the South African NGO Coalition (SANGOCO), the Rape Crisis Centre and the National Youth Commission. Presentations were made by Dr Helen Rees, Chairperson of the Medicines Control Council, Dr Des Martin of the National Institute of Virology, Liesl Gernholtz of the CGE and Bronwyn Pithey of the Rape Crisis Centre in Cape Town. Personal testimony was also provided by a woman who told of her experience of contracting AIDs through rape. The decision to host the seminar grew out of the recognition that despite numerous national guidelines on rape and domestic abuse written by the Departments of Correctional Services, Justice, Health and the South African Police Services, none of these dealt with HIV/AIDS or the inter-relationship between violence against women and the risk of HIV transmission. In view of this, Tshwaranang and the AIDS Law Project decided that the inter-relationship between HIV and violence against women needed to be explored and that other NGOs needed to be informed about this. (excerpt)
In August 1993, an outbreak of group C rotavirus-associated gastroenteritis occurred among children attending a day-care centre in Belém, Brazil. Of the 64 children, 21 (33%) became ill. Group C rotavirus was identified in faecal specimens from 8 (38%) children with diarrhoea by electron microscopy (EM) and an enzyme immunoassay (EIA), using antibodies specific to the Cowden strain of porcine group C rotavirus. By polyacrylamide gel electrophoresis (PAGE), a pattern similar to that of group C rotavirus was observed in 5 (62.5%) of the 8 EM- and EIApositive samples. These 5 faecal samples were confirmed to be positive for group C rotavirus by reverse transcriptase-polymerase chain reaction, using specific VP6 and VP7 primers. This is the first report of an outbreak of diarrhoea in North Brazil associated with group C rotavirus. These findings suggest that group C rotavirus may be an important aetiological agent of diarrhoea in this region, which requires further study. (author's)
The implications of early marriage for HIV / AIDS policy.
In the past decade, policy attention has turned toward adolescent reproductive health and social development issues. During that same decade, women came to comprise half of those infected with HIV/AIDS. In some parts of the world, most notably sub-Saharan Africa, HIV prevalence rates among young women aged 15–24 outpace those of men in that age group by two to eight times. Of substantial consequence, yet largely ignored, is the fact that the majority of sexually active girls aged 15–19 in developing countries are married, and these married adolescent girls tend to have higher rates of HIV infection than their sexually active, unmarried peers. Thus married adolescent girls not only represent a sizeable fraction of adolescents at risk, but they also experience some of the highest rates of HIV prevalence of any group. Nonetheless, married adolescents have been marginal in adolescent HIV/AIDS policies and programmes and have not been the central subjects for programmes aimed at adult married women. It is time—indeed past time—to give substantially greater attention to the role that early marriage plays in potentially exposing girls and young women to severe reproductive health risks, including HIV. Protecting these young women may not only serve to help prevent the disease from spreading from “high-risk” groups to the general population in their own generation, but also to the next generation by reducing mother-to-child-transmission among this most intensive childbearing group. (excerpt)
The accompanying tables provide background data on health spending in AGOA countries; background data on successful applications for grants from the Global Fund to Fights AIDS, Tuberculosis and Malaria and grants received by AGOA countries under the World Bank Multisectoral AIDS Program (MAP) for Africa; and background data on HIV/AIDS prevalence. These data may help orient and clarify discussion of progress and objectives. Table 1. AGOA Countries: Share of Public Budgets Allocated to the Health Sector, 1997–2001. Table 2. GFATM Grants to AGOA Countries (Rounds 1, 2, and 3), and World Bank Multisectoral AIDS Program (MAP) Grants to AGOA Countries (preliminary data), US$ millions. Table 3. Adult HIV Prevalence, 2001, and Numbers of Orphans, 2005 (projected), AGOA Countries. Figure 1. AGOA Countries: General Government Expenditure on Health as Percentage of Total Government Expenditure, 2001. (excerpt)
AGOA representatives met late in 2001, again in 2002, and now for a third time in December 2003. Background papers from previous meetings suggested a number of actions that AGOA member countries could consider to enhance the effectiveness of responses to the threat of HIV/AIDS. This paper summarizes a few issues and actions, linking the actions specifically to (1) finance and planning ministries, (2) trade, labor, and commerce ministries, (3) the business sector, and (4) donors and assistance agencies. The delegates could discuss which key actions they would like to monitor and possibly report on at the next AGOA forum. They are welcome to recommend fresh approaches to maximize the benefits that can derive from a results-oriented, cooperative effort in the fight against HIV/AIDS. (excerpt)
HIV / AIDS in Malawi: estimates of the prevalence of infection and the implications.
The HIV/AIDS epidemic has become a serious health and development problem in many countries around the world. The Joint United Nations Programme on AIDS (UNAIDS) estimates the number of HIV infections worldwide at about 40 million by the end of 2001. About 28 million infected people—70 percent of the total—were in sub-Saharan Africa. The virus that causes AIDS has already infected and is infecting many Africans. About 20 percent of the entire adult population aged 15–49 is currently infected in nine southern African countries— Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe. This is a staggering level, and most of these people do not even know they are infected. From the beginning of the epidemic through 2000, about 4.4 million persons may have developed AIDS in southern Africa, although most of these have not been officially recorded. No cure is available for AIDS, and the disease threatens the social and economic well being of the countries. However tragic the HIV/AIDS epidemic is for Africa, there is still occasion for hope. HIV is not spread by casual contact or by mosquitoes or in the air or water. Africans do not have to wait for expensive vaccines to be developed at some time in the unknown future to protect themselves. HIV is spread by certain types of human behaviours; therefore, it can be controlled by changes in those behaviours. What is needed is continued involvement from all sectors of society to promote interventions to reduce high-risk sexual behaviours, treat and control other sexually transmitted diseases, maintain a safe blood supply, ensure safe use of needles, care for those already infected, ensure that human rights are respected and mitigate the problems of those already infected with HIV or otherwise affected by the epidemic. Most of the adult population remains free of the infection and all of these people have the opportunity to protect themselves from the disease. This report presents the latest estimates of the extent of the HIV/AIDS epidemic in Malawi and discusses some of the implications. (excerpt)
The first national home/community based care (HCBC) conference as called by the Minister of Health in 2001, was held by the National Department of Health, Chief Directorate: HIV/AIDS, STIs and TB from 18 to 21 September 2002 in Rustenburg, North West province. More than 380 delegates attended. They included officials from the provincial and national Departments of Health and Social Development, representatives from non-governmental organisations (NGOs) and community based organisations (CBOs) in each province, the Southern African Development Community (SADC), donor organisations, the private sector, faith-based organisations and traditional healers and leaders. HIV/AIDS is a significant development challenge facing South Africa. It is having and will continue to have an enormous impact on children, youth, families and communities in the coming decade. (excerpt)
The conference aimed to provide strategic direction for the delivery of care and support services through HCBC programmes in South Africa, and also to focus on strengthening their impact. An over view of the specific aims, objectives and expected outputs are contained in the section “The HCBC Conference at a glance” on page 5. Debates and presentations were structured around four tracks, and focused on issues that have been identified as critical barriers to developing HCBC services. The tracks of the conference were: Context for Care, Continuum of Care, Partners for Care, and Living Positively. The conference was based on presentations of real projects, not on abstract concepts. People involved with implementation were given the opportunity to present their projects, and this allowed practical issues to surface. Discussions were also guided by the challenges identified during the track and project presentations. These included: Scaling up HCBC and support programmes; Strategically integrating programmes; Coordinating services; Building referral mechanisms; and The sustainability of programmes, including volunteer turnover. (excerpt)
Policy on women, the girl child and STI / HIV / AIDS.
The existence of HIV/AIDS presents a serious challenge to every nation. It becomes a serious health and development problem throughout the world, and a potential threat to the social and economic fabric of whole nations. HIV/AIDS is now an issue of national importance in Cambodia. Therefore, it has received a careful attention at all levels, particularly it has been graced a strong support from Their Majesties The King and The Queen. However, gender perspectives are not systematically addressed in policies and programs related to STI/HIV/AIDS. The concerns of gender equity and equality, and women's empowerment are essential to the prevention of STI/HIV/AIDS transmission and to the protection of their reproductive rights. Cambodian people, especially women and girls, must be able to have a satisfying and safer sex life, dignity in the society, and full access to the health information, prevention, treatment, and care. This "Policy on women, the girl child and STI/HIV/AIDS", which aims at reducing the risks and impact faced by women and girls as well as the whole family related to STIs and HIV/AIDS epidemic, is a significant contribution to the promotion of the reproductive rights and represents a gender based response. It also includes a wide range of topics such as the findings of the situation analysis on women and girls regarding STI/HIV/AIDS in Cambodia and will help for a better understanding of their specific needs. The Ministry of Women's and Veterans' Affairs expresses its gratitude to the government ministries, NGOs and the UN agencies in supporting and contributing to the achievement of this policy. We hope that this document will be a valuable resource for all types of organizations involved in STI/HIV/AIDS interventions in Cambodia. (excerpt)
Construction workplace interventions for prevention, care, support and treatment of HIV / AIDS.
This paper identifies eight interventions for HIV/AIDS prevention, care, and treatment of construction workers. Where prevalence is low, cost of the eight interventions is 0.14 percent of the cost of a major construction project. With high prevalence levels of ten percent of the workforce, costs of the package of interventions would still fall below one percent of total project costs. These percentages are low enough to permit contractors to include the costs of such services among the indirect costs for worker injury protection, insurance and emergency care without substantially increasing total project costs. Sustained contracting agency financing of the package could provide a model for local sustainability of HIV/AIDS services. Contract agreements, labor legislation, and regulation of this industry could lead the way toward reducing stigma, financing essential interventions on a sustainable basis independent of general taxation, and generating new attitudes toward HIV/AIDS as a multisectoral issue. (author's)
Networking for policy change: an advocacy training manual. Maternal health supplement.
This document serves as a supplement to Networking for Policy Change: An Advocacy Training Manual, a resource for trainers of family planning and reproductive health advocacy issues worldwide. The training manual includes information on networking, communications, and policy environments; exercises on conceptualizing, implementing, monitoring, and evaluating advocacy campaigns; and relevant materials for advocates working in any area of reproductive health. Trainers can use the training techniques employed in the manual in various contexts, including when maternal health is the focus of advocacy. (excerpt)
Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In addition to the medical sequelae from these fistulas, they often have a profound effect on the patient’s emotional well-being. This article reviews the etiology of VVF, the surgical principles of repair, and the techniques developed for their repair. The earliest evidence of a VVF was found in 1923, when Derry examined the mummified body of Queen Henhenit (2050 BC). These dissections revealed a large VVF in a markedly contracted pelvis. The first clear documented reference to genital fistula was reported in the Ebers papyrus in approximately 2000 BC. However, not until 950 AD did Avicenna correlate the combination of pregnancy at a young age and difficult labor with the formation of a vesicovaginal communication. The term fistula (previously called ruptura) was not used until 1597, when Luiz de Mercado first coined the term. (excerpt)
Essential tips for successful collaboration.
In response to the social and economic costs associated with teen pregnancy, the Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health (DASH) launched an innovative initiative in 1997, The Joint Work Group on School-Based Teen Pregnancy Prevention (JWG). Comprised of eight national organizations representing a diverse group of policymakers and practitioners, the mission of the JWG was “to explore and strengthen the role that state and local education and health policymakers and personnel can play in preventing teen pregnancy.” To achieve its mission, the JWG sought to facilitate greater collaboration between health, education, and legislative entities, first at the national level, then at the state level. Specifically, the JWG engaged in efforts to educate their diverse constituencies, and to provide technical assistance to state teams seeking to integrate and strengthen multidisciplinary collaboration around teen pregnancy prevention. (excerpt)
Measuring HIV / AIDS Stigma and Discrimination. Program update: Mexico. Quarterly Update No. 1.
The objective of the POLICY Project’s “Stigma and Discrimination Initiatives” is to demonstrate how HIV/AIDS-related stigma and discrimination can be reduced using careful analysis and replicable interventions. The initiatives, based in Mexico and South Africa, are funded by the U.S. Agency for International Development (USAID). The aim of the projects is to develop indicators to measure internal and external stigma and discrimination as well as the impacts of interventions to address these issues. The identification and sharing of lessons learned will be an important result of the initiatives. (excerpt)
An evaluation of POLICY's advocacy manual: Networking for Policy Change.
The Advocacy Manual has become a major resource for FP/RH organizations and/or projects outside the POLICY Project. The Institute for Training and Research on Family Planning (ITRFP) of the Egypt Family Planning Association adapted and translated the manual into Arabic and subsequently used the curriculum to train nearly 900 multisectoral leaders in 14 governorates. UNFPA/Philippines and the Philippines Population Commission adapted selected portions of the Advocacy Manual to include in their RH advocacy guide for working with local governments and NGOs. The UNFPA Country Support Team in Slovakia used the manual to train NGOs in advocacy for RH. ASICAL, a regional coalition of NGOs representing men who have sex with men, is working with POLICY to adapt and expand the manual into an advocacy training guide, focusing exclusively on issues and concerns to their members. The manual has also been a resource for non-FP/RH applications. The World Wildlife Fund and the Biodiversity Project in Indonesia translated major sections of the manual into Bahasa and adapted materials for advocacy on environmental issues. Cognizant of the dearth of advocacy materials in Croatia, the Croatian NGO Democratic Youth Initiative (DYI) translated the manual into Croatian. It has already been used in training youth activists from NGOs, trade unions, student organizations, and political parties. (excerpt)
Facility Improvement Fund operation manual. Health centres.
This manual is designed to help you to manage the Facility Improvement Fund successfully in your health centre. Experience in the health centres has shown that implementation of the policies and procedures described in the manual will improve the collection and use of funds, and enhance patient and staff satisfaction with services. This list shows the key actions that the officer in charge must take to achieve success. They are described under the sections in which they appear. Section 1: Policy Staff support: Make sure that all health, administrative and support staff are aware of policies through meetings and circulars. Section 2: Managing for Success Performance targets: Use your service statistics and fee levels to set targets so that you know how much you should be collecting and waiving. Set priorities: See which departments have the greatest revenue potential and focus on improving performance in such departments. (excerpt)
This manual is intended for use in training and as a reference tool for the adolescent module named NewGen, which is a component of the software system of policy models known as Spectrum. Spectrum contains a number of components that are built on specific projection models. The oldest of these is the RAPID model, which helps to demonstrate the socioeconomic impacts of high fertility and population growth. One Spectrum component of particular importance is the demography module (DemProj), as it must be active to run NewGen and other Spectrum models. Spectrum also contains a family planning module (FamPlan), a module for the Benefit-Cost model, an AIDS module (AIM) and a Prevention of Mother-to-Child Transmission Model (PMTCT). In concert with DemProj, NewGen produces single or multiple population-based projection scenarios important to policy and program considerations related to young people between the ages of 10-24 (although 15-24 may be the most common age range used due to available data). Given available data constraints and the particular objectives of NewGen users, up to nine outputs may be generated by the model: number of pregnancies, number of abortions, percentage of pregnancies aborted, number of births, HIV prevalence, HIV incidence, AIDS deaths, STD incidence, and cost of treating STD infections. (excerpt)
TAHSEEN Project: first year work plan development workshop, October 23-25, 2002. Workshop report.
Improving Our Health by Planning Our Families (TAHSEEN Sihitna Bi Tanzeem Usritna), or TAHSEEN, is a seven-year (2002-2009) program to provide assistance to the public, private commercial and NGO sectors in order to solidify reproductive health/family planning (RH/FP) investments and progress of the last three decades. Funded by USAID, the program will be characterized by a broad, multi-sectoral approach, wherein there will be coordination between private, NGO and public services as well as between USAID-sponsored initiatives in health and education. TAHSEEN represents USAID’s final population project in Egypt. In order to draw together the numerous governmental and nongovernmental agencies and private companies that will play a part in TAHSEEN’s development and implementation, a workshop was held from October 23-25 in the Sixth of October City. With over 100 participants from all sectors of the RH/FP market and from all regions of the country, three days were spent discussing and refining the First Year Draft Integrated Work plan for TAHSEEN. The event proved to be a very productive and successful means of beginning to develop the partnerships that will be necessary to ensure that TAHSEEN meets its’ objectives and carries the Egyptian RH/FP program closer to full sustainability. (excerpt)
HIV/AIDS is the most devastating epidemic in human history. With 40 million people now living with HIV/AIDS and an estimated 3 million people having died in 2003 alone,1 the international community is working diligently to identify effective mechanisms to prevent HIV transmission and provide care, support and treatment for those affected by and living with the virus. Human and financial resources are still considerably inadequate to meet the overwhelming level of existing need. It is, therefore, imperative that existing resources be used wisely, based on the best available evidence of what works. Recently, there has been significant interest on the part of both multilateral and governmental agencies to increase the role of faith-based/religious organizations (FBOs) in mobilizing HIV prevention efforts, as well as in providing care and support services. The UNAIDS Global Strategy Framework on HIV/AIDS ,2 in laying out the principles and elements necessary for a coordinated and effective global AIDS response, calls for “partnerships of key social groups, government service providers, nongovernmental organizations, community-based groups and religious organizations.” While religious organizations have long delivered social, educational and health services in many countries, their activities have often not been well-documented and independent analyses of their impact is lacking. The increasing involvement of FBOs in delivering HIV/AIDS services warrants a balanced and impartial examination of their contributions to determine their optimal involvement in the future. (excerpt)
UNAIDS, USAID and the POLICY Project have developed the AIDS Programme Effort Index (API) to measure programme effort in the response to the HIV/AIDS epidemic. The index is designed to provide a profile that describes national effort and the international contribution to that effort. The API was applied to 40 countries in 2000. The results show that programme effort is relatively high in the areas of legal and regulatory environment, policy formulation and organizational structure. Political support was somewhat lower but increased the most from 1998. Monitoring and evaluation and prevention programmes scored in the middle range, about 50 out of 100 possible points. The lowest rated components were resources and care. The API also measured the availability of key prevention and care services. Overall, essential services are available to about half of the people living in urban areas but to only about one-quarter of the entire population. International efforts to assist country programmes received relatively high rating in all categories except care. The results presented here will be supplemented later in 2001 with a new component on human rights. (excerpt)
The overall objective of the study is to develop a financial sustainability strategy for contraceptive self-reliance (CSR) in the Philippines using a market segmentation approach. The development of such a strategy is in keeping with the statement of the Department of Health (DOH) in its 2001 Family Planning (FP) Policy that PhilHealth shall be a key partner in the mobilization of investments in the FP program, and that the DOH will adopt the recommendations of the technical working group on the Contraceptive Independence Initiative (CII). In particular, the CII will segment the population and will ensure the availability of commodities for all segments through direct subsidy, health insurance, socialized pricing, and/or commercial procurement. (excerpt)
Resource requirements for Cambodia's 2001-2005 HIV / AIDS national strategic plan.
The following report provides a summary analysis of the resources required to achieve the broad objectives outlined in Cambodia’s National Strategic Plan (NSP). This report outlines the costs associated with each strategic objective. This costing study began with the UN model, which was used to determine that $9.2 billion would be required globally for HIV/AIDS programs by 2005. The data specific to Cambodia were then revised and updated using a combination of: 1) key informant interviews with 40 Cambodian policymakers, implementers and researchers, 2) a review of 6 existing HIV/AIDS budgets in Cambodia, and 3) various demographic and economic surveys conducted on HIV/AIDS interventions in Cambodia. In costing Cambodia’s NSP, it was necessary to develop a set of strategic objectives that could be costed. Since Cambodia’s NSP includes a number of strategies that could not be costed (due to a lack of detail included in these strategies), it was necessary to merge the set of UN objectives used in their modeling exercise with the NSP strategies. (excerpt)
Assessment of policy environment for HIV / AIDS in Tanzania.
The Tanzania Public Health Association (TPHA) was commissioned by the POLICY Project to develop an HIV/AIDS questionnaire for conducting interviews with various stakeholders in the field at the national level. This questionnaire covers an assessment on political support, policy features, organisational structure, programme resources, monitoring, evaluation, and research, legal and regulatory, and programme components. This initial assessment covered stakeholders in the field of HIV/AIDS at the national level only. In the second phase, a sample of five districts will be included in the assessment. It is envisioned that the national questionnaire will be implemented every other year. The objectives were: to review and adapt the POLICY Project tool (HIV/AIDS Policy Environment Index) to the Tanzanian situation; to sensitise various stakeholders on the use of the tool; to assess the knowledge of the HIV/AIDS policy environment among stakeholders. (excerpt)
The first behavioural survey conducted in the Nigerian Armed Forces to elicit behavioural information that would contribute to a better understanding of the dynamics and underlying factors of the spread of sexually transmitted diseases (STDs) and HIV/AIDS in the military was carried out between May and August 2001. The nationally representative survey was conducted amongst nearly 1,600 military personnel randomly selected from the three service arms of the Nigerian Armed Forces. Detailed information on the knowledge and attitudes regarding STDs and HIV/AIDS and on risky behaviour patterns was elicited. Also, information on some socio-demographic factors that could have possible explanatory value or confounding effects was obtained. The survey reveals that Nigerian military personnel are very educated and dedicated, with long-term career investments in the military that imply personal and professional hardships and risks. Of concern is that Nigerian military personnel find themselves in professional and personal situations that lead to engaging in high-risk behaviours that could put them at risk of contracting STDs, including HIV. Furthermore, in view of the fact that military personnel live with and interact freely with the civilian population, they could serve as a potential core transmission group for these infections to the larger population. This is of great concern and calls for prompt interventions. Whilst military personnel are more aware of HIV/AIDS than the general population, more could be done by the Nigerian military to protect their dedicated officers and men to the extent possible from the risks to which they are exposed. (excerpt)
Initiated by USAID in 1984, the DHS assists developing countries to collect, analyze, and use data to improve national programs to address family planning, maternal and child health, child survival, HIV/AIDS and other STIs, and reproductive health. The household questionnaire of the DHS collects information on the nutritional status (anthropometric indicators) of women and young children, anemia prevalence, and use of iodized salt. The women’s questionnaire covers questions on infant and young child feeding including breastfeeding and complementary feeding practices, and micronutrient supplementation of women and children. The Food and Nutrition Technical Assistance (FANTA) Project, in collaboration with ORC Macro/DHS hosted a meeting on November 14, 2003 to review the nutrition sections of the current questionnaire as well as the presentation of nutrition data in the DHS documents. FANTA and its partners and colleagues in other cooperating agencies, academic institutions, and bi- and multilateral institutions draw on the DHS reports to inform their policy guidance and applied programming work in the areas of nutrition, health, and food security. As USAID prepares to begin a new five-year DHS program, it is an opportune time to discuss and recommend modifications to the current indicators, survey questions, and presentation of data related to nutrition. (excerpt)
Synthesis report on the famine forum.
In response to the 2002 National Security Strategy, USAID issued its White Paper, Foreign Aid: Meeting the Challenges of the Twenty-first Century. The White Paper outlines USAID’s proposed reforms and guiding principles to increase development aid effectiveness and policy coherence. In it, the developing world is divided into two groups of countries: relatively stable developing countries and fragile states. USAID’s strategy for fragile states has significant implications for how USAID responds to the challenges of famine in a constantly shifting global context. According to the White Paper: Fragile states include those on a downward spiral towards crisis and chaos, some that are recovering from conflict and crisis, and others that are essentially failed states. The challenge for these countries is to strengthen institutions, basic governance and stability, and thereby join the group of countries where more conventional development cooperation and progress are possible. (excerpt)
Program graduation and exit strategies: Title II program experiences and related research.
An exit strategy for a program is a specific plan describing how the program intends to withdraw from a region while assuring that the achievement of development goals is not jeopardized and that further progress toward these goals is made. The goal of an exit strategy is to assure sustainability of impacts and activities after the program has departed. "Exit" refers to the withdrawal of externally provided program resources (material goods, human resources, technical assistance) from the entire program area. "Graduation" refers to the withdrawal of resources from particular communities, program sites or program activities. The "strategy" is an explicit plan that includes the following: Specific criteria for graduation (of communities) and exit (of the program from the region); Specific and measurable benchmarks for assessing progress toward meeting the criteria; Identification of action steps to reach the stated benchmarks and of the responsible parties to take those steps; A time line, recognizing that the time line, especially in early stages, needs some flexibility; and Mechanisms for periodic assessment of progress toward the criteria for exit and for possible modification of the exit plan. This report is based on interviews with key individuals and reviews of the available literature on exit strategies and the experience of programs --- primarily USAID- PL 480 Title II food aid programs, which are required to include plans for exit in their Development Assistance Programs (DAPs). This review has examined specific Title II program experiences and strategies in India up to April 2003. (excerpt)
Good nutrition is increasingly being recognised as a key component in the care and support for people living with HIV/AIDS (PHA). These guidelines are meant for use by service providers in sectors such as health, agriculture, gender and development, and local government, among others. They are targeted at service providers who have the primary responsibility of support and care for HIV/AIDS patients. The guidelines are the result of considerable collective effort of nutritionists and service providers in both the public and private sectors. The guidelines recognise that most support and care for PHA takes place in their homes, where behavioural change will need to take place. Where possible we have provided the guidelines in a language and format that is user friendly to frontline service providers, and we have used up-to-date knowledge in the area of nutrition and HIV/AIDS. However, it is hoped that stakeholders will adapt these guidelines to suit their environments and to ensure the best care and support for PHA. Finally, we appeal to you to use these guidelines in the routine care and support of PHA. Use them in counseling, in training service providers, in the design of development of programs, and in the evaluation of programs serving PHA. (excerpt)
Local capacity building in Title II food security projects: a framework.
Although food security projects have always included capacity building activities, there is not enough monitoring, evaluation, and documentation of these activities to generate lessons learned and best practices. The USAID Office of Food for Peace's new strategic plan for 2004-08 will give a higher priority to capacity building activities within projects, providing an incentive for cooperating sponsors to more systematically conduct, monitor and evaluate capacity building activities within their projects. This paper establishes a conceptual framework for local capacity building within food security projects. It is designed to provide Title II policy-makers and cooperating sponsors with a basic reference tool for the design, implementation, monitoring and evaluation of projects’ capacity building activities at the local level. This framework builds on the USAID food security framework, in which food availability, access and utilization constitute the three pillars of food security. It focuses on the local level and, therefore, accounts for all actors who work toward food security within a geographic community, such as a district, village or neighborhood. These actors include individuals, households and associations, as well as the local leadership. Each plays a different and useful role in producing community food security. Community food security is the result of their combined activities and efforts. (excerpt)
Traditionally, the management of severe acute malnutrition (SAM) in emergencies includes setting up therapeutic feeding centers (TFCs). Over the last decade, the focus has been on the attainment of acceptable minimum standards of mortality. Recovery and clinical outcomes in TFCs managed by experienced agencies has been positive. However, TFCs have critical limitations; they are difficult to establish, expensive to operate, and they often have very limited coverage. Furthermore, TFCs do not build on the capacity of the community, and at times, they can undermine traditional coping strategies. Mothers or caregivers are often required to stay with their malnourished children for three weeks or longer in the TFC. Such a demand has tremendous opportunity costs and disrupts family life. Moreover, the congregation of people in and around feeding centers can lead to the spread of infection, an important cause of increased morbidity and mortality in an already weakened population. Despite technical advances in the management of SAM, including the implementation of national protocols in many countries, there are important gaps between projected numbers of SAM and the capacity of existing mechanisms to respond effectively. For example, UNICEF projections in Ethiopia in 2003 showed an estimated 60,000 severely malnourished children with less than 30% of these treated in some regions. Projections in Southern Africa in 2003 showed a similar situation with significant increases in SAM partly attributed to the high prevalence of pediatric HIV/ AIDS. (excerpt)
A study (ISRCTN 77665712) was undertaken to test the effectiveness and the acceptability of vitamin E and low-dose aspirin, alone or in combination, as treatment for prolonged vaginal bleeding induced by Norplant. A total of 486 Norplant users who were requesting treatment for bleeding lasting longer than 7 days were enrolled in five centers: Beijing, China; Jakarta, Indonesia; Santiago, Chile; Santo Domingo, Dominican Republic; and Tunis, Tunisia. They were randomized to one of four different 10-day oral treatments: 200 mg vitamin E daily, 80 mg aspirin daily, both or a placebo. Treatment packs were designed to ensure blinding of both the subjects and the clinical staff. Neither vitamin E nor low-dose aspirin nor their combination was found to have any effect on reducing the length of the bleeding episode for which treatment was taken or on the vaginal bleeding patterns these women experienced during the year of follow-up. (author's)
Progestogen-only contraception in women at high risk of venous thromboembolism.
The objective of the study was to evaluate the venous impact of a progestogen-only contraception on women at high risk of venous thromboembolism (VTE). In this retrospective cohort study, 204 consecutive women at high risk of VTE were recruited between January 1992 and June 1997 and were prospectively followed. Women using chlormadinone acetate (CMA) at antigonadotropic doses (n=102) were matched by age and date of referral and history of venous thrombosis with women who had no hormonal contraception (n=102). During follow-up (mean of 33 months), nine episodes of VTE were observed: three in women receiving CMA and six in nontreated women. Using the Cox model to adjust for confounding variables such as age, thrombophilia and body mass index, the relative risk of VTE associated with the use of CMA was not significant [relative risk: 0.8 (0.2–3.9)]. These reassuring results need to be confirmed in other prospective studies. (author's)
This prospective cohort study of 257 rural Zimbabwean women was designed to compare patient satisfaction with levonorgestrel subdermal implants (Norplant and reg;) versus tubal ligation (TL) as a method of long-term contraception. Women were equally satisfied with both methods. At 1 year, 96% of Norplant users and 97% of the TL group reported being “satisfied” or “very satisfied” and 98% of Norplant users, and 99% of the TL cohort would recommend their chosen method to a friend or relative. Rating scores at both 6 months and 1 year were high and equal, with women in each cohort rating their method, on average, as 9 out of 10. Norplant users were significantly more likely to rate birth spacing as a reason for satisfaction with their method, whereas women in the TL cohort were more likely to select multiparity. The 1-year continuation rate with Norplant was 90%, with 4% discontinuing in order to have more children. Selecting the most appropriate method depends primarily on the potential desire of the woman to have more children. (author's)
Abstinence education grants and welfare reform.
Today's crowded room is due to what the new $50 million federal abstinence education program is not about. It is not about consensus abstinence which holds that abstinence is valuable and needs to be taught; this approach holds, as well, that contraceptive information for sexually active individuals is as important - including for those who do not wait until marriage at the average age of 25/27. The $50 million is about a brand of abstinence which likely does not reflect current cultural standards, on the continuum of abstinence it is at the "extreme" - extreme abstinence. It teaches that sexual activity outside of marriage - at any age - is wrong. Presumably it is as wrong for Members of Congress between marriages in their 40's as it is wrong for 17 year old school drop outs. My task is to explore some legal issues that surround implementation. I've not been asked to address the political ironies that abound - conservatives who champion devolution imposing an 8 point prescriptive definition on local education programs; conservatives who urge federal fiscal restraint creating a brand new $50 million entitlement for an unproven social program? (nearly 2 billion over 5 years combined state and fed money will be spent on the issue - with no body of research...). (excerpt)
Through Section 510, an expansion of the Maternal and Child Health (MCH) block grant enacted as part of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), $50 million in federal funds are available each year to support abstinence programs that preclude education about contraception. A state match of $3 for every $4 federal dollars is required. The law’s definition of a fundable program has eight points, including that the program teach that “sexual activity outside the context of marriage is likely to have harmful psychological and physical effects.” Sometimes called “abstinence-unless-married” education, it holds that one should abstain except when married (thus, the divorced, widowed or never-married should abstain whether age 15 or 50). (excerpt)
Advice from the field: youth employment programs and unintended pregnancy.
CLASP(Center for Law and Social Policy) has worked for several years to bring attention to the role youth employment programs can play in addressing unintended pregnancy by conducting research projects (like the survey mentioned above) and by holding a meeting in June 2002 with individuals interested in these topics. At that meeting, CLASP brought together nationally renowned experts in both the pregnancy prevention and youth employment fields, local youth employment practitioners, as well as federal Department of Labor staff members, for a day-long meeting. Key lessons emerged from the meeting, including: 1) Collaboration and partnership by local community organizations is necessary for youth employment programs to successfully address unintended pregnancy among their program participants; and 2) Youth employment programs should better track the fertility outcomes of their participants in order to measure such outcomes against client needs, curricula development, and program retention. This report further explores the connection between the fields of pregnancy prevention and youth employment. It provides “advice from the field” from five youth employment providers about their efforts to combat unintended pregnancy and to provide family planning services. In addition, it includes interviews with two experts in the youth employment and teen pregnancy prevention fields, who provide advice and essential information for practitioners. This report is intended to provide “how-to’s” for staff in the youth employment field who wish to more innovatively integrate reproductive health education and unintended pregnancy prevention services into their programs. (excerpt)
Caps on kids: family cap in the new welfare era. A fact sheet.
Traditionally, a family’ welfare grant modestly increases when a baby is born; for example, the increment is 80 cents per day in Mississippi to $3.50 per day in California. In 1992, New Jersey became the first state to change this practice by “capping” the family’s grant. Today, 23 states are implementing some type of “family cap” or “child exclusion” policy which typically precludes the family from receiving the incremental grant increase. By limiting families’ access to this increment, policymakers have sought to reduce birth rates and encourage “personal responsibility.” The 1996 federal overhaul of welfare law creates an entirely new policy context. Previously, families could access assistance for as long as they qualified and many participants were not subject to work requirements. Today, federal welfare is restricted to a life-time limit of 60 months of assistance for the entire family; it also generally requires that the head of household work within 24 months. In other words, while family cap policies sought to limit a family’s grant, the 1996 welfare law eliminates federal assistance for the entire family after 60 months of cumulative receipt. Thus, it is possible to view the family cap as a vestige of a defunct welfare law. Evaluation data from early implementation states is mixed. New Jersey’s final findings are the first and only to indicate that the family cap achieved the intended goal of decreasing births among welfare recipients; however, the decrease in births is accompanied by an increase in abortions and the denial of the traditional grant increase for many newborns. (excerpt)
Leave no youth behind: opportunities for Congress to reach disconnected youth.
This report discusses six programs being considered by the 108th Congress for reauthorization, using a lens of policies to assist disconnected and at-risk youth. By bringing together these programs, this report provides a rare opportunity to identify their common challenges and concerns related to disconnected youth. The six programs are: Adult education and literacy programs of the Adult Education and Family Literacy Act (AEFLA) in Title II of the Workforce Investment Act (WIA); Financial aid programs and programs addressing cultural and academic barriers to access to higher education under the Higher Education Act (HEA); Special education and related services under the Individuals with Disabilities Education Act (IDEA); Services and programs for homeless and runaway youth funded by the Runaway and Homeless Youth Act (RHYA); Services and cash assistance provided to youth under the Temporary Assistance for Needy Families (TANF) block grant; and Youth services and activities funded under WIA. These six programs are certainly not the only ones that serve at-risk youth, but their reauthorizations provide an important opportunity to look across a set of key programs. (excerpt)
Thank you for seeking comments concerning reauthorization of the Temporary Assistance to Needy Families (TANF) Block Grant and related programs. In this letter, we expand upon the overall comments offered by the Center for Law and Social Policy (CLASP) by focusing on some initial ideas for provisions related to teen parents, reducing out-of-wedlock births, and teen pregnancy prevention. We believe that reauthorization presents an opportunity to recognize that teen pregnancy prevention is a vital strategy in addressing non- marital births. It is a “doable” strategy since recent research points to effective program interventions. Reauthorization also permits us to redirect our approach to needy teen parents, which too often has pushed them away; instead, such teens should be engaged in TANF rules and services. (excerpt)
Add it up. Teen parents and welfare -- undercounted, oversanctioned, underserved.
Teen parents were of particular interest in the 1996 welfare debate. Research showed that almost one-half of all welfare recipients were single women who had first been teen mothers. While not all teen mothers immediately became welfare recipients, about one-half did so within five years of becoming parents; most received aid for two years, with many remaining on the welfare caseloads longer. Such findings led to stricter welfare eligibility requirements for teen parents as part of the Temporary Assistance for Needy Families (TANF) program, the new welfare program created in 1996. Under TANF, minor parents are required to adhere to rules related to schooling and living arrangements in order to receive federal assistance. Specifically, unless a minor mother is participating in school/training and living in an approved arrangement, she is ineligible for TANF. Add It Up examines how states and teen parents have fared during implementation of the 1996 requirements. Few national data have been available to answer basic facts, such as how many teen parents have been subject to the rules and how they have been treated under the rules. Consequently, in July 2000, the Center for Law and Social Policy (CLASP) undertook a survey to collect state data on teen parents who received TANF assistance. In addition to quantitative data, the survey sought insight and opinions from administrators of TANF teen parent programs about implementation. (excerpt)
Homeless young parents live life on the edge. Many have escaped abusive and neglectful home situations. They and their children are often in unsafe situations with poor access to basic resources like adequate food, clothing, and health care. Some struggle with substance abuse and mental health problems. As some of the most vulnerable members of society, homeless young parents need access to public services, including welfare. In 1996, the Aid to Families with Dependent Children (AFDC) program, a system of cash grants for eligible low-income families, was replaced by the Temporary Assistance for Needy Families (TANF) program, which places a 60-month lifetime limit on federal assistance to families and emphasizes work over education as the means toward family self-sufficiency. As a block grant program, TANF gives states significant responsibility—and flexibility—to design and implement their own welfare programs. This report focuses on the experiences of homeless young parents with the TANF program. For young parents, TANF can be an important tool—a “leg up”—in helping these families achieve long-term stability and economic self-sufficiency. Most low-income young parents struggle to secure child care and transportation, to continue their education, and to find reliable jobs that pay livable wages. Homeless young parents face the additional challenge of locating permanent and safe housing. (excerpt)
Emancipated teen parents and the TANF living arrangement rules. A fact sheet.
Emancipation is a legal process in which a minor (a person under 18) petitions the court to have herself declared a legal adult. Emancipation laws vary from state to state, but generally emancipation ends the parents legal duty to support the minor, and also ends the parents right to make decisions about the minors residence, education, health care, and to control the minors conduct. However, it does not mean that the minor is the same as an adult for all purposes (for example, voting and alcohol-purchase age laws are not affected by emancipation). The extent to which an emancipated minor is treated as an adult varies from state to state, but emancipated minors generally can enter into binding contracts, sue and be sued, establish a residence, and consent to medical treatment on the same basis as adults. (excerpt)
Excluded children: family cap in a new era.
Excluded Children: Family Cap in a New Era draws on information compiled from research evaluations, academic studies, and state surveys to apprise policymakers and the public of what is now known about the efficacy and impact of the family cap. This document examines how different states have interpreted child exclusion policies, reports on state outcomes resulting from the family cap, and considers the ramifications of these policies in an era of welfare change. Initiated in 1992 in New Jersey, family cap policy was originally implemented to “promote personal responsibility” while discouraging births to families receiving cash assistance by eliminating or reducing cash assistance traditionally available to families with newborn children. To date, 23 states have established some type of family cap or child exclusion policy. (excerpt)
JOHN HUTCHINS, CLASP COMMUNICATIONS DIRECTOR: Hello, and welcome to the 2004 CLASP Audio Conference Series entitled “The Squeeze: Helping Low-Income Families in an Era of Dwindling Resources.” My name is John Hutchins, and I’m the Communications Director here at CLASP. I’ll be filling in this year for your regular host, Jodie Levin-Epstein, who’s on a fellowship in New Zealand until July. We’re really pleased to kick off this 11th season of CLASP Audio Conferences with today’s guest, Wade Horn, who, as you all know, is the Assistant Secretary for Children and Families at the U.S. Department of Health and Human Services. Welcome, Dr. Horn. WADE HORN, ASSISTANT SECRETARY FOR CHILDREN AND FAMILIES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES: It’s good to be with you, John. JOHN HUTCHINS: Thanks for being a part of this call. WADE HORN: My pleasure. JOHN HUTCHINS: Interest in this conference call has been overwhelming. In fact, Dr. Horn, you’ve set a record for the number of registrants for a CLASP Audio Conference. We estimate that there are nearly 800 people listening in more than 220 locations in 43 states and D.C. WADE HORN: I didn’t realize I had that many relatives out there. (excerpt)
The IRA: individual responsibility agreements and TANF family life obligations.
The 1996 welfare law, Temporary Assistance for Needy Families [TANF], includes a specific provision entitled individual responsibility plans. One part of the provision requires that each state agency conduct an assessment of the recipient within a prescribed time frame; it is then a state option whether to develop an activities plan based upon the assessment. Most states developed, or already had in place, some type of activities plan for participants. These plans take a variety of shapes. Many states have employability plans that address the activities and timing associated with job search, job training, etc. Some states also focus on more personal activities, such as immunization of children. Some states have one document that is an employability plan and another that addresses personal obligations; other states combine these activities in a single plan. This document seeks to identify the family life obligations required in individual responsibility agreements used by welfare agencies. This analysis is based upon a review of state documents called personal responsibility plans or personal responsibility agreements or any similar name; since the focus is on family life obligations, this analysis does not include a review of employability plans4 that solely address work activities. In this text, we refer to the individual responsibility agreement, or IRA. (excerpt)
Senate Finance Committee "marks up" welfare bill: what it means for youth and teen parents.
On Wednesday, September 10, 2003, the Senate Finance Committee approved a welfare reauthorization bill. Called PRIDE (Personal Responsibility and Individual Development for Everyone), the bill reauthorizes the Temporary Assistance for Needy Families (TANF) program as well as a number of other programs (e.g., the abstinence-unless-married education program). PRIDE is Senator Charles Grassley’s (R-IA) bill, and, as he is Chair of the Senate Finance Committee, the bill is considered the Chairman’s “mark.” The Chairman’s “mark” gets circulated a couple of days in advance of a committee hearing so that Committee Members can see what is included. Members then submit or “file” amendments. A filed amendment may or may not be debated in the Committee when Members “mark up” the bill. While the Senate has now taken a critical step in moving the reauthorization of TANF, the House passed a measure earlier in 2003. The next step in the Senate is consideration on the floor. Given the Senate’s schedule and press of business, it is not clear when or whether the reauthorization will reach the Senate floor but it is not expected to move rapidly. In the meantime, TANF is operating under a series of “continuing resolutions” that extend the current program, which was technically scheduled to expire on October 1, 2002. (excerpt)
In the new year, a new beginning to end HIV / AIDS.
Few of us can grasp the scope of the AIDS pandemic. Since the first diagnosis in 1981, over 20 million people have died from this disease. Almost 38 million people worldwide, more than the entire population of California, the most populous state in the United States, are infected with HIV, according to estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS). In Botswana and Swaziland, one in three adults is infected. In seven sub- Saharan countries, life expectancy has fallen to just 49 years. Even though the force and devastation of HIV/AIDS have long been recognized, the global response to the disease and its devastation remains sluggish and inadequate. From the beginning of the epidemic, the U.S. government response has been late, half-hearted, and far too small for the scope of the disease. In recent years, efforts to address the disease have been further compromised by unfulfilled promises of funding and misguided policies and ideologies that undercut program effectiveness. (excerpt)
Comparing vaginal and buccal misoprostol when used after methotrexate for early abortion.
The primary objective of this study was to determine if buccal misoprostol was as effective as vaginal misoprostol in medical abortions. The secondary objectives were to compare side effects and acceptability. This was a randomized controlled trial of 600 µg misoprostol by the buccal or vaginal routes used 3 to 6 days after 50 mg/m2 methotrexate. The participants were women presenting for abortion at 49 days or less gestation. The outcome measures were the number of women who had aborted by Day 8, side effects and acceptability. Day 8 completion rate was 53.5% for the buccal route and 67.5% for the vaginal route (p=0.012). Side effects were similar in the two groups except that there was more burning with the buccal route. Overall acceptability and route acceptability were similar in the two groups. When used after methotrexate for early abortion, the vaginal route for misoprostol is more effective and preferred to the buccal route. (author's)
The combined oral contraceptive (COC) pills, injectables, intrauterine contraceptive device (IUCD) and female sterilization are the most common contraceptive methods used by women. Women’s choice, compliance and satisfaction with specific contraceptive methods are influenced by any impact of the method on their quality of life and sexual function. Anxiety regarding possible adverse effects of the contraceptive methods on their quality of life and sexual function is one of the common concerns. The aim of this prospective observational study was to determine the impact of the above-mentioned contraceptive methods on the quality of life and sexual function of the users. A sample of 361 Hong Kong Chinese women who were first-time users of the following contraceptive methods completed the study: COC pills (n =87), injectables (n =67), IUCD (n =96) and female sterilization (n =111). Quality of life and sexual function of the subjects were assessed before and 3–4 months after use of the method by a standardized questionnaire. The questions were adopted from the validated Chinese versions of the World Health Organization Quality of Life (WHOQOL) questionnaire and the Derogatis Sexual Functioning Inventory (DSFI). In the female sterilization group, we found a significantly higher score for sexual satisfaction (p=.004) and sexual drive (p=.003) 3–4 months after sterilization, as well as an improved WHOQOL social domain score (p=.009). However, the other DSFI subscale scores and WHOQOL domain scores were not significantly different (p>.05). No significant difference was demonstrated in all the WHOQOL domain scores and DSFI subscale scores after use of COC pills, injectables and IUCD (p>.05). We conclude that the COC pills, injectables, IUCD and female sterilization all do not have significant adverse impact on quality of life and sexual function. After female sterilization, there is a significant improvement in sexual satisfaction and sexual drive. (author's)
Objectives: To examine the changes caused by tubal sterilization (TS) in ovarian hormone secretion and uterine and ovarian circulation. Design: Tubal sterilization was performed by minilaparotomy and laparoscopy methods in 36 women. Blood samples were taken for hormonal tests on Preoperative Day 3 (D3) of the menstrual cycle, on Postoperative Days 13-15 (periovulatory period) of the same cycle and on D3 in the 1st and 6th months post-TS. Uterine and ovarian artery blood flow rates of the women were measured on the same days as hormonal tests by transvaginal color Doppler ultrasonography (TVCDUSG). The control group was composed of 15 volunteers in the same age group who preferred the barrier method and who had the same TVCDUSG and hormonal analyses in the same periods. Results: There was a decrease in the uterine and ovarian artery pulsatility index (PI) measurements and an increase in serum luteinizing hormone (LH) and estradiol (E2) values during the periovulatory period as compared with preoperative and postoperative menstrual measurements in all groups. There was no difference between baseline uterine and ovarian artery PI and serum follicl