India's efforts to boost neonatal survival.
Home to the world's largest number of neonatal deaths, India has put together a strategy to help more babies survive by training rural health workers in simple techniques. But, says Patralekha Chatterjee, the programme's biggest problems lie in negotiating India's rural infrastructure. India is home to the highest number of births and neonatal deaths in the world. Of the 27 million babies born in the country every year, 1.2 million die during the neonatal period or in the first 4 weeks, according to the latest available data from State of India's Newborns, a report jointly compiled by UNICEF, WHO, the World Bank, and Save the Children. Two-thirds of India's infant deaths are neonatal, a situation experts say is the result of undernutrition, often a consequence of incorrect breastfeeding by mothers who are malnourished themselves. Unfortunately, existing programmes do not treat the health of newborn babies in a holistic way. "We need to consider that mortality happens due to combined morbidities", says Marzio Babille, UNICEF's Chief of Health in India. (excerpt)
Ann Veneman: getting UNICEF back to basics.
Ann M Veneman, a farmer's daughter who was the first female US Agriculture Secretary and is now Executive Director of the United Nations Children's Fund (UNICEF), has made child mortality public enemy number one for the agency, which had broadened its agenda under former head Carol Bellamy. Under Veneman, UNICEF is returning to an earlier mission of tackling diseases such as pneumonia, diarrhoea, and malaria that, together with other factors, claim the lives of 10.5 million children each year. The attainment of Millennium Development Goal 4--to reduce under-5 child mortality by two-thirds by 2015--is a key part of this strategy, said Veneman. "In order to do that we really have to figure out what works and how to measure the results", she told The Lancet. Veneman cited the example of Ghana, which is benefiting from the Accelerated Child Survival and Development programme that aims to strengthen community-based health systems and implement cheap, evidence-based health and nutrition measures. Initial surveys indicate that child mortality has been cut by up to 50% in a region where this programme was implemented, whereas in other regions rates have stagnated or even increased. "It's not just getting immunisation to kids, it's getting the mother good nutrition early on, it's being sure that the children then get the nutrition as well as the immunisation, it's making sure you get clean water", she commented. (excerpt)
Public health approach to HIV treatment in resource-poor settings [letter]
We applaud the emphasis on free care, drugs at the point of service delivery, and patient and community participation in Charles Gilks and colleagues article on public health approaches to the scale-up of antiretroviral treatment. The HIV epidemic exploits and exacerbates gender inequities, and the move to universal access makes these all the more pertinent. The tried and tested DOTS approach to tuberculosis care and treatment shows that even where drugs are provided free at the point of delivery, there are still patients "missing" from care: an estimated 52% in Malawi. These missing patients are likely to be from the vulnerable sectors of society, and the barriers they face in accessing and adhering to antiretroviral treatment will be even greater than those for antituberculosis drugs because stigma is greater and adherence is for life. Voices from women and men in resource-poor contexts highlight the importance of community-based care, strategies to address stigma, and creative approaches to the involvement of men in programme design and promotion of women's access to antiretroviral treatment. (excerpt)
Achieving Millennium Development Goal 4.
The statistics are stark: an estimated 10·5 million children aged under 5 years die every year from largely preventable conditions. That is a number roughly equivalent to the entire population of Portugal. Some 40% of these deaths occur within the first month of life. About half a million women die each year as a result of pregnancy, most during delivery or in the first few days thereafter. The death toll is only part of the overall disease burden. Hundreds of millions more women and children are undernourished, have an illness, or a long-term disability. The two Lancet series on child and neonatal survival, published in 2003 and 2005, reminded us of these harsh realities and helped galvanise international attention. If current trends continue, the 60 countries with the highest under-5 mortality rates will fail by a wide margin to reach the Millennium Development Goal (MDG-4) of reducing under-5 mortality rates by two-thirds by 2015. (excerpt)
Mastitis has been implicated as a risk factor for mother-to-child transmission (MTCT) of HIV-1 through breast-feeding. Maternal vitamin A deficiency is also associated with increased MTCT, as well as with episodes of mastitis in lactating animals. This review describes the complex interrelationship between vitamin A, mastitis, and MTCT of HIV-1 via mothers' milk. Current gaps in knowledge, as well as recommendations for future research efforts, are also discussed. (author's)
Science says: Teens' attitudes toward sexual activity, 2002.
The National Survey of Family Growth (NSFG) is the premier source of national information on teen sexual behavior, contraceptive use, and pregnancy. This Science Says issue brief uses the most recent round of the NSFG, collected in 2002, to examine teens' attitudes about sexual activity outside of marriage. The majority of teens disapprove of unmarried 16-year-olds having sex. Disapproval of teens having sex at an early age is widespread. Teens young and old--and of all racial/ethnic groups--generally do not think it is appropriate for unmarried 16-year-olds to have sex. (excerpt)
Science says: Teens' attitudes toward nonmarital childbearing, 2002.
The National Survey of Family Growth (NSFG) is the premier source of national information on teen sexual behavior, contraceptive use, and pregnancy. This Science Says issue brief uses the most recent round of the NSFG, collected in 2002, to examine teens' attitudes about childbearing outside of marriage. Older teens, sexually experienced teens, and teen mothers are more likely than younger teens and virgins to believe that it is okay for an unmarried woman to have a child. (excerpt)
Science says: Early childhood programs.
While most programs aimed at preventing teen pregnancy focus on adolescents, research suggests that children's experiences in programs many years earlier may also contribute to a reduced likelihood that they will become parents too soon. Indeed, studies indicate that early childhood and elementary school programs can contribute to reduced risk of adolescent pregnancy. This Science Says research brief highlights three such programs that were evaluated and found to be associated with lower risks of pregnancy in adolescence. With funding from the U.S. Centers for Disease Control and Prevention (CDC), the National Campaign to Prevent Teen Pregnancy has joined with Child Trends to assess the effects of these early childhood programs on adolescent sexual behavior. The three programs described in this report have been carefully evaluated and have met several criteria. (excerpt)
Science says: Characteristics of effective curriculum-based programs.
In Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy (published by the National Campaign to Prevent Teen Pregnancy in 2001), author Douglas Kirby, Ph.D. identified a number of programs that have been shown through rigorous evaluation to increase the age of first sex, improve use of condoms or contraception among sexually active teens, and/or to actually reduce teen pregnancy. Many of these effective programs were guided by a clear curriculum, and are therefore referred to here as curriculum-based programs, or "c-b programs." Some of these c-b programs were offered in schools, others outside of school. Interestingly, Kirby found that the effective programs share ten common characteristics. This Science Says research brief summarizes these characteristics and offers a few additional thoughts about their wider applicability to other programs to reduce teen pregnancy. (excerpt)
Science says: Characteristics of teens' first sexual partner.
Even though about half of all high school students in the U.S. have had sexual intercourse, relatively little is known about the characteristics of teens' first sexual relationships. This Science Says research brief fills in some of these knowledge gaps by providing information about the following: 1. How teens meet their first sexual partners; 2. The types of intimate things teens do and don't do before having sexual intercourse for the first time, and 3. Teens' likelihood of discussing contraception with their partner before having sex for the first time. Using national data on teens in grades 7-12, this research brief presents information by gender, race/ ethnicity, and age. Readers should note that all the differences reported in this brief (for example, differences in answers between males and females) are considered statistically significant. (excerpt)
Science says: The sexual behavior of young adolescents.
Few adults or teens think it is appropriate for young adolescents to have sex. Still, a significant minority of those age 14 and younger say they have had sexual intercourse. One large data set even suggests that while the proportion of unmarried teen girls age 15-19 who have had sex declined between 1988 and 1995, the proportion of unmarried teen girls age 14 and younger who had sex increased appreciably over the same time period. This Science Says research brief provides data on the sexual behavior of young adolescents and offers recommendations based on this research to parents, policymakers and those who work with teens. Readers should be aware that all of the following data is nationally-representative except where noted. For more detailed information on the sexual behavior of young adolescents, please see the National Campaign publication, 14 & Younger: The Sexual Behavior of Young Adolescents. (excerpt)
Science says: Where and when teens first have sex.
Almost half (46%) of high school-aged teens in the United States have had sexual intercourse. Because of continued concern about teenage sexual activity and support for messages that encourage young people to delay sexual debut, where and when teens first have sex is a matter of interest to those who run programs for teens, to policymakers, and to parents. This "Science Says" research brief uses data from a recent national survey to examine the time and place teens first have sex and provides recommendations based on these findings. (excerpt)
Science says: The sexual attitudes and behavior of male teens.
The 850,000 teen girls who become pregnant each year don't do so alone. Still, teen pregnancy is usually seen as a "girls' problem." Happily, the past decade has brought increased attention to the importance of directly involving boys and men in efforts to prevent teen pregnancy. This Science Says brief provides information on teen boys' sexual activity and contraceptive use, their attitudes toward both, and advice for parents and program leaders. (excerpt)
This review of young people's sexual and reproductive health (YPSRH) and gender issues affecting young people ages 10--24 in 19 Arab States and the Islamic Republic of Iran (hereafter referred to as 'Iran'), was undertaken to: 1) strengthen the knowledge base on YPSRH, including gender issues, and on the regional programme and policy context; 2) provide recommendations for national YPSRH and gender policies and programmes based on evidence from international programmes and regional data; and 3) identify gaps in the knowledge base on YPSRH and gender issues in the region and recommend research priorities. The authors and three research assistants conducted: 1) a YPSRH literature review globally and from the 20 specified countries; 2) policy analyses related to the countries' compliance with international human rights treaties and agreements on issues related to YPSRH and gender; 3) interviews with international and regional experts; 4) interviews with and email surveys of national programme professionals. (excerpt)
Over the last few decades, the world has made great strides in recognizing the importance of young people's sexual and reproductive health and rights. In 1994, at the International Conference on Population and Development, governments of the world adopted the Cairo Programme of Action, a comprehensive plan that linked the reproductive health and human rights of individuals to the global struggle to reduce poverty and achieve sustainable development. In 1995, at the Fourth World Conference on Women, governments adopted the Beijing Platform for Action, a roadmap to securing women's human rights, providing equal opportunities, and eliminating discrimination and violence from women's public and private lives. Both agreements paid significant attention to young people's health and rights, and both made reference to the central role young people can and should play in moving the world from words to action. Today, many reaffirmations later, advocates around the world--many of them close colleagues of the International Women's Health Coalition--are engaged in the hard work of making Cairo and Beijing tangible in their communities. Young people are playing a vital role in this struggle. At 1.2 billion, the world's current generation of adolescents (ages 10 to 19) is the largest ever, and in developing countries worldwide, a third or even half of the population is under the age of 20. Many of these young people are spearheading their own organizations and networks. And around the world, more and more adult-led organizations are recognizing the critical contributions that young people can make in a wide range of advocacy and programs serving youth. (excerpt)
Not just another single issue: teen pregnancy and athletic involvement.
When it comes to preventing teen pregnancy, few make the link with women's athletic participation. Common sense and a growing body of research suggests, however, that creating opportunities for girls to play sports can play a key role in reducing teen pregnancy. For example, female athletes in grades 9 through 12 are less than half as likely to get pregnant as their non-athlete peers, and they tend to have higher self-esteem and more positive body images. Participating in athletics also decreases the chance that both girls and boys will abuse drugs and alcohol, both of which can lead to risky decisions about sex. These interrelationships are further highlighted by two important trends: the teen birth rate has declined 31 percent between 1991 and 2002, and over approximately this same period, young women's participation in high school athletics increased by 47 percent. (excerpt)
The major remaining challenge in the prevention of mother-to-child transmission is the reduction of the risk in settings where breast-feeding is common. This review gives an update on ongoing or planned antiretroviral intervention studies in resourcelimited settings that are aimed at reducing the risk of mother-to-infant HIV transmission during lactation. These strategies include antiretroviral therapy given to the mother to reduce viral load in plasma and breast milk as well as antiretroviral regimens providing prophylaxis to uninfected infants during the period of breast-feeding. The rationale for the interventions based on animal models and human studies is described as well as the study designs of clinical trials. Potential risks and benefits of these interventions to mothers and infants are also highlighted. Laboratory studies nested within several of these trials will provide a better understanding of the pathogenesis of postnatal HIV transmission and its potential prevention using antiretroviral drugs. (author's)
There is evidence that breast-feeding by women with human immunodeficiency virus-1 (HIV-1) infection carries a substantial risk of viral transmission. In a resource-poor setting, however, formula feeding might lead to an increase in infectious infant morbidity and mortality. This randomized trial, undertaken at four antenatal clinics in Nairobi, Kenya, during 1992-1998, compared outcomes in breast-fed and formula-fed infants of HIV-infected women. Participating were 371 live-born singleton (or first-born twin) infants of seropositive mothers. The parturients were randomly assigned to use formula (N = 186) or to breast-feed their infants (N = 185). Ninety-two infants acquired HIV-1 infection. Cumulative rates after 2 years of follow-up were 37% in the breast-fed group and 21% in the formula-fed group. Mortality rates did not differ significantly at either 1 or 2 years of follow-up. Among infants who became infected during the study, 40% of those fed formula and 46% of breast-fed infants died within 2 years. Hazard ratios did not differ significantly. Mortality was, however, much increased for infants infected in the first 2 months of life compared with those infected later (63% vs. 9%). Women assigned to breast-feeding had 3-fold higher mortality than those assigned to formula feeding during the 2 years of follow-up. Moreover, maternal deaths were associated with a higher risk of subsequent infant death. Considering HIV infection and death together as adverse outcomes, formula feeding conferred protection amounting to 28%. Diarrheal illness and pneumonia occurred at similar rates despite the mode of feeding. HIV-infected children were about twice as likely to be malnourished at some time if fed formula than if breast-fed. (excerpt)
Youth, poverty, gender. ICT for development success stories.
If ever there was an area where young people are leaders not just of tomorrow, but also of today, it is undoubtedly in the fields of Information and Communication Technologies (ICT). As you will see in the following pages ---- from the youth of Thailand connecting rural villages, to Sri Lankan youth developing television programmes ---- young people are at the forefront of transforming their societies through the information and communications revolution. They are early adopters and adapters of technologies, and often at the forefront of linking ICTs to development goals. Yet, too often youth initiatives face a lack of mainstream recognition, opportunities to participate in decision-making processes, and a sense of a peer community to learn from. The inaugural Global Knowledge Partnership Youth Award is a major component of the Youth Creating Digital Opportunities initiative, a multi-stakeholder effort to realize the potential of young people to use Information and Communication Technologies to achieve more sustainable development in their communities. The Award aims to reward and bring international recognition to youth-led and focused ICT projects. Eleven finalists have been selected by an international body of ICT4D policy-makers and practitioners from around the world, and the winner shall be honoured at the 2003 World Summit on the Information Society (WSIS). (excerpt)
Science says: The relationship between teenage motherhood and marriage.
Teenage childbearing is associated with many adverse consequences for teen mothers, their families, and children. Many of the negative consequences for teen mothers are due to the disadvantaged situations in which many of these girls already lived before having a teen birth. While the disadvantaged backgrounds of most teen mothers account for many of the burdens that these young women shoulder, having a baby during adolescence often restricts economic and educational opportunities, and these disadvantages tend to be passed on to the next generation. Children born to teen mothers are often worse off than children born to older mothers. They are at higher risk of poverty, low educational attainment, problem behavior, early sexual activity, and becoming a teen parent themselves. Marriage, or more specifically, the absence of marriage, helps explain this cycle of disadvantage. Many family-related factors affect how children fare and develop over time, and marriage is one of them. Research suggests that children do best when they are raised by two parents who have a stable marriage. Yet only 20 percent of teen births occur within marriage and teen pregnancy itself is associated with a lower likelihood of marriage. Teen mothers are unlikely to marry the biological fathers of their children, and those teenage mothers who do wed often end up in unstable marriages. For their part, the unmarried fathers are less likely to be involved in their children's lives, and reduced paternal involvement is associated with lower child well-being. For all of these reasons, helping more women reach adulthood before they have children would go a long way toward ensuring that more children grow up in stable, married families. And considering the large body of research on the benefits to children of growing up in such families, the link between reducing teen pregnancies and improving overall child well-being is clear. (excerpt)
Teen pregnancy rates in the United States, 1972-2000.
The U.S. teen pregnancy rate for teens aged 15-19 decreased 28 percent between 1990 and 2000. After reaching 117 pregnancies per 1,000 females aged 15-19 in 1990, the pregnancy rate has decreased to 84 pregnancies per 1,000 females aged 15-19 in 2000. (Pregnancy data include births, abortions, and miscarriages.) The chart and table in this document reflect pregnancies per 1,000 teen girls aged 15-19 in the United States and are the most recent national data available. Numbers have been rounded to the nearest whole number. (excerpt)
What you should know about contraception! Updated.
Contraception (also known as birth control) refers to the many different methods of preventing pregnancy. Abstinence from sexual activity until marriage is the only 100% sure contraception. Also, abstinent teens are not at risk for pregnancy or STDs, including HIV/AIDS. Teens who choose to be sexually active should remain faithful (not have sex with anyone else) to reduce the possibility of getting or giving someone an STD or HIV/AIDS. The latex condom is the only contraceptive method that may provide protection against some STDs, including HIV/AIDS. Research shows that latex condoms may not be effective against some STDs such as Human Papilloma Virus (HPV - the virus that causes genital warts.) Anyone who has sex and doesn't want to get pregnant or get someone pregnant needs contraception. Any time you have sex, there is a risk of pregnancy. Not having sex--abstinence--is the only 100% sure way to avoid pregnancy. (excerpt)
What docs should know about ... the impact of teen pregnancy on young children.
The teen pregnancy rate in the United States has declined in recent years but many teens are still becoming pregnant with important consequences for their children. The United States has the highest teen pregnancy rate in the industrialized world. Thirty-five percent of girls get pregnant at least once by age 20 in this nation --- nearly 850,000 teen pregnancies annually. Teen childbearing costs taxpayers at least $7 billion each year in direct costs associated with health care, foster care, criminal justice, and public assistance, as well as lost tax revenues. Although overall teen birth rates have declined dramatically in the last decade, additional births to teens that are already mothers are disturbingly common; nearly one-quarter of teen mothers have a second birth before turning twenty. (excerpt)
Understanding and challenging HIV / AIDS stigma.
This book will help you to understand why so many people have such negative attitudes towards those who have HIV/AIDS, and their families. It shows how these attitudes - which are called stigma - undermine HIV/AIDS care and prevention, and cause great personal suffering and tragedy. The fight against HIV/AIDS and the fight against stigma have to go hand-in-hand: it is not possible to get rid of one without getting rid of the other. At the moment those who most need to understand and tackle stigma sometimes have a limited understanding of what it is, how it is caused and how it can be addressed. Until this can be reversed, the HIV/AIDS epidemic will continue. The aim of this book is to encourage individuals, groups and communities to think and talk about stigma and its causes, using their own first-hand experiences and then to develop ways to overcome it. Some anti-stigma programmes try to stop stigma by providing information about HIV/AIDS. On its own, this is not enough. In addition to receiving information, communities need to examine how stigma affects them in their particular situation, and what responses are possible and appropriate for their situation. (excerpt)
HIV / AIDS education: a gender perspective. Tips and tools.
The information, strategies and actions presented in this booklet are based on the findings and recommendations of a series of reviews of HIV/AIDS teaching and learning materials conducted by UNICEF in 1998 and 1999 in Latin America and the Caribbean; Asia and the Pacific; and East and Southern Africa. Together, these studies indicated that a huge number of materials and variety of formats already exist; how ever, there is an urgent need to strengthen both the content of these materials and the teaching and learning methodologies in relation to gender issues. Therefore, the priority is probably not to create more materials, but rather, to utilise what we have in much more effective ways. Sensitising educators, and others, to HIV/AIDS and its implications is also a central theme of this publication. The HIV/ AIDS pandemic has developed into a major threat to human development especially in the poorest regions of the world. Women and girls are at particular risk because of skewed power relations and concepts of masculinity that undermine their right, and ability, to make their own decisions in the family and in society in general. This includes decisions about when to have sex and with whom, and about protecting themselves against sexually transmitted diseases, including HIV-AIDS. Poverty and economic dependence, as well as harmful traditional practices increase the risks for women and girls. (excerpt)
Preventing teen pregnancy: why it matters.
The teen birth rate declined by one-third between 1991 and 2002. But…what if it had not? What if the teen birth rate in the United States had stayed at the 1991 level? 1.2 million more children would have been born to teen mothers. 460,000 additional children would be living in poverty. 700,000 more children would be living in single mother households. What are the chances of a child growing up in poverty if: (1) the mother gave birth as teen, (2) the parents were unmarried when the child was born, and (3) the mother did not receive a high school diploma or GED. 27% if one of these things happen. 42% if two of these things happen. 64% if three of these things happen. But, if none of these things happen, a child's chance of growing up in poverty is 7%. Put another way, if these three things happen, a child's chance of growing up in poverty is 9 times greater than if none of these things happen. (excerpt)
From 1999 to 2004, Save the Children was supported by the Bill & Melinda Gates Foundation to implement an Adolescent Reproductive and Sexual Health program in Bhutan, Malawi, Nepal, and Vietnam. Save the Children chose to focus its work to improve young people's reproductive and sexual health status in the four countries through three main objectives: improving the availability and accessibility of quality reproductive health services for youth; empowering young people and building youth capacity to make positive life planning decisions; and building social and political support for youth reproductive health. (excerpt)
The objective was to better understand the role that men who have sex with men and women (MSM/W) play in the spread of HIV in young adults in North Carolina, we determined the prevalence of MSM/W among newly diagnosed HIV-infected men, compared social and behavioral characteristics of this group with MSM and MSW, and examined the sexual networks associated with HIV-infected college students among these groups. We reviewed state HIV surveillance records for all new diagnoses of HIV in males 18 to 30 years living in North Carolina between January 1, 2000, and December 31, 2004. Of 1105 records available for review, 15% were MSM/W and 13% were college students. Compared with MSM, MSM/W were more likely to be enrolled in college, to report > 10 sex partners in the year before diagnosis, or have sex partners who were also MSM/W. Sexual network analysis of the HIV-infected college students revealed that MSM/W occupied a central position. Of 20 individuals who described themselves as either MSW or abstinent at the time of their initial voluntary counseling and testing visit, 80% reported that they were either MSM or MSM/W during follow up. MSM/W represent a unique risk group within the population of MSM that deserve further investigation. College MSM/W appear to occupy a unique, central place in the network of HIV-infected students. (author's)
The objective of this study was to examine chlamydia prevalence and its risk factors from the first universal screening in socioeconomically disadvantaged young men. The goal of this study was to evaluate the need for universal screening in young men. We calculated chlamydia prevalence by demographic and geographic characteristics from 51,478 men aged 16 to 24 years who were screened from July 2003 to December 2004. Results: Overall, chlamydia prevalence was 8.2%. Only 2.4% of the young men had sexually transmitted disease symptoms. Blacks had the highest prevalence (13.0%), whereas non-Hispanic whites had the lowest (3.1%). Men who smoked marijuana had a significantly higher prevalence compared with those who did not (11.9% vs. 6.4%). Men who used cocaine or PCP also had a significantly higher chlamydia prevalence compared with those who did not. Men who lived in the southern region of the United States had the highest prevalence. Chlamydial infection is highly prevalent among socioeconomically disadvantaged young men. Young men entering the National Job Training Program represent an important population for screening. (author's)
Fluoroquinolone-resistant Neisseria gonorrhoeae in Bali, Indonesia: 2004.
In the mid-1990s, fluoroquinolones were introduced in Indonesia for the management of gonorrhea and are now part of the national recommended treatment guidelines. We recently documented introduction of ciprofloxacin-resistant Neisseria gonorrhoeae strains in female sex workers (FSWs) in Timika, Indonesia, 5 years after treating gonococcal cervicitis with ciprofloxacin and periodically monitoring antimicrobial susceptibility of isolates. To assess the importance of this observation, we determined antimicrobial susceptibilities and strain types of N. gonorrhoeae isolates from FSWs seen in a sexually transmitted infection (STI) clinic in Denpasar, Bali, Indonesia. The goal of this study was to determine antimicrobial susceptibilities and strain types among N. gonorrhoeae isolated from FSWs in Denpasar, Bali. FSWs in Denpasar were screened for N. gonorrhoeae by standard culture. Endocervical isolates were frozen in Microbank tubes and sent to the University of California at San Francisco on dry ice. Antimicrobial susceptibility testing using a Clinical Laboratory Standards Institute-recommended agar dilution method was performed at the Centers for Disease Control and Prevention. Isolates were characterized by ß-lactamase production, antimicrobial resistance phenotypes, and auxotype/serovar class. One hundred forty-seven N. gonorrhoeae isolates were characterized. All isolates were highly resistant to tetracycline (minimum inhibitory concentration, = 16.0 µg/mL): 117 (79.1%) were ß-lactamase-positive (PP-TR), 3 (2.0%) exhibited chromosomally mediated resistance to penicillin (PenR-TRNG), and 27 (18.2%) were susceptible to penicillin (TRNG). All isolates were susceptible to ceftriaxone, cefixime, and spectinomycin; lack of interpretive criteria do not allow interpretation of susceptibilities of cefoxitin, cefpodoxime, or azithromycin. Fifty-nine (40.1%) isolates were ciprofloxacin-resistant; 35 (59.3%) of the ciprofloxacin-resistant isolates exhibited high-level resistance to ciprofloxacin (Cip-HLR; minimum inhibitory concentration, = 4.0 µg/mL of ciprofloxacin). Three (2.0%) isolates were intermediate to ciprofloxacin. Twenty-two strain types were identified among these isolates; small clusters were identified with 3 strain types. N. gonorrhoeae isolates from FSWs in Denpasar were resistant to penicillin and tetracycline; 40.1% of the isolates were fluoroquinolone-resistant. With gonorrhea prevalence of 35% at this clinic (by nucleic acid amplified tests), ongoing surveillance for antimicrobial resistance will be needed to appropriately choose treatment for infections caused by these resistant organisms. (author's)
The objectives of this cross-sectional study were to determine correlates of syphilis seroprevalence among HIV-infected and -uninfected antenatal attendees in an African multisite clinical trial, and to improve strategies for maternal syphilis prevention. A total of 2270 (86%) women were HIV-infected and 366 (14%) were HIV-uninfected. One hundred seventy-five (6.6%) were syphilis-seropositive (7.3% among HIV-infected and 2.6% HIV-uninfected women). Statistically significant correlates included geographic site (odds ratio [OR] = 4.5, Blantyre; OR = 3.2, Lilongwe; OR = 9.0, Lusaka vs. Dar es Salaam referent); HIV infection (OR = 3.3); age 20 to 24 years (OR = 2.5); being divorced, widowed, or separated (OR = 2.9); genital ulcer treatment in the last year (OR = 2.9); history of stillbirth (OR = 2.8, one stillbirth; OR = 4.3, 2--5 stillbirths); and history of preterm delivery (OR = 2.7, one preterm delivery). Many women without identified risk factors were syphilis-seropositive. Younger HIV-infected women were at highest risk. Universal integrated antenatal HIV and syphilis screening and treatment is essential in sub-Saharan African settings. (author's)
The prevalence of sexually transmitted diseases among adolescents is high. Innovative screening and treatment programs need evaluation. The objectives of this study were to identify, treat, and describe the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among Philadelphia public high school students. We analyzed cross-sectional data from the first year of an annual program offering education, screening, and treatment for CT and GC. For the school year analyzed, screening took place between January 2003 and June 2003. In the first year, 19,394 students aged 12--20 years were voluntarily tested; 1052 students were identified with GC, CT, or both; 1051 received treatment. Prevalence of CT among females (95% confidence interval [CI] = 8.1) was 3.3 times higher than among males (95% CI = 2.5%). Attending disciplinary schools and residing in high reported morbidity areas were also related to higher prevalence of CT and GC. A high prevalence of CT infections was identified among Philadelphia public high school students. This program demonstrated the effectiveness of a school-based screening program to identify and treat these infections. (author's)
The objective of this study was to estimate the cost-effectiveness of syndromic management, with and without periodic presumptive treatment (PPT), in averting sexually transmitted infections (STIs) and HIV in female sex workers (FSWs) participating in a hotel-based intervention in Johannesburg. Financial and economic providers' costs were estimated. A mathematical model, fitted to epidemiologic data, projected the HIV and STIs averted by the intervention. Cost per HIV infection and DALY averted were estimated for different general population HIV prevalences. Projections suggest 53 HIV infections were averted (July 2000--June 2001) and a 3.1% decrease in the FSW HIV incidence. Cost-effectiveness was $78 per DALY averted. Incremental cost of PPT was $31 per disability-adjusted life year (DALY) averted. Initiating the intervention at 15% general HIV prevalence would have improved cost-effectiveness by 35%. Expanding PPT coverage to mass-treat all FSWs (instead of < 17%) and their clients could increase impact 14-fold. The results highlight targeted interventions can be cost-effective at all stages of HIV epidemics and suggests PPT could improve the cost-effectiveness of targeted STI interventions. (author's)
The objective of this study is to estimate the annual costs of information, education, and communication (IEC), both community- and school-based; strengthened public and private sexually transmitted infections treatment; condom social marketing (CSM); and voluntary counseling and testing (VCT) implemented in Masaka, Uganda, over 4 years, and to explore how unit costs change with varying population use/uptake. Total economic provider's costs and intervention outputs were collected annually to estimate annual unit costs between 1996 and 1999. In early intervention years, uptake of all activities grew dramatically and continued to grow for public STI treatment, CSM, and VCT. Attendance at IEC performances started to drop in year 4. Unit costs dropped rapidly with increasing uptake of and participation in interventions. When implementing long-term community-based interventions, it is important to take into account that it takes time for communities to scale up their participation, since this can lead to large variations in unit costs. (author's)
The objective of this study is to assess the costs, cost-effectiveness, and HIV epidemic impact of 3 antiretroviral therapy (ART) policy options. We constructed an epidemiologic model to predict the course of the HIV epidemic in the absence of expanded ART availability. Based on background studies of the willingness to pay for ART among patients with AIDS, of the costs to the government of the alternative treatment interventions, and of ART's likely effects on HIV transmission, we simulated the consequences of 3 possible alternative government ART policies. A program to reduce the negative consequences of the currently unstructured private-sector provision of ART is the most cost-effective of the 3 options at a 10% discount rate and least cost-effective at a 3% rate. The costs and cost-effectiveness of all options are highly sensitive to the effect of ART on condom use. The design of ART policy should capitalize on the potential of ART to decrease HIV transmission through institutional arrangements that reward effective prevention programs, thereby raising the likelihood that treatment has beneficial rather than negative external effects. (author's)
The objective was to estimate annual costs of a multifaceted adolescent sexual health intervention in Mwanza, Tanzania, by input (capital and recurrent), component (in-school, community activities, youth-friendly health services, condom distribution), and phase (development, startup, trial implementation, scale-up). Financial and economic providers' costs and intervention outputs were collected to estimate annual total and unit costs (1999 --2001). The incremental financial budget projects funding requirements for scale-up within an integrated model. The 3-year economic costs of trial implementation were $879,032, of which ~70% were for the school-based component. Costs of initial development and startup were relatively substantial (~21% of total costs); however, annual costs per school child dropped from $16 in 1999 to $10 in 2001. The incremental scale-up cost is ~1/5 of ward trial implementation running costs. Annual costs can reduce by almost 40% as project implementation matures. When scaled up, only an additional $1.54 is needed per pupil per year to continue the intervention. (author's)
Calls for increased investment in sexually transmitted infection (STI) treatment across the developing world have been made to address the high disease burden and the association with HIV transmission. The goals of this study were to systematically review evidence on the cost of treating curable STIs and to explore its key determinants. A search of published literature was conducted in PubMed and supplemented by reviews of gray literature. Studies were analyzed by broad focus. Regression analysis explored how intervention characteristics affect unit costs, accounting for differences in costing methods. Fifty-three primary studies were identified, of which 62% used empirical data, 35% presented economic costs, and 22% presented full costs. The median STI treatment cost was $17.80. Clinics serving symptomatic patients were consistently cheaper than outreach services, services using syndromic management protocols had lower costs, and unit costs decreased with scale. The compiled cost data provide an evidence base that can be used to help inform resource planning. (author's)
The objective was to define the bacteriological and histological correlates of the three predominant clinical forms of cutaneous tuberculosis and to evaluate the efficacy of a 9-month daily regimen containing rifampicin and isoniazid. In the dermatological clinics of two major teaching hospitals in Chennai, 213 patients with suspected clinical manifestations of cutaneous tuberculosis underwent examination and a skin biopsy for bacteriological and histological tests. They were treated with a daily regimen of rifampicin and isoniazid for 9 months and follow-up for 3 years. Bacteriological and/or histological confirmation of tuberculosis was obtained in 88% of the cases. Lupus vulgaris lesions were seen mainly in the extremities and verrucosa cutis occurred predominantly on the sole and foot, while the cervical and axillary regions were the commonest sites for scrofuloderma. Ninety-two per cent of the patients showed resolution of the lesions within the first 6 months of chemotherapy; 1% failed to respond to this regimen. There was no relapse in any of the cases during the follow-up period of 3 years. Clinical findings were adequate to identify major forms of cutaneous tuberculosis as evidenced by bacteriological and histopathological examination. A daily regimen of rifampicin and isoniazid for 9 months was effective in treating cutaneous tuberculosis. (author's)
The objectives were to assess the impact of intensified malaria control interventions in an ethnic minority community in Betul using existing tools. Two rounds of indoor residual spraying with synthetic pyrethroid insecticide were applied and larvivorous fish introduced, followed by intensive surveillance for early detection of Plasmodium falciparum with rapid diagnostic tests and prompt treatment with sulphadoxine pyrimethamine. Pre-intervention surveys revealed a very high fever rate in the community in all age groups with a slide positivity rate of >50% with >90% P. falciparum. The post-intervention phase showed a sharp steady decline in number of malaria cases (b 0.972; P < 0.0001, 95% CI 0.35--0.47). Monitoring of entomological results revealed a significant decline in both Anopheles species and An. culicifacies (P < 0.0001). A combination of indoor residual spraying and early detection and prompt treatment complemented by rapid diagnostic tests and larvivorous fishes successfully brought malaria under control. These approaches could be applied in other regions of different endemicity to control malaria in India. (author's)
Self-care as a response to diarrhoea in rural Bangladesh: empowered choice or enforced adoption?
The literature is growing on the subject of coping strategies. However, with the exception of some work on the promotion of oral rehydration therapy (ORT), very few studies have examined coping strategies as a response to the ongoing diarrhoeal disease burden. This is particularly relevant in the case of self-care, previously documented as the most readily implemented treatment in the developing world and an increasingly common health behaviour in rural Bangladesh. This study analysed the socioeconomic factors that influence the adoption of self-care and the role that varied asset availability plays in relation to households choosing, or being forced to implement, a coping strategy. Qualitative methods were used to collect data from three villages in Nilphamari District, North West Bangladesh, in 2004. The findings produced a detailed picture of asset availability and its influence on household use of self-care treatment practices. The strong role of aspects of social capital in building human capital was highlighted, as well as how these aspects of social capital can assist household welfare through self-care in times of diarrhoeal disease. In contrast, households exhibiting weakened social and human capital were more excluded from information on appropriate self-care treatments. Development agencies and health care policies might therefore strengthen levels of household resilience to diarrhoeal disease more cost-effectively by focusing on activities that facilitate self-care through support of social networks and education channels. (author's)
The economics of sexually transmitted infections.
Recent decades have revolutionized the study of sexually transmitted disease (STD) epidemiology and prevention in many ways. Social and behavioral aspects of both epidemiology and prevention have become important components of a multidisciplinary approach; use of mathematical models and policy studies have become widespread; randomized, controlled trials, and even cluster randomized trials with their many strengths and weaknesses, have come to occupy a central place in the field. Increasingly, health economics is becoming an indispensable element in the STD scientific tool kit. The number of health economics papers published in the STD literature has increased substantially since the 1980s. For example, a literature search using OVID MEDLINE of manuscript titles in Sexually Transmitted Diseases and Sexually Transmitted Infections (including the former names of these journals, Genitourinary Medicine and British Journal of Venereal Diseases) for the terms "cost" or "resource allocation" found 7 articles published during the period 1985 to 1994 and 41 articles published during the period 1995 to 2004. The magnitude of the increase in health economics papers is likely understated because this search 1) excluded many journals that publish STD-related research, 2) examined article titles only, not key words or abstracts, and 3) used search terms that focused only on cost and resource allocation, which are just part of the full scope of health economics research. (excerpt)
The objectives were to evaluate the impact of the universal hepatitis B (HB) vaccination programme on the prevalence of hepatitis B surface antigen (HBsAg) carriers and immunity to HB virus infection among children < 18 years and to determine the HB seroprevalence in the Thai population. We enrolled people in four provinces, including Chiangrai, Udon Thani, Chonburi and Nakhon Si Thammarat to geographically represent populations in the North, Northeast, Center and South of the country respectively. Serology for HBsAg, anti-hepatitis B surface (anti-HBs), and antihepatitis B core (anti-HBc) was tested using ELISA commercial kits. In total, 6213 subjects aged 6 months to 60 years from the four provincial hospitals and two to three district hospitals of each participating province participated. Overall HBsAg, anti-HBs, and anti-HBc seropositive rates amounted to 4%, 41.6% and 26.5% respectively. Of 2887 participants aged 6 months to 18 years, 2303 were born after (group I) and 584 prior to (group II) HB vaccine integration into the expanded programme on immunization of each participating province. The HBsAg seropositive rate was 0.7% among group I children and 4.3% among group II children. The prevalence rate of anti-HBc was 2.9% in group I and 15.8% in group II. In children under 18 years, the HBsAg carrier rate was 0.98% among complete vaccinees and 1.36% among participants without vaccination. This finding supports the efficacy of universal HB immunization in reducing the prevalence of HB infection in Thailand which is a highly endemic country. (author's)
The objective was to estimate the proportion of antiretroviral therapy (ART) eligible adults (15--49 years) with tuberculosis potentially identifiable through tuberculosis services using a CD4 count below 350 cells/mm3 as cut-off value for ART initiation. Using TB notification rate data, HIV seroprevalence data, and estimates of the size of the adult population (15--49 years) in 18 sub-Saharan African countries with an HIV seroprevalence of > 5%, calculations of the number of ART eligible adults with tuberculosis presenting to tuberculosis services were made. Assumptions were made on the tuberculosis notification rates in the age-group 15--49 years, the HIV-infected population with a CD4 count below 350 cells/mm3 and the relative risk of developing tuberculosis, and average duration from HIV infection to death. The probability of having a CD4+ count below 350 cells/mm3 given a diagnosis of tuberculosis was estimated using Bayes' theorem, and estimates of the number of patients with a CD4 count below 350 cells/mm3 identifiable through tuberculosis were made. The number needed to screen to identify one ART eligible patient through tuberculosis services was estimated for each country. ART eligible adults with tuberculosis potentially identifiable through tuberculosis services in the 18 countries ranged from 2% to 18% of the total HIV-infected adult population with a CD4+ count below 350 cells/mm3 and would average 10% of all such HIV patients. The number needed to screen to identify ART eligible patients through tuberculosis services ranged from 1.4 to 4.2, against 8.6 to 65.4 if adults aged 15--49 are randomly screened for low CD4 counts. Tuberculosis services are an important entry point for identifying ART eligible patients. Given that dually infected patients identified through tuberculosis services contributed to 10% of the HIV-infected adult population with a CD4 cell count below 350 cells/mm3 in the 18 sub-Saharan African countries, major efforts are required beyond the tuberculosis services in detecting patients that should benefit from ART. However, the low number needed to screen gives opportunity to use tuberculosis services in AIDS control and ART scaling-up programmes. (author's)
Communicable diseases are of particular concern in conflict and disaster-affected populations that reside in camp settings. In the acute emergency phase, diarrhoeal diseases have accounted for more than 40% of deaths among camp residents. Clear limitations exist in current water treatment technologies, and few products are capable of treating turbid water. We describe the findings of a 12-week effectiveness study of point-of-use water treatment with a flocculant--disinfectant among 400 households in camps for displaced populations in Monrovia, Liberia. In intervention households, point-of-use water treatment with the flocculant--disinfectant plus improved storage reduced diarrhoea incidence by 90% and prevalence by 83%, when compared with control households with improved water storage alone. Among the intervention group, residual chlorine levels met or exceeded Sphere standards in 85% (95% CI: 83.1--86.8) of observations with a 95% compliance rate. (author's)
The objectives were to investigate whether domestic violence during pregnancy is a risk factor for antepartum hospitalization or low birthweight (LBW) delivery. A prospective cohort study was conducted in Mulago hospital, Kampala, Uganda, among 612 women recruited in the second pregnancy trimester and followed up to delivery, from May 2004 through July 2005. The exposure (physical, sexual or psychological violence during pregnancy) was assessed using the Abuse Assessment Screen. The relative and attributable risks of LBW and antepartum hospitalization were estimated using multivariate logistic regression analysis. The 169 women [27.7% 95% CI (24.3--31.5%)] who reported domestic violence during pregnancy did not differ significantly from the unexposed regarding sociodemographic characteristics, but differed significantly (P < 0.05) regarding domicile variables (had less household decision-making power, more resided in extended families and more had unplanned pregnancy). They delivered babies with a mean birthweight 2647.5 ± 604 g, on average 186 g [(95% CI 76--296); P = 0.001] lower than those unexposed. After adjusting for age, parity, number of living children, pregnancy planning, domicile and number of years in marriage, the relative risk (RR) of LBW delivery among women exposed to domestic violence was 3.78 (95% CI 2.86--5.00). Such women had a 37% higher risk of obstetric complications (such as hypertension, premature rupture of membranes and anaemia) that necessitated antepartum hospitalization [RR 1.37 (95% CI 1.01--1.84)]. In this pregnancy cohort, domestic violence during pregnancy was a risk factor for LBW delivery and antepartum hospitalization. (author's)
Impact of a communication programme on female genital cutting in eastern Nigeria.
This study describes a female genital cutting (FGC) elimination communication programme in Enugu State and assesses its impact in changing relevant knowledge, attitudes and behavioural intentions. The FGC programme combined a community mobilization component with targeted advocacy and mass media activities. Data for assessing the impact of the programme derived from baseline and follow-up surveys in three intervention local government areas (LGA) in Enugu State and three comparison LGAs in Ebonyi State. An ideation model of behaviour change guided the analyses of the impact of the programme on personal advocacy for FGC, perceived self-efficacy to refuse pressure to perform FGC, perceived social support for FGC discontinuation, perceived benefits of FGC, perceived health complications of FGC and intention not to perform FGC on daughters. The analytical methods include comparing change in pertinent outcome variables from baseline to follow-up in the two study states and using logistic regression on follow-up data for the intervention state to assess the link between programme exposure and the relevant outcome indicators. The data show that while the pertinent ideational factors and the intention not to perform FGC either worsened or remained stagnant in Ebonyi State, they improved significantly in Enugu State. The logistic regression results show that programme exposure is associated with the expected improvements in all the pertinent indicators. The multimedia communication programme has been effective in changing FGC-related attitudes and promoting the intention not to perform FGC. (author's)
The objective was to explore Bambara language terminology and classification for locally available antimicrobial medicines in order to better target promotional messages and improve evaluation measures in Bougouni District, Mali. Mothers (n = 20) and drug vendors (n = 15) were asked to freelist medicines used to treat childhood illnesses, and to identify all medicines that corresponded to each of the listed terms from an array of medicines displayed with their packaging. Each Bambara language medicine term can refer to numerous modern medicines, and each modern medicine has several Bambara names. The term nivakini (Nivaquine), often translated as 'chloroquine', refers to a wide range of medicines commonly used to treat malaria, many with no antimalarial effect. Antibiotics were also identified as common treatments for malaria. Mothers and vendors used slightly different terminology when discussing treatments for malaria, and sometimes employed the same term to refer to different medicines. Neither mothers nor vendors clearly differentiated between antimalarial medicines. Colour, shape and packaging play a large role in their recognition, classification and use. Current household survey methods are likely to provide inaccurate estimates of appropriate treatment of febrile illness, and thus alternative approaches are recommended. In introducing new malaria treatments, malaria control programmes should differentiate recommended treatments from other medications through distinctive packaging, drug appearance and appropriate Bambara language terms. (author's)
Greater expectations: adolescents' positive motivations for sex.
Effective STD and pregnancy prevention efforts should benefit from knowledge of what motivates adolescents to have sex. Positive motivations, and how they differ by gender and sexual experience, are poorly understood. A sample of 637 ninth graders were asked about their relationship goals, expectations of the degree to which sex would satisfy these goals and sexual experience. Three scales measured adolescents' goals for intimacy, sexual pleasure and social status within a romantic relationship. Another three scales measured expectations that sex would lead to these goals. Data were examined in analyses of variance and mixed models. Participants valued intimacy the most, then social status and, finally, sexual pleasure. These relationship goals differed significantly by gender and sexual experience. Females valued intimacy significantly more and sexual pleasure less than males. Sexually experienced adolescents valued both intimacy and pleasure more than sexually inexperienced adolescents. Among females, but not males, sexually experienced adolescents valued the goal of social status less than those with no sexual experience did. Adolescents expected that sex would most likely lead to sexual pleasure, then intimacy and, finally, social status. Females and sexually inexperienced adolescents reported lower expectations that sex would meet goals than did males and sexually experienced participants. Adolescents view intimacy, sexual pleasure and social status as important goals in a relationship. Many have strong positive expectations that sex would satisfy these goals. Prevention programs and providers should address the risks of sex in the context of expected benefits. (author's)
Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.
Many pregnancies are unintended, particularly in certain population groups. Determining whether unintended pregnancy rates and disparities in rates between subgroups are changing may help policymakers target reproductive health services to those women most in need. To calculate rates of unintended pregnancy and related outcomes, data on pregnancy intendedness from the 2002 National Survey of Family Growth were combined with birth, abortion and population data from federal, state and nongovernmental sources. In 2001, 49% of pregnancies in the United States were unintended. The unintended pregnancy rate was 51 per 1,000 women aged 15--44, meaning that 5% of this group had an unintended pregnancy. This level was unchanged from 1994. The rate of unintended pregnancy in 2001 was substantially above average among women aged 18--24, unmarried (particularly cohabiting) women, low-income women, women who had not completed high school and minority women. Between 1994 and 2001, the rate of unintended pregnancy declined among adolescents, college graduates and the wealthiest women, but increased among poor and less educated women. The abortion rate and the proportion of unintended pregnancies ending in abortion among all women declined, while the unintended birth rate increased. Forty-eight percent of unintended conceptions in 2001 occurred during a month when contraceptives were used, compared with 51% in 1994. More research is needed to determine the factors underlying the disparities in unintended pregnancy rates by income and other characteristics. The findings may reflect a need for increased and more effective contraceptive use, particularly among high-risk groups. (author's)
Boyfriends, girlfriends and teenagers' risk of sexual involvement.
Having a boyfriend or girlfriend, especially an older one, is associated with increased sexual risk in early adolescence. The mechanisms underlying this association are unclear. Middle school students in Northern California were surveyed annually from 1997 to 2000. For a sample of 1,214 males and 1,308 females who were sexually inexperienced in seventh grade, logistic and linear regression were used to explore associations between relationship status in seventh grade and sexual activity in ninth grade, controlling for sixth-grade and eighth-grade characteristics. Males who had had a girlfriend their age by seventh grade were more likely than those who had had no relationship to report sexual activity in ninth grade (odds ratio, 2.1). Similarly, for females, the odds of being sexually active in ninth grade were elevated among those who had had a boyfriend their age (2.9); however, they also were higher among those who had had an older boyfriend than among those who had had one their age (2.1). With sixth-grade risk factors controlled, relationship status in seventh grade remained significant only for females; the association was explained by early menarche and by participation in situations that could lead to sex and riskier peer norms in eighth grade. For males, eighth-grade situations that could lead to sex, Hispanic ethnicity and sixth-grade peer norms explained ninth-grade sexual behavior. To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships. (author's)
Reducing AIDS-related stigma and discrimination in Indian hospitals.
AIDS-related stigma and discrimination is a pervasive problem worldwide. People living with HIV/AIDS (PLHA) in India, as elsewhere, face stigma and discrimination in a variety of contexts, including the household, community, workplace, and health care setting. Research in India has shown that stigma and discrimination against HIV-positive people and those perceived to be infected are common in hospitals and act as barriers to seeking and receiving critical treatment and care services (UNAIDS 2001). Recognizing the need to move beyond documentation of the problem, three New Delhi hospitals; SHARAN, an Indian NGO; and the Horizons Program, with support from the National AIDS Control Organisation (NACO), carried out an operations research project to develop and test responses to hospital-based stigma and discrimination against people living with HIV/AIDS. The objectives of the project were to identify the strengths and limitations of existing services for HIV-infected individuals in hospitals, and to use this information to design tools and approaches for motivating hospitals to become more "PLHA-friendly" through improved policies, staff training, and services. (excerpt)
Peru 2004-05: Results from the Demographic and Family Health Survey.
The Peru Demographic and Family Health Survey 2004--05, or Perú Encuesta Demográfica y de Salud Familiar (ENDES Continua 2004 and 2005) was conducted by the Instituto Nacional de Estadística e Informática and USAID, with technical assistance from MEASURE DHS+ ORC Macro. For the nationally representative ENDES Continua 2004 and 2005, complete interviews were conducted with 11,717 women aged 15--49. The fieldwork took place from 3 December 2003 to 4 September 2004 and from January to September 2005. The summary statistics presented below were taken from the Peru country report, with exceptions as noted. (excerpt)
Examining adherence and sexual behavior among patients on antiretroviral therapy in India.
Very high levels of patient adherence (greater than 95 percent) are required for antiretroviral therapy (ART) to be effective and to prevent the emergence of resistant viral strains. Since 1997, antiretroviral (ARV) medications have been available in India through the private sector and some employer-supported health insurance programs. It is estimated that India has 5.1 million HIV-infected persons (NACO 2004), some of whom have been on ART for several years. However, very little information is available on the levels of adherence to ART among people living with HIV/AIDS in India. With increased availability of ART, HIV-positive individuals are living healthier lives and continuing or resuming sexual activity. But, optimism related to ART's success in slowing disease progression, reducing viral load, and improving health status may lead to more risky sexual practices and a possible increase in transmission of infections. Determining the sexual behavior of HIV-positive persons on ART is therefore an area of special interest and concern. To meet these knowledge gaps, the Horizons Program, in collaboration with research partners in Delhi and Pune, conducted a study to assess current levels of adherence to ART among a sample of people living with HIV/AIDS, identify the factors that influence their adherence to treatment, and determine their sexual risk behaviors. The study also examined the economic burden of ART on the household. Findings from the study provide important insights that are immediately relevant to the scale-up of the national ART program, which was launched in April 2004. (excerpt)
Tanzania 2004-05: Results from the Demographic and Health Survey.
The Tanzania Demographic and Family Health Survey 2004-- 05 (TDHS 2004--05) was conducted by the National Bureau of Statistics of the United Republic of Tanzania and USAID, with technical assistance from ORC Macro. Data for the nationally representative TDHS were collected from 9,735 households, and complete interviews were conducted with 10,329 women aged 15--49 and 2,635 men aged 15--49. The fieldwork took place from 7 October 2004 to mid-February 2005. The summary statistics presented below were taken from the Tanzania country report, with exceptions as noted. (excerpt)
This Environmental Impact Assessment (EIA) has been prepared to address the potential environmental impacts that could arise from the construction and operation of a solid waste treatment facility. The intended facility will be located in the village of Ain Baal, planned to serve the inhabitants of Tyre Caza, South Lebanon. Additionally, the EIA evaluates various alternative treatment technologies and presents technical criteria on which to base the selection of most suitable site and technology. The purpose of the project is to alleviate the severe impacts of uncontrolled solid waste disposal into the environment. Proper design/selection, construction, and management of the solid waste treatment facility (and upgrading of solid waste collection networks) would mitigate such negative impacts. The main sections of the EIA include definition of the legal and institutional frameworks, description of the project and the environment, impacts assessment, identification of mitigation measures, and presentation of an environmental management plan (EMP). (excerpt)
Early predictors of sexual behavior: implications for young adolescents and their parents.
In this issue of Perspectives on Sexual and Reproductive Health, Marín and colleagues examine sixth-, seventh- and eighth-grade characteristics as predictors of sexual activity in ninth grade among roughly 2,500 students in California. The study provides empirical evidence of the independent contribution of nonsexual romantic relationships in the seventh grade to the onset of sexual intercourse by the ninth grade for both males and females. In addition, it shows that among females, seventh graders in serious relationships with older teenagers--uniquely defined as those two or more years older--have an increased likelihood of sex in the ninth grade. Finally, the study demonstrates that seventh graders of both genders who have had serious romantic relationships were already significantly different in the sixth grade from those who have not: They had peers who were more accepting of sexual activity, they had experienced more unwanted sexual advances and situations that could lead to sex (i.e., where parental monitoring is limited) and, for females, they had undergone earlier menarche. The findings suggest important aspects of the pathways to early sexual intercourse that have not typically been addressed in either school- or parent-based sex education programs. (excerpt)
Contraceptive use and pregnancy risk among U.S. high school students, 1991-2003.
Trends in teenagers' contraceptive use have received less attention than trends in adolescent sexual intercourse, despite the importance of contraceptive use to preventing teenage pregnancy. Sexually active high school students' use of contraceptives and risk of pregnancy from 1991 to 2003 were examined using data from the national Youth Risk Behavior Survey and published contraceptive failure rates. Changes in pregnancy risk were assessed using weighted least-squares regression. Between 1991 and 2003, contraceptive use improved among sexually active U.S. high school students. Improvements among women included an increase in the proportion reporting condom use at last sex (from 38% to 58%) and declines in the proportions using withdrawal (from 19% to 11%) and no method (18% to 12%). Hormonal method use changed little, as a decline in pill use (from 25% to 20%) was offset by use of injectables (5% in 2003). Similar patterns were found among men. Women's risk of pregnancy declined 21% over the 12 years. The largest improvements in contraceptive use and pregnancy risk occurred among ninth graders, and whites and blacks. In 2003, 46% of pregnancy risk resulted from failure to use any method of contraception, and 54% resulted from contraceptive failure. Improvement in the use of contraceptives by sexually active high school students during the 1990s is encouraging. To sustain this trend, programs need to encourage contraceptive use among teenagers who do not use it and to stress consistent and correct use among those who do. (author's)
Several studies have found a relationship between abortion and prior substance use, suggesting that a reduction in substance use might help decrease abortion rates. However, such a conclusion requires a greater understanding of the processes linking abortion and prior substance use. Path analysis of longitudinal data from 1,224 women was used to simultaneously test two pathways from adolescent substance use to abortion by age 29, one mediated by higher rates of unplanned pregnancy and the other independent of unplanned pregnancy rates. The model was then expanded to examine how these pathways change when unconventional attitudes and behaviors (such as rebelliousness and low religiosity) are taken into consideration. In the analysis that did not control for unconventionality, women who reported smoking cigarettes or using marijuana or hard drugs at age 18 had an increased likelihood of subsequent unplanned pregnancy and, as a result, higher rates of abortion. In addition, women who had used marijuana had an increased likelihood of abortion independent of unplanned pregnancy rates. In the final model, unconventionality strongly predicted both abortion and unplanned pregnancy. Moreover, it explained the associations between the use of hard drugs or marijuana and abortion that were due to higher unplanned pregnancy rates. Unconventionality mediates certain associations between substance use and abortion, perhaps because unconventional women are more likely both to use substances and to engage in behaviors that increase their risk of unplanned pregnancy. Hence, it seems unlikely that reducing substance use will result in substantially fewer abortions. (author's)
Early adolescents' cognitive susceptibility to initiating sexual intercourse.
Better methods for investigating sexual risk before the initiation of sexual intercourse are needed to support programming for younger adolescents, especially for abstinent adolescents who are susceptible to initiating intercourse. A sample of 854 adolescents in seventh or eighth grade who had never had sexual intercourse completed sexuality surveys in 2002 and 2004. A five-item index that assessed beliefs and expectations about the onset of intercourse was created to indicate adolescents' cognitive susceptibility to initiating intercourse. Logistic regression analysis was used to assess associations between levels of susceptibility and initiation of intercourse by follow-up. The construct and predictive validity of the index were examined using a variety of tests. Thirty-eight percent of respondents were classified as being nonsusceptible to initiating intercourse, 34% as having low susceptibility and 28% as being highly susceptible. Adolescents who were susceptible were more physically mature, had greater sexual feelings and competency, perceived that more peers were sexually active and had fewer positive connections with parents, school and religion than nonsusceptible respondents. Males, blacks and older adolescents were more susceptible than females, whites and younger adolescents, respectively. Compared with nonsusceptible respondents, those with low and high susceptibility had higher odds of initiating intercourse two years later (odds ratios, 2.5 and 8.1, respectively). The cognitive susceptibility index provides a valid method for assessing sexual risk before the onset of intercourse. Assessing susceptibility among early adolescents could support efforts to delay the onset of intercourse through targeted research and health programming. (author's)
Promoting female condom use to heterosexual couples: findings from a randomized clinical trial.
The female condom remains the only female-initiated method for preventing pregnancy and STDs, including HIV. Innovative methods for promoting its use, and for involving male partners in its use, are needed. A sample of 217 women and their main male sexual partners were randomly assigned to one of three study conditions: a six-session relationship-based STD prevention intervention provided to the couple together, the same intervention provided to the woman only or a single-session education control provided to the woman only. Assessments were conducted at baseline and three months postintervention. Contrast coding was used to examine whether the effects of the two active interventions differed from those of the control intervention, and whether the effects of the two active interventions differed from each other. Regression analyses were used to estimate treatment effects. During follow-up, participants in either active intervention were more likely to use a female condom with their study partner and with all partners, and used female condoms at a higher rate with all partners, than individuals assigned to the control intervention; at the end of three months, they were more likely to intend to use the condom in the next 90 days. No significant differences in outcomes were found between the active intervention groups. Focusing on both a woman and her main male sexual partner is efficacious in increasing female condom use and intention to use among heterosexual couples at risk for HIV and other STDs. (author's)
Understanding sex partner selection from the perspective of inner-city black adolescents.
Black adolescents in inner-city settings are at increased risk for HIV and other STDs. Sex partner characteristics, as well as individual behavior, influence individuals' STD risk, yet little is known about the process of sex partner selection for adolescents in this setting. Semistructured in-depth interviews were conducted during the summer and fall of 2002 with 50 inner-city black adolescents (26 females and 24 males) who had been purposively recruited from an STD clinic. Content analysis was used to study interview texts. Young women desire a monogamous romantic partner, rather than a casual sex partner; however, to fulfill their desire for emotional intimacy, they often accept a relationship with a nonmonogamous partner. Young men seek both physical and emotional benefits from being in a relationship; having a partner helps them to feel wanted, and they gain social status among their peers when they have multiple partners. For men, these benefits may help compensate for an inability to obtain jobs that would improve their financial and, as a result, social status. Both women and men assess partners' STD risk on the basis of appearance. HIV and other STD prevention initiatives must go beyond the scope of traditional messages aimed at behavior change and address the need for social support and socioeconomic opportunities among at-risk, inner-city adolescents. (author's)
Strengthening workplace HIV / AIDS programs: the Eskom experience in South Africa.
A workforce that is highly infected with HIV can lead to many illness-related absences and a loss of skilled workers. In addition to the burden on workers and their families, AIDS-related morbidity and mortality can result in reduced company profits and difficulty in delivering products and services. To minimize these potential negative effects, it is essential that businesses play a key role both in HIV prevention efforts and in mitigating the effects of the AIDS epidemic on their employees. Some companies, including South Africa's main electrical power company, Eskom, have taken up the challenge of creating workplace AIDS programs and policies. However, once an HIV/AIDS program is in place, it is important for companies to determine if it is meeting the needs of employees and if the program is having an impact. Eskom asked the Horizons Program to help strengthen its existing HIV/AIDS program by testing new strategies in three areas of KwaZulu-Natal (KZN) province, which has one of the highest HIV prevalence rates in South Africa and the world. (excerpt)
Provision of contraceptive and related services by publicly funded family planning clinics, 2003.
In addition to contraceptive services, publicly funded family planning clinics provide low-income women with a range of reproductive diagnostic, treatment and educational services. Nationally representative information about the scope of services available from clinics is needed to formulate policy and programmatic recommendations. In 2003, more than 1,000 U.S. clinics responded to an eight-page survey on service availability and clinic policies. Differences in the proportions of clinics reporting each service or policy were examined by clinic type and receipt of Title X funding. Nearly all clinics offer pills, injectables and condoms; 75% offer the patch; and 80% offer emergency contraception. Most clinics (73%) typically use a conventional Pap smear for initial cervical cancer screenings; 27% use liquid-based Pap tests. For follow-up, 68% of clinics use liquid-based or other advanced testing. Virtually all clinics screen at least some clients for chlamydia; Planned Parenthood and Title X--funded clinics, more than others, tend to focus screening efforts on sexually active women aged 25 and younger. Single-dose treatments are provided by 58% of clinics. Nine in 10 clinics offer HIV testing on-site, most of them to any client who requests it. Services targeted to specific populations include counseling about abstinence for minors (91%); non--reproductive health services for men (36%); and availability of staff such as translators (81%) and bilingual administrative (59%) or clinical personnel (57%) for non-English-speaking clients. More public funding is imperative for clinics to keep up with the demands of new technologies and a diverse client base. (author's)
Strengthening workplace HIV / AIDS programs: the Eskom experience in South Africa. Research update.
A workforce with a high HIV prevalence can lead to many illness-related absences and a loss of skilled workers, causing lower profits and greater difficulty in delivering products and services. Due to these potential negative effects, it is essential that businesses play a key role in both HIV prevention efforts and mitigating the effects of the AIDS epidemic on their employees. Some companies, including South Africa's main power company, Eskom, have taken up the challenge of creating workplace AIDS programs and policies. However, once an HIV/AIDS program is in place, it is important for companies to determine if it is meeting the needs of employees and if the program is having an impact. Eskom asked the Horizons Program to help strengthen its existing HIV/AIDS program by identifying gaps and testing new strategies through an intervention study conducted in three areas of KwaZulu Natal (KZN) province, which has one of the highest HIV prevalence rates in South Africa. (excerpt)
Clinics that receive Title X funding have a mandate to encourage parent-child communication for minors seeking family planning services. Little is known about the programs and practices that clinics have adopted to achieve this goal, or whether clinics not receiving Title X funds encourage family participation. As part of a larger project examining parental engagement among adolescents using family planning clinics, 81 clinics that served 200 or more adolescent contraceptive clients in 2001 completed a questionnaire containing closed- and open-ended items. Topic areas included clinic counseling and policies regarding clients younger than 18, activities to improve parent-child communication and community relations. Frequency distributions were calculated for the prevalence of activities, and cross-tabulations were used to compare prevalence by clinic characteristics. Every clinic engaged in at least one activity to promote parent-child communication, and nine in 10 offered multiple activities. Most of the clinics used counseling sessions to talk to adolescent clients about the importance of discussing sexual health issues with parents (73--94%, depending on the reason for the visit). More than eight in 10 clinics (84%) distributed pamphlets on how to talk about these issues. A substantial minority (43%) offered or referred interested individuals to educational programs designed to improve communication. Some of these exploratory findings reflect the prevalence of activities among all U.S. family planning clinics that serve adolescent clients. Evaluation and expansion of clinic efforts to promote voluntary communication about sexual health issues between parents and children could help encourage family participation. (author's)
Since the advent of highly active antiretroviral therapy (HAART) in 1996, the incidence of HIV--especially among young men who have sex with men--and the prevalence of unprotected sex among HIV-positive persons have increased. The characteristics associated with unprotected sex among youth living with HIV since the advent of HAART have not been explored. Samples of HIV-positive youth aged 13--24 were taken from two intervention studies that targeted the sexual behaviors of HIV-positive youth--one from 1994 to 1996 (pre-HAART) and the other from 1999 to 2000 (post-HAART). Generalized estimating equations were used to identify characteristics associated with unprotected sex in each sample. The prevalence of unprotected sex in the post-HAART sample was more than twice that in the pre-HAART sample (62% vs. 25%). Among the pre-HAART sample, being a man who has sex with men and having sex with a casual partner were negatively associated with the odds of unprotected intercourse (odds ratios, 0.5 and 0.2, respectively). Among the post-HAART sample, unprotected sex was negatively associated with knowing that a partner was HIV-negative (0.2) and positively associated with poorer mental health (1.02). In analyses among the post-HAART sample, poorer mental health was associated with increased odds of unprotected sex among youth living with HIV who were not receiving the treatment (1.02). Interventions for HIV-positive youth must be designed to address the complex needs of those youth who simultaneously suffer from HIV and poor mental health. (author's)
HIV voluntary counseling and testing programs play an important role in helping clients adopt HIV preventive behaviors and identifying people who need follow-up treatment and support services (UNAIDS/WHO 2004). Even though most HIV infections are estimated to be occurring among young people ages 15-24 (UNAIDS 2004), this group, particularly those still in their teens, have been underrepresented among those accessing VCT services (McCauley 2004). Research conducted by Horizons and partners (2001) revealed that social relationships, including family interactions, may influence young people's decisions regarding HIV testing. The Young Voices of Hope research study builds upon these findings by examining how individual, relational, and environmental factors influence adolescents' demands for and experiences with VCT. Such information is important in order to identify strategies for increasing the uptake of VCT by youth so that they can take advantage of the prevention and care benefits of knowing their HIV status. (excerpt)
Community involvement in Mali can help prevent trachoma and blindness.
This two-page summary describes the "Right to Sight" program designed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP) with support from the International Trachoma Initiative (ITI). The program included interventions to improve access to trachoma prevention and treatment services. The program also worked to increase demand for trachoma prevention, treatment information, and services as well as increase trachoma preventive and treatment behaviors.
ABCs for HIV prevention in Kenya: messages, beliefs, and barriers. Research summary.
A great deal of attention has been focused recently on the promotion of the "ABCs" of HIV prevention--being abstinent or delaying sex, remaining faithful to one sexual partner or reducing the number of sexual partners, and consistently using condoms during sex. Yet even as programs that focus on the ABCs to prevent sexual HIV transmission are rolled out, questions remain about how well different groups in varied cultural contexts actually understand the terms, as well as how best to address challenges to adopting the ABC behaviors. The Horizons Program and FHI/IMPACT developed a collaborative research study in 2004 to explore how adults and youth in Kenya define and perceive the ABC terms and behaviors. Additional objectives of the study were to identify attitudes and norms around the ABC behaviors that influence perceptions of them, and the role of important actors in transmitting messages about them. Findings highlight potential challenges in promoting each of the ABC behaviors, as well as some positive elements that can be built upon when developing programs. (excerpt)
A powerful television serial drama about young adults living in a rural South African town impacted by HIV/AIDS has led to improved attitudes about HIV/AIDS, stigma, living openly and positively with HIV, and faithfulness among its viewers. Tsha Tsha is a gritty Nguni language drama (with English subtitles) set in the Eastern Cape that focuses on the lives of several young people exploring love, sex, and relationships in a world affected by the realities of the AIDS pandemic. The South African Broadcasting Corporation Limited, Education Division (SABC), Curious Pictures, the Centre for AIDS Development Research and Evaluation (CADRE), and the Health Communication Partnership (HCP) collaborated to develop this entertainment-education drama series, which premiered in April 2003. By depicting the challenges facing young South Africans, the series aims to enhance its young adult viewers' capacity to reflect on their own problems, engage in developing solutions, and become active agents in shaping their future. (excerpt)
Little is known about the use of generic severity scores in severe childhood infectious diseases. The purpose of this prospective study was to evaluate the performance of the Pediatric Risk of Mortality (PRISM) scoring system in predicting the outcome of falciparum malaria in African children. All children admitted to a 120-bed pediatric ward in a tertiary care hospital in Dakar, Senegal, with a primary diagnosis of acute malaria were assigned a PRISM score after 24 hrs or at time of death. Interventions: None. PRISM discrimination, evaluated by areas under receiver operating characteristic curves (AUC), was good both for all acute malaria cases (n = 311; lethality, 9%; AUC, 0.89; 95% confidence interval [CI], 0.85-- 0.92) and for severe malaria cases (n = 233; lethality, 12%; AUC, 0.86; 95% CI, 0.81-- 0.90). However, the number of children who died was greater than the number of deaths predicted by PRISM (standardized mortality ratio, 2.16; 95% CI, 1.46 --2.87). This discrepancy observed in five classes of expected mortality (Hosmer-Lemeshow chi-square test, p < .001) may have been due to chance (sample size too small for a valid test), to a lower standard of care in Dakar than in the American hospitals where PRISM was designed, or to a failure of PRISM to classify risk in severe malaria. (author's)
In 2005, more than half a million children died of AIDS, the vast majority of whom lived in the developing world. In sub-Saharan Africa, AIDS has become one of the leading causes of mortality among children under the age of five years. Yet despite increased availability of antiretroviral therapy (ART), children remain a neglected population group. In many countries in Africa, there is a lack of experience in the identification, treatment, and management of young children who are HIV positive, and limited knowledge of how community and health service providers can work together to improve children's access to treatment. As the burden of care for children affected by and infected with HIV is now evident in many countries in Africa, governments must increase their level of response swiftly to deal with the crisis. The goal of providing ART to children is to increase survival and decrease HIV- and AIDS-related morbidity and mortality. In South Africa, 40 percent of deaths of children less than 5 years of age are attributable to HIV. The South African Cabinet approved a plan for a national HIV treatment program in 2003, the goal of which was to have at least one service delivery point in each district providing treatment by the end of March 2004. Initial treatment sites were identified and inspected under the auspices of the Department of Health (DOH) in terms of meeting a set of minimum criteria for service delivery. Once these service delivery points are deemed to be functioning adequately, the roll-out process will cascade to lower levels as the government's experience improves. This report presents the results of a rapid situational analysis of the pediatric roll-out in South Africa. The study provides much needed information on critical issues of pediatric HIV care, especially regarding health service and contextual issues surrounding the expansion of access to treatment for HIV-infected children, and key factors that facilitate sustainability of treatment by young children. (excerpt)
State of the world's mothers 2006. Saving the lives of mothers and newborns.
Every year, 60 million women in the developing world give birth at home, without a skilled person to help them. Approximately 4 million newborns die each year from disease or complications of childbirth before they have seen a month of life, and more than 3 million are stillborn. Newborn mortality is one of the world's most neglected health problems. While there has been significant progress in reducing deaths among children under age 5 over the past decade, mortality rates among babies during the first month of life have remained relatively constant. This year's State of the World's Mothers report shows which countries are succeeding -- and which are failing -- in saving the lives of mothers and their babies. It examines the ways investments in health care, nutrition, education and communication can make a difference for newborns, mothers, communities and society as a whole. It also points to low-cost, low-tech solutions that could save the vast majority of these young lives. (excerpt)
This study was conducted from May to June 2005 to determine demographic characteristics and factors that affect VCT acceptance as well as HIV prevalence amongst youths VCT acceptors in Addis Ababa. Both quantitative and qualitative methods of data collection were employed. Quantitative data was generated over two years (October 2002 to December 2004) VCT service utilization data obtained from four youth centers located in Addis Ababa. Data was analysed using univariate and multivariate analysis and results are presented in the form of text, table and figures. The significance and level of associations between independent and dependant variables was computed using 2 tests and odds ratios with 95% confidence interval. The qualitative data was presented in a form of narrations using excerpts. During the period a total of 3220, youth age 15 - 24 years sought VCT service from four youth centers VCT service outlets. Higher proportions of females (60.2%) and youths in the age category of 20 -- 24 years (58.0%) accessed the service. Major reasons given for seeking VCT were found to be similar for male and female acceptors. About 71.2% said they sought for VCT service because they wanted to know their HIV status, 9.5% reported because they were suspicious of being infected with HIV and 5.0% tested because they wanted to go abroad. HIV prevalence rate was found to be significantly higher, (p = 0.00), among females 9.2 % than in males 1.7 %. Gender segregated multivariate analysis of risk factors indicated significant association of HIV infection with lack of formal education for both males and female: for males P= 0.045, OR = 18.3, 95% CI: 1.1 -- 317.7 and for females P=0.00, OR=19.4, 95 % CI: 5.1 -- 73.8. Additionally for females HIV infection is markedly associated with being widowed and commercial sex worker. The most common barrier for youth in Addis from accessing VCT were found to be: fear of being emotionally affected if found out HIV positive, stigma and discrimination, lack of money to pay for VCT service, absence of care and support services for people who are already infected. Challenges encountered by youth VCT counsellors were stress, absence of medical care for PLWHA, inadequacy of budget, lack of counsellors and supportive supervision. This study shows a high burden of HIV infection among female youth and the risk factors associated with it. Formal education for both females and males is strongly recommended. Female focused HIV prevention interventions are indicated. Additional recommendations are also made in relation to barriers to access youth VCT and for the challenges encountered by youth VCT service providers. (author's)
Introduction to the special issue on men's role in the heterosexual HIV epidemic.
Twenty-five years ago in San Francisco, California, the first case of HIV was diagnosed in a gay man. Since then, the HIV epidemic has become increasingly feminized, and heterosexual sex is now the dominant mode of transmission worldwide. The feminization of HIV/AIDS has spawned an entire field of research investigating the characteristics of women at risk. Through this endeavor, we have learned much about women at risk for HIV acquisition, yet we still know relatively little about heterosexual transmission of HIV. Why? Perhaps because conspicuously absent from the impressive, thoughtful, and extensive literature on women is a parallel literature on heterosexual men. The goal of this special issue of the Journal of Urban Health is to begin to shift the focus of research to men. This issue is comprised of quantitative and qualitative work describing men who are sexually active with women in the United States and abroad. The first paper is from Harvey and colleagues, who report on condom use among Latino men in committed relationships with women. Their findings reveal that both men's attitudes and expectations about partners' reactions are important determinants of condom use. (excerpt)
It is well recognized that a large proportion of youth in juvenile detention exhibit mental health disorders, and although treatment is legally mandated, many do not receive it. These investigators studied a random sample of 1,829 detainees at intake into the Cook County Juvenile Temporary Detention Center to determine what proportion of those with major mental disorders were detected and treated and which variables predicted who received services. Criteria were established to define which youth needed treatment: presence of a major depressive episode, manic episode, or psychosis in the previous 6 months, and impaired functioning. Youth who met these criteria, 303 altogether, were identified by independent interviewers using the Diagnostic Interview Schedule for Children and the Children's Global Assessment Scale. Records from the juvenile justice and public health systems were reviewed to discover if a mental disorder had been detected (defined as notations of a recommendation, referral or judicial sentence that included mental health services) or treated (defined as provision of a psychotropic medication or at least one contact with a mental health professional) within 6 months following intake or until the case was disposed by the judge, if that came earlier. (excerpt)
Men's extramarital sex, marital relationships and sexual risk in urban poor communities in India.
The objectives of this paper are to (1) understand the nature of men's extramarital sexuality in three low income communities in Mumbai, India, (2) explore the associations between marital relationships and extramarital sex, and (3) assess the implications of the research results for intervention. Results are based on survey data collected from 2,408 randomly selected men from the three study communities and a matched subset of 260 randomly selected men and their wives who responded to a female version of the men's survey. These surveys produced a unique data set, which allows sociodemographic, attitudinal and behavioral variables from husband and wife and variables that are the product of husband and wife interaction to be utilized to predict men's extramarital sex through multiple sequential logistic regression analysis. Results indicate that men's extramarital sex is significantly associated with husband's and wife's age, wife's perception of domestic violence, husband's education and place of birth, husband's alcohol use, wife's willingness to engage in marital sex, and types of marital sexual acts. These results confirm the need to move from the individual to the couple as the unit of research and the need for intervention to reduce the risk of HIV/STI transmission within marriage both in India and internationally. (author's)
HIV/AIDS has disproportionately affected Latino communities. The majority of research addressing HIV risk behaviors within this population has focused on women. However, men who have sex with women (MSW) are a population increasingly becoming infected with HIV and heterosexual contact is the primary source of HIV transmission among Latinos diagnosed with AIDS. It has been assumed that because men are likely to control condom use, relationship factors are less likely to influence safer sex behavior among men. However, because condom use is an interdependent behavior, understanding factors that predict safer sex behavior among MSW is critical. This study examined the influence of multiple factors on condom use behavior in a community-based sample of young Latino men. Data from 191 Latino men who completed baseline interviews for an intervention were analyzed to examine the association of background, intrapersonal and relationship factors with intentions to use condoms and condom use in the past three months. Findings from multivariate analyses indicated that more positive attitudes toward condoms, stronger partner condom norms and greater participation in decision-making about condom use were significantly associated with both condom use and condom use intentions. Additionally, men reporting lower expectations of negative partner reactions to condom requests were more likely to use condoms, and condom use intentions were higher among men reporting more health protective communication in the relationship. Findings suggest that interventions to prevent HIV need to include men as well as women and address the role of relationship factors and dynamics in safer sex practices. (author's)
This study sought to assess the association between traditional masculine gender role ideologies and sexual risk and intimate partner violence (IPV) perpetration behaviors in young men's heterosexual relationships. Sexually active men age 18--35 years attending an urban community health center in Boston were invited to join a study on men's sexual risk; participants (N = 307) completed a brief self-administered survey on sexual risk (unprotected sex, forced unprotected sex, multiple sex partners) and IPV perpetration (physical, sexual and injury from/need for medical services due to IPV) behaviors, as well as demographics. Current analyses included men reporting sex with a main female partner in the past 3 months (n = 283). Logistic regression analyses adjusted for demographics were used to assess significant associations between male gender role ideologies and the sexual risk and IPV perpetration behaviors. Participants were predominantly Hispanic (74.9%) and Black (21.9%); 55.5% were not born in the continental U.S.; 65% had been in the relationship for more than 1 year. Men reporting more traditional ideologies were significantly more likely to report unprotected vaginal sex in the past 3 months (OR/adj = 2.3, 95% CI = 1.2--4.6) and IPV perpetration in the past year (OR/adj = 2.1, 95% CI = 1.2--3.6). Findings indicate that masculine gender role ideologies are linked with young men's unprotected vaginal sex and IPV perpetration in relationships, suggesting that such ideologies may be a useful point of sexual risk reduction and IPV prevention intervention with this population. (author's)
Few studies have examined sexual risk behaviors of HIV-positive, heterosexual, injection drug using (IDU) men. We investigated such behaviors and associations with risk among sexually active, HIV-positive IDU men who reported only female sex partners in the 3 months prior to baseline interview. We examined associations separately for four non-exclusive groups of men by crossing partner type (main or casual) and partner serostatus (HIV-positive or HIV-negative/unknown). Of 732 male participants, 469 (64%) were sexually active with only female partners. Of these 469 men, 155 (33%) reported sex with HIV-positive main partners, 127 (27%) with HIV-negative or unknown serostatus main partners, 145 (31%) with HIV-positive casual partners, and 192 (41%) with HIV-negative/unknown serostatus casual partners. Significant multivariate associations for unprotected sex with HIV-negative or unknown serostatus main partners were less self-efficacy to use condoms, weaker partner norms supporting condoms, and more negative condom beliefs. Similar correlates were found for unprotected sex with HIV-positive main and casual partners. In addition, alcohol or drug use during sex was a significant correlate of unprotected sex with HIV-positive main partners, while depression was significant for HIV-positive casual partners. For unprotected sex with HIV-negative/unknown status casual partners, self-efficacy for condom use, sex trade, and education were significant multivariate correlates. A combination of broad and tailored intervention strategies based on the relationship pattern of men's lives may provide the most benefit for reducing unprotected sex with female partners. (author's)
HIV-positive men sexually active with women: sexual behaviors and sexual risks.
This study examines patterns of sexual behavior, sexual relating, and sexual risk among HIV-positive men sexually active with women. A total of 278 HIV-positive men were interviewed every 6--12 months between 1994 and 2002 and reported considerable variability in sexual behaviors over time. Many were not sexually active at all for months at a time; many continued to have multiple female and at times male partners. Over one-third of the cohort had one or more periods when they had engaged in unprotected sex with a female partner who was HIV-negative or status unknown (unsafe sex). Periods of unsafe sex alternated with periods of safer sex. Contextual factors such as partner relations, housing status, active drug use, and recently exchanging sex showed the strongest association with increased odds of unsafe sex. A number of predictors of unsafe sex among African American men were not significant among the Latino sub-population, suggesting race/ethnic differences in factors contributing to heterosexual transmission. Implications for prevention interventions are discussed. (author's)
Determinants of HIV/AIDS risk behaviors in expectant fathers in Haiti.
Haiti has an HIV/AIDS epidemic of the highest magnitude outside of sub-Saharan Africa. Factors such as relationship power imbalances, traditional gender role acceptance, and patriarchal belief systems that devalue women's sexuality have increased Haitian women's vulnerability to HIV infection. Because of these influences and since the HIV epidemic is largely heterosexually transmitted, it is important to understand the role that men's beliefs and behaviors play in the continuing risk of young men and women in Haiti. The purpose of this study was to gather information from male community members through semi-structured interviews in order to describe the prevalence of HIV/AIDS risk behaviors (e.g., condom use, number of sexual partners) among expectant fathers in Haiti and identify predictive psychosocial variables of HIV/AIDS risk behaviors. Results from this study showed that men who were not married (OR = 0.22, p = 0.05) and men who had medium (OR = 22.50, p G 0.001) and high sexual communication (OR = 36.51, p G 0.001) were more likely to use condoms. This study also showed that high stigma associated with HIV (OR = 16.07, p G 0.05), low HIV knowledge (OR = 0.10, p G 0.01), and high decision making power (OR = 62.52, p G 0.001) were predictors of multiple sex partners for the expectant fathers in the sample. HIV prevention programs should be designed to increase knowledge about HIV transmission, treatment, prevention and personal risk of contraction as well as correct misconceptions about individuals with HIV or AIDS and promote sex communication among partners. (author's)
Correlates of unprotected sex among adult heterosexual men living with HIV.
The correlates of unprotected sex among a sample of heterosexual men living with HIV (n = 121) were examined to determine whether patient characteristics can be used as a basis for tailoring safer sex counseling in the clinic setting. Potential correlates of self-reported unprotected oral sex (fellatio) and vaginal sex included participant demographics (e.g., age, ethnicity), disease status (CD4 counts, viral load, years since diagnosis), safer sex beliefs (e.g., condom attitudes), substance use, psychological characteristics (depressive symptoms, dispositional optimism and pessimism), and sex partner characteristics (main/casual partner, HIV status of partner, and duration of relationship). A series of logistic regression analyses were used to determine significant relationships. Correlates of reported levels of prior 3-month unprotected fellatio (24%) and vaginal (21%) sex were not associated with the type of relationship (main or casual) or perceived HIV serostatus of the partner (positive, negative, or unknown). Unprotected fellatio was positively associated with age and CD4 count and inversely associated with optimism and positive condom attitudes (all p's < 0.05). Unprotected vaginal sex was positively associated with duration of relationship and inversely associated with positive condom attitudes. Prevention efforts among sexually active adult heterosexual men living with HIV may benefit from focusing on improving attitudes towards condom use regardless of partner relationship status. (author's)
Disproportionately high HIV/AIDS rates and frequent non-gay identification (NGI) among African American men who have sex with men or with both men and women (MSM/W) highlight the importance of understanding how HIV-positive African American MSM/W perceive safer sex, experience living with HIV, and decide to disclose their HIV status. Thirty predominately seropositive and non-gay identifying African American MSM/W in Los Angeles participated in three semi-structured focus group interviews, and a constant comparison method was used to analyze responses regarding condom use, sexual activity after an HIV diagnosis, and HIV serostatus disclosure. Condom use themes included its protective role against disease and pregnancy, acceptability concerns pertaining to aesthetic factors and effectiveness, and situational influences such as exchange sex, substance use, and suspicions from female partners. Themes regarding the impact of HIV on sexual activity included rejection, decreased partner seeking, and isolation. Serostatus disclosure themes included disclosure to selective partners and personal responsibility. Comprehensive HIV risk-reduction strategies that build social support networks, condom self-efficacy, communication skills, and a sense of collective responsibility among NGI African American MSM/W while addressing HIV stigma in the African American community as a whole are suggested. (author's)
Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men's sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men's and women's relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18--24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men's endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults. (author's)
Preventing AIDS: the British experience.
The UK is described by the Department of Health in London as "a relatively low prevalence country for HIV infection." The word "relatively" is the key. By comparison with the huge numbers of cases seen in much of sub-Saharan Africa, for example, HIV/AIDS is a minor problem in the UK. However, that is no grounds for complacency, as shown by the need for an official target for further reduction, which is a 25% decrease in new diagnoses of HIV infection by the end of 2007. To see how achievable this might be, we need to look at the ways in which new cases are currently arising. Last year saw 7,750 new diagnoses of HIV infection in the UK, but the more detailed breakdown is available up to the end of 2004. As of Dec 31, 2004, there were an estimated 58,300 people over the age of 15 years living with HIV in the UK, and this number is rising not only because of new diagnoses but also because of successful anti-HIV drug regimens. Male-to-male transmission remains an issue, at a plateau of around 1,800 new diagnoses annually. Heterosexual intercourse accounts for 4,000 new diagnoses each year, but most of those are acquired outside the UK. Injecting drug use accounts for just 150 new cases; mother-to-child transmissions number only 130 or so (the introduction of antenatal testing as a routine will have helped here); HIV infection due to blood transfusions or blood products is now very rare, most cases being acquired overseas; occupational HIV exposure is also very uncommon. (excerpt)
Xerophthalmia: a study among malnourished children of West Mednipur District.
Most people in India live in rural areas and urban slums where poverty, illiteracy, ignorance and poor hygienic condition still prevail. Hence the population is vulnerable to various health hazards and malnutrition including vitamin A deficiency resulting in visual disability and blindness. Most people in developing countries live under the burden of malnutrition. The great majority of cases of malnutrition, nearly 80% are the intermediate ones, that is mild to moderate cases, which go frequently, unrecognised. The term xerophthalmia comprised all the ocular manifestations of vitamin A deficiency ranging from night blindness to keratomalacia. In this study, all eye changes were graded according to 'WHO classification' for various ophthalmic manifestations of vitamin A deficiency. Although the manifestation of vitamin A deficiency is many, the most important crippling feature is xerophthalmia leading to keratomalacia and ultimately blindness. The gradation of malnutrition according to expected weight of babies in different age groups be done by percentage of median value as suggested by Gomez et al and accepted by Indian Academy of Pediatrics. Though malnutrition is common in Indian population, incidence of xerophthalmia is aggravated by rice (devoid of carotene) eating habits of people residing in southern and eastern states of India notably in West Bengal. (excerpt)
Reassessing mental health of women in Calcutta.
Mental health has no precise meaning; it is generally used to denote psychological well-being. Psychiatric categories are based on mood and behaviour of patients, which are dependent on observation; and so subjective factors influence diagnoses. Human interactions based on emotion are myriad; its presentation is determined by culture, which indicates that there is more diversity in presentation of disordered conditions. These few lines are meant to highlight that we are dealing with matters where precision and definitive statements are difficult. (excerpt)
Efficacy of yoga in pregnant women with abnormal doppler study of umbilical and uterine arteries.
The normal growth and development of the foetus can be adversely affected by a number of factors such as infections, complications of pregnancy like, pregnancy-induced hypertension [PIH], diabetes, etc, teratogens and psychosomatic stress. Pregnancy is a unique state of physiological stress, which necessitates physical, mental and social adaptation. In earlier observational studies in the 1960s, psychosocial measures have been examined as possible risk factors contributing to adverse birth outcomes. More recently, though the quality of studies has improved, evidence for such associations remains equivocal. The definition of stress remains ambiguous and is generally considered in the context of factors inducing stress (stressors), altered homeostasis, and adaptive response. Life exists by maintaining a complex dynamic equilibrium, or homeostasis, that is constantly challenged by intrinsic or extrinsic adverse forces or stressors. Stress is, thus, defined as a state of threatened homeostasis, which is re-established by a complex repertoire of physiologic and behavioural adaptive responses of the organism. The adaptive responses may be inadequate for the reestablishment of homeostasis or may be excessive and prolonged; in either case a healthy steady state is not attained, and pathology may ensue. (excerpt)
Changing trends in the management of eclampsia from a teaching hospital.
Eclampsia causes 12% of all global maternal deaths. It is also a major source of perinatal morbidity and mortality. Fortunately the maternal mortality in eclampsia has fallen dramatically in the past three decades. In the management of eclampsia, the role of magnesium sulphate (MgSO4) as anticonvulsant and its superiority over diazepam and phenytoin are proven. Use of antihypertensives to control the BP and early delivery within 12 hours of first convulsion is widely accepted. But Eclampsia Collaborative Trial 2, one of the best obstetrical trials and certainly the largest randomised control trial (RCT), still did not have the statistical power to show that MgSO4 reduces the maternal mortality rate (MMR) significantly. In future it will be impossible to ethically withhold MgSO4 in one arm of a large RCT to show reduced MMR. So it was decided to compare maternal mortality (MM) and perinatal mortality (PNM) due to eclampsia from 1995-1997 with those of 2002-2004. The two major changes that occurred in the said periods were: (1) MgSO4 was not used in a single case in the first period but was used almost universally in the latter year. The caesarean section (CS) rate in eclampsia has climbed from nearly 10% to about 50%. Debate continues regarding the route of delivery. Major concern with CS is anaesthesia. The figures from 2002-04 showed the results of general anaesthesia (GA) used with proper precautions. (excerpt)
In the global literature on HIV/AIDS, much attention has been paid to the role of gender inequalities in facilitating the transmission of HIV. For women, gender inequality may be manifested in sexual coercion, reduced negotiating power and partnering with older men, all practices that heighten risk for HIV. Less attention, however, has been paid to how men's relationship behaviors may place them at risk for HIV. Using six culturally specific psychometric scales developed in South Africa, this study examined men's and women's gender role and relationship norms, attitudes and beliefs in the context of ongoing partnerships. These measures were then examined in relation to four sexual risk behaviors: frequency of condom use (with primary or secondary partners) and number of partners (last 3 months and lifetime). Participants were 101 male and 199 female young adults, aged 18--24, recruited from a secondary school in northern KwaZulu/Natal province. Associations between gender and relationship scale scores and sexual risk outcomes yielded both expected and contradictory findings. For men, more frequent condom use was associated with higher levels of partner attachment (hyper-romanticism) but also with stronger approval of relationship violence and dominant behavior. In contrast, for women, more frequent condom use was correlated with a lower endorsement of relationship violence. Men with lower relationship power scores had fewer sexual partners in the preceding 3 months, while women with more egalitarian sexual scripts reported more sexual partners, as did those with higher hyper-romanticism scores. In logistic regression analysis, more egalitarian relationship norms among men were predictive of less consistent condom use, as were higher relationship power scores for women. These findings are discussed in relation to previous research on gender, heterosexual interactions and masculinity in this area, as well as the implications for HIV prevention programs. (author's)
The present study explored perceived sexual norms and behaviors related to sexual risk and pregnancy involvement among adolescent males (ages 13 to 20) participating in programs for perpetrators of dating violence. The purpose of this study was to generate hypotheses regarding the contexts and mechanisms underlying the intersection of adolescent dating violence, sexual risk and pregnancy. Six focus groups were conducted (N = 34 participants). A number of major themes emerged: 1) male norm of multiple partnering, 2) perceived gain of male social status from claims of sexual activity, 3) perception that rape is uncommon combined with belief that girls claiming to be raped are liars, 4) perception that men rationalize rapes to avoid responsibility, 5) condom non-use in the context of rape and sex involving substance use, 6) beliefs that girls lie and manipulate boys in order to become pregnant and trap them into relationships, and 7) male avoidance of responsibility and negative responses to pregnancy. The combination of peer-supported norms of male multiple partnering and adversarial sexual beliefs appear to support increased male sexual risk, lack of accountability for sexual risk, and rationalization of rape and negative responses to pregnancy. Further research focused on the context of male sexual risk and abusive relationship behaviors is needed to inform intervention with young men to promote sexual health and prevent rape, dating violence, and adolescent pregnancy. (author's)
Objective: Sex exchange is a well-established risk factor for HIV infection. Little is known about how correlates of sex trade differ by biologic sex and whether length of homelessness is associated with sex trade. We conducted a cross-sectional study among a sample of 1,148 homeless and marginally housed individuals in San Francisco to assess correlates of exchanging sex for money or drugs. Key independent variables included length of homelessness; use of crack, heroin or methamphetamine; HIV status; and sexual orientation. Analyses were restricted by biologic sex. In total, 39% of women and 30% of men reported a lifetime history of sex exchange. Methamphetamine use and greater length of homelessness were positively associated with a history of sex trade among women while heroin use, recent mental health treatment, and homosexual or bisexual orientation were significantly associated with sex trade for men. Crack use was correlated with sex trade for both genders. Correlates of sex trade differ significantly according to biologic sex, and these differences should be considered in the design of effective HIV prevention programs. Our findings highlight the critical need to develop long-term services to improve housing status for homeless women, mental health services for homeless men, and drug treatment services for homeless adults involved in sex work. (author's)
Sexual violence inside prisons: rates of victimization.
People in prison are exposed to and experience sexual violence inside prisons, further exposing them to communicable diseases and trauma. The consequences of sexual violence follow the individual into the community upon release. This paper estimates the prevalence of sexual victimization within a state prison system. A total of 6,964 men and 564 women participated in a survey administered using audio-CASI. Weighted estimates of prevalence were constructed by gender and facility size. Rates of sexual victimization varied significantly by gender, age, perpetrator, question wording, and facility. Rates of inmate-on-inmate sexual victimization in the previous 6 months were highest for female inmates (212 per 1,000), more than four times higher than male rates (43 per 1,000). Abusive sexual conduct was more likely between inmates and between staff and inmates than nonconsensual sexual acts. Sexual violence inside prison is an urgent public health issue needing targeted interventions to prevent and ameliorate its health and social consequences, which spatially concentrate in poor inner-city areas where these individuals ultimately return. (author's)
Population explosion - a grave concern.
The quality of life is dependent on various factors such as eradication of poverty, to raise the literacy level of the mass, to meet the ecological challenge and so on. The desired quality-life demands, out of many factors, a reasonable growth of population. But in a developing country like ours the mere existence is going to be at stake, in the face of this serious challenge in the coming days, if proper planning and its execution is not effected immediately to control the population which has exploded exponentially to a devastating end as is reflected by the census and different statistical reports. Here I like to present a brief outline of the problem for highlighting IMA's concern and attitude toward it. At the beginning of the Christian era, nearly 2,000 years ago, world population was estimated to be around 250 million. Subsequent estimates of the world population, and rates of increase put the projected figure to 8 billion in 2025 (from 6.054 billion as estimated in 12th October, 1999). About three-fourths of the world's population lives in the developing countries. Three countries of SEAR, ie, India (16.87 per cent), Indonesia (3.49 per cent) and Bangladesh (2.13 per cent) are among the most populous ten countries of the world. At present India's population is second to that of China. (excerpt)
No-scalpel vasectomy - hope for future: historical aspects.
In the developing world, fruits of development were always neutralised by the rise of population. Hence, sociologists and medical fraternity are trying their best to control/reduce the population and there is a quest for more and more acceptable methods of sterilisation/contraception. These include methods of temporary contraceptions for males/females eg; external barriers or oral pills, etc, a permanent sterilisation for females by tubal ligation and for males by vasectomy. Female sterilisation involves more risks, higher failure rates, needs more skills ie, difficult to perform, needs better settings of anaesthesia, operation room, instruments and consequently more complications. Whereas male sterlisation offers less risk, more safety, less chances of failure, easy to perform even in OPD set-up under local anaesthesia. Still, due to various socio-economico-religious reasons, male sterilisation is less acceptable. With the advent of 'No-Scalpel Vasectomy' (NSV), male sterilisation is becoming more acceptable. (excerpt)
A new look at male sterilisation (no-scalpel vasectomy) in Orissa.
Vasectomy operation, a popular method for male sterilisation has been adopted in National Family Planning Programme for more than 45 years. In Orissa, first vasectomy operation was recorded officially in the year 1956-57 and during that year 22 operations were conducted. This method of male sterilisation reached its climax between 1965 and 1977. Highest number (158,911 cases) of vasectomies were conducted in Orissa during the year 1976-77. Then this method of vasectomy gradually declined during last two decades and the lowest record in comparison to that of tubectomy was during the year 1997-98. The reason of gradual decline of vasectomy during last two decades may be due to the following causes : (1) Failure at operation; (2) Complications of operation; (3) Misconceptions regarding vasectomy operation, eg; (a) Psychological aberration/trauma (b) Fear of impotency, etc (c) Apprehension of loss of energy and working capacity; (4) Poor follow-up of postvasectomy cases for seminal fluid examination; (5) Male dominating society; (6) Conducting vasectomy without sufficient motivation and counselling (prevasectomy evaluation); (7) Inadequate facility for recanalisation operation. (excerpt)
The population boom in India, continues to grow exponentially (average annual exponential growth rate 1.93%; 1991-2001) and is really alarming in that it is projected to reach 1.53 billion in 2050, making India the most populous country in the world, surpassing China. The objective of the Family Welfare Programme in India is that people should adopt the "small family norm" to stabilise the country's population. Of the various methods advocated, voluntary sterilisation is one well-established contraceptive procedure for couples desiring no more children. Currently female sterilisation (tubal ligation/tubectomy) accounts for about 85% and male sterilisations for 10-15% of all sterilisations in India, despite the fact that male sterilisation or vasectomy is simpler, safer and cheaper than female sterilisation (tubal ligation/tubectomy). This trend is the same worldwide. Vasectomy is a one-time method, does not require sustained motivation of the user and provides the most effective protection against pregnancy (low failure rate, 0.15 per 100 person-years); the risk of complications is small when the procedure is performed according to the accepted medical standards and it is most cost-effective. It can be performed on a mass scale even in primary health centres by trained doctors, under local anaesthesia. Patient selection and proper counselling (eg, sexually active and psychologically adjusted husbands having 2 living children) are important. Some men fear pain, loss of working days and other complications while others equate the procedure, quite falsely so, with castration or loss of masculinity -- these problems should be properly attended to make vasectomy more acceptable to the potential candidates. (excerpt)
High prevalence of bacteriuria in pregnancy and its screening methods in north India.
Urinary tract infections (UTI) are the most common bacterial infections encountered among pregnant patients. Despite the fact that most women with bacteriuria of pregnancy have a benign course, it has been clearly established that untreated bacteriuria can have serious implications for both mother and foetus. Approximately one-third to one-half of women with untreated infections progresses to pyelonephritis. Besides, it has also been implicated as a risk factor for adverse perinatal outcomes like premature birth, low birth weight and perinatal deaths. In addition, associations have been documented between antepartum UTI and a variety of maternal complications of pregnancy including hypertension, pre-eclampsia, anaemia, amnionitis and endometritis. Prevalence of asymptomatic bacteriuria in the obstetric population ranges from 3-10%. It is generally accepted that 11-40% of women who have bacteriuria in early pregnancy and 1-3% of those who do not will develop overt infection before delivery. Studies have also shown that only 30-50% of women with clinical symptoms have infected urine. Observations suggest, but do not prove that a proportion of patients with asymptomatic bacteriuria go on to develop symptomatic infection. It is also conceivable that the development of symptomatic disease may ultimately protect the patients from complications, since symptomatic disease leads to treatment. Although these observations offer an attempt to delineate those at risk, at present it seems safest to make a sweeping recommendation to screen all pregnant women and to treat bacteriuria when detected, regardless of symptomatology of the patient. (excerpt)
Diabetes and tuberculosis interface.
Diabetes mellitus (DM) and tuberculosis (TB), both are well recognised disease entities known to persist from ancient history in human life. Both the diseases affect each other and the manifestations and management differ from situations where one of them exists as single one. DM predisposes a person to infection and infection in turn overwhelms the metabolic control. Effective control of each affects the control of the other condition. Chronic hyperglycaemia impairs host defense and some infections occur more in diabetics whereas some other infections occur both in diabetics and non-diabetics. Diabetes is considered as a secondary immune deficiency disorder by World Health Organisation as the disease has the following characters: (i) Elimination of underlying cause, leads to resolution, (ii) frequent severe, prolonged and recurrent infections, (iii) alteration of at least one of the immune response mechanisms (eg, polymorphonuclear leucocytes or lymphocyte response) determines the development of infection. (excerpt)
Vanishing female foetuses and its consequences in India.
A particular manifestation of continuing gender inequality and its accentuation is the phenomenon of declining sex ratios, measured as the number of females for 1000 males in the population. Technologies like amniocentesis and ultrasound used in most parts of the world largely for detecting foetal abnormalities are used in large parts of the Indian sub-continent for determining the sex of the foetus so that the mother can have an abortion if the foetus in the womb happens to be a female. The practice of female infanticide in India -- first documented by the British in the late 18th century chiefly among upper castes in North India is still rampant in many parts of the country today. The British outlawed infanticide in 1870, and a century later, educated Indians believed that the practice, like "Sati", had all but died out. The assumption was shattered in June, 1986, when "India Today" published an explosive cover story, "Born to Die", which estimated that 6000 female babies had been poisoned to death in the preceeding decade in the district surrounding the town of Madurai in Tamil Nadu. The magazine reported that the practice of female infanticide was prevalent there among the members of poor sub-caste called "Kallars" who fed their infant daughters the lethal oleander berries growing in the fields and there was hardly a "Kallar" family in which a female baby has not been murdered. (excerpt)
No-scalpel vasectomy at a glance.
Vasectomy has long been a safe, effective, easy-to-perform method of contraception for men. Noscalpel vasectomy was developed and first performed in China in 1974 by Dr Li Shunquiang of the Chongqing Family Planning Scientific Research Institute. It differs from a conventional vasectomy in the way that we get to the vas to block them from passing sperm out of the testicles. An improved method of anaesthesia helps make the procedure less painful. In a conventional vasectomy, one or two small cuts in the skin are made with a scalpel, and the doctor would then use sutures or stitches to close these cuts at the end of the procedure. In the no-scalpel vasectomy, instead of making incisions, the doctor makes only one or two tiny punctures into the scrotal skin over the median raphe with a special instrument (the dissecting forceps). This same instrument is used to gently stretch the skin opening so that the tubes can be reached easily. The tubes are then blocked, using the same methods as conventional vasectomy, but because of the lack of scalpel technique there is very little bleeding and no stitches are needed to close the tiny opening. This opening will heal quickly with little or no scarring. No-scalpel vasectomy was introduced in the United States in 19852 and is now used by many doctors in this country who have mastered the technique. (excerpt)
Epidemiological study of eclampsia in a referral teaching hospital.
Eclampsia, the occurrence of seizure in association with pre-eclampsia, remains an important cause of maternal mortality and morbidity. Compared to normotensive gravidas, patients with elevated blood pressure have significantly greater maternal and foetal mortality and morbidity. It has been estimated that worldwide approximately 50,000 women die each year from eclampsia. The most common causes of maternal death in eclampsia are intracranial bleeding and acute renal failure caused by abruptio placentae. The incidence of eclampsia is now modified by obstetric practices -- motivating more antenatal care, early detection of pre-eclampsia, hospitalisation and proper treatment. Still eclampsia remains among the most important unsolved problems in obstetrics. The purpose of this study was to analyse the incidence, type of eclampsia, patient profile, mode of delivery and maternal and foetal outcome of eclampsia in a referral teaching hospital. (excerpt)
The objective of the study is to evaluate the bioavailability, efficacy and safety of a new modified -- release (MR) formulation of carbonyl iron (45 mg) relative to a commercially available conventional formulation of ferrous fumarate (300 mg) in adult Indian patients with clinical and laboratory diagnosis of nutritional iron deficiency anaemia. This prospective, comparative, randomised, double-blind study was carried out among 60 patients received a single daily dose of either MR carbonyl iron or ferrous fumarate for 12 weeks. The effect of therapy on haematological parameters and iron status and estimation of bioavailability were the main efficacy outcomes. There was a significant (p < 0.05) increase in mean haemoglobin levels, reticulocyte counts, haematocrit and mean corpuscular volume in MR carbonyl iron group compared to ferrous fumarate group. There was also an increase in mean serum iron and ferritin levels and a corresponding decrease in total iron binding capacity in MR carbonyl iron group compared to ferrous fumarate group at the end of 12 weeks therapy. The estimated overall bioavailability of MR carbonyl iron was about 147% that of ferrous fumarate. Both the formulations were equally well -- tolerated and adverse events were mainly gastro-intestinal in nature. The prevalence of adverse events was slightly more in the ferrous fumarate group. It can be concluded that the MR formulation of carbonyl iron was more efficacious than ferrous fumarate in correcting haematologic abnormalities and improving iron status in patients with nutritional iron deficiency anaemia. In conditions where efficacy is an important consideration, the higher bioavailability of MR carbonyl iron may make it the treatment of choice for nutritional iron deficiency anaemia. (excerpt)
As a part of 'let's give health to every Indian' in Aao gaon chalen programme of the IMA, the organisation with about 1.6 lacs members throughout the country and abroad is going to launch 'Anaemia free India' on the occasion of the Doctors' Day on 1st July 2005. Healthy mothers and children as the theme for World Health Day, 2005 with the slogan 'make every mother and child count', which reflects the reality today, the health of the women and children is not a high enough priority for many governments and international community. The IMA is coming up with the idea to launch anaemia free India, so that the health of the mother and child can make the best possible answers in thwarting anaemia prevalent among a large section of rural masses mainly pregnant mothers. It is noted painfully that after 58 years of independence India leads iron deficiency anaemia cases in the world and more than 90% of Indian women, adolescent girls and children are anaemic. Everyone is aware that anaemia results in physical weakness, mental shortcomings, low intelligence and increased vulnerability to a number of diseases and causes adverse pregnancy outcomes and even death of expectant mother. The anaemic mothers also bear anaemic children. The children's academic performance is also hampered and linear growth and development is arrested. (excerpt)
Childhood cancers: perspectives in India.
Cancer afflicts a substantial number of children. In western world, it is second only to trauma as a cause of childhood mortality. Even in developing countries like India, cancer is gradually assuming an important place as a cause of childhood mortality. Cancer in children as compared to adults is clinicobiologically distinct. All paediatric cancers are considered as potentially curable. Also its sociologic impact in terms of disruption of family life, loss of productive years of life and generation of sympathy for its victims is far greater than cancer in the adults. A disease with an invariably fatal outcome in the past now enjoys a 5-year survival (equivalent to cure) of more than 70% and is one of the most gratifying illnesses to treat. (excerpt)
Oncology - its relevance in a developing country like ours.
Why is it necessary to devote an entire issue of JIMA to 'Oncology'? This is because according to World Cancer Report (2004) cancer rates are expected to rise by 50% leading to 50 million new cancer cases by 2020. Similar to industrialised countries, cancer has emerged as a major public health problem in developing countries and it is estimated that nearly 75% of all cancer deaths will be in developing countries after 20 years. In the background of low socioeconomic status and low awareness level, most patients are diagnosed at an advanced stage leading to survival figures of only 30% compared to nearly 60% in the economically advanced countries. What is noteworthy is that WHO has specified that healthy lifestyles and suitable public health-action plans can control nearly one-third cancers. (excerpt)
Maternal mortality reduction by improving emergency obstetric care (EmOC) service.
According to WHO estimates 585,000 maternal deaths occur worldwide every year. Maternal death is defined by WHO as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes". The maternal mortality ratio (maternal death per 100,000 live births) in our country is 407, according to one estimate. The maternal mortality rate (maternal death per 100,000 women aged 15-49 per year) is 1201. Though, considering the abysmal situation of data collection in our country, these figures may not be accurate and differ widely in different estimates, the figures are quite high compared to developed countries. This disproportional burden of death and disease borne by women in developing countries is indicative of dysfunctional and inequitable health care systems. The five major causes responsible for 80 per cent of maternal deaths are haemorrhage, sepsis, pre-eclampsia and eclampsia, obstructed labour and unsafe abortion. Although reduction in maternal mortality does not depend on the development of new technologies, it does require access to a functional health care system. The five major causes of maternal death are neither predictable nor treatable without access to facility-based emergency obstetric care as a part of responsive, equitable health care system. (excerpt)
Ovarian neoplasms in adolescence and childhood - an analysis of twenty cases.
Ovarian neoplasms in adolescents and children, unfortunately are not infrequently encountered in clinical practice. Though adolescents contribute only about 6% of women with ovarian neoplasms it is the most common genital tract malignancy in adolescent. Ovarian neoplasms are detected in 2 to 25% of adolescents with adnexal masses. However, it accounts for only 1-1.6% of all neoplasms in children. Rarity of the condition, asymptomatic nature in earlier stage and variations in clinical presentation, unawareness among the girls, parents and even among clinicians sometimes make the diagnosis delayed and difficult. The management of ovarian neoplasm in this age group also poses a great challenge to the clinicians owing to the need of conservation of reproductive, endocrinal and menstrual functions in one hand and the malignant potentiality on the other. Controversy still exists regarding the extent of surgery and role of adjuvant therapy in malignant lesion even if it be in very early stage. In this study, 20 cases of ovarian neoplasms in girls of below 20 years were analysed to probe the diagnostic problems, surgical and pathological diversities and the management dilemma. (excerpt)
Child Survival and Safe Motherhood (CSSM).
The population of India has increased from 34.2 crores in 1947 to more than 110 crores at present. Women of reproductive age group along with children under 5-year age constitute about 62% of total population (vulnerable section). Nearly 7.6 million perinatal deaths occur each year throughout the world of which nearly 98% usually occur in developing countries. Nearly 8 million infants die each year, two-thirds of them, even within the first month of life. In accordance with the revised estimates for the year 1990 by WHO and UNICEF approximately 585,000 women die each year throughout the world from causes related to pregnancy and child birth. In India, the Child Survival and Safe Motherhood (CSSM) programme was launched in the month of August, 1992. The objective was to improve the health status of women and children and reducing maternal and infant mortality rates. The year 1998 was celebrated as the year of 'Safe Motherhood' by WHO and the slogan raised, was "pregnancy is special-- let's make it safe". In 1997 the Government of India decided to launch Reproductive and Child Health (RCH) programme. (excerpt)
National Rural Health Mission (NRHM).
When the Honourable Prime Minister announced National Rural Health Mission (NRHM), it was welcomed by everybody. It generated a new hope among the majority of Indians living in the rural areas. Perhaps now they will be able to get potable drinking water, safe latrines, the basic amenities of health and at least proper primary medical care in their villages. Perhaps no child will die untreated, no mother will bleed to death, no road traffic accident victim will die unattended even in the remotest corner of the country, no farmer will succumb to snake or scorpion bite in the paddy field and no labourer will die due to heat stroke. Great expectation and belief replaced the gloom and despair. Perhaps all the essential medicines will be available in the primary health centres. Perhaps rickety and malnourished Ramu and Dhania will be able to get rid of scabies, lice and intestinal worms infestations and their complexion will change from pale to pink. Nothing of the sort is going to happen. NRHM is going to be yet another red herring. Do not get misled by the middle words "Rural Health". In fact it is a National Mission for opening more medical colleges, even by relaxing or removing MCI norms for infrastructure, staff and clinical material requirements. Private entrepreneurs will be given all help to open these medical colleges flouting the MCI rules. Even the government district hospitals will be given to businessmen to utilise them for medical colleges. (excerpt)
Epidemiology of cancer: Indian scenario.
Incidence of cancer varies dramatically between geographic regions. There is substantial global variability in cancer incidence occurring in people living in developing countries and those in developed countries. Although, cancer incidence rates are still substantially lower in developing countries than in developed countries, the incidence rates are showing a rising trend in developing countries. According to one estimate, there were 10.9 million new cases, 6.7 million deaths, and 24.6 million persons living with cancer in the year 20021. Fifty-three per cent of all new cases (5-8 million) and 60% of deaths (4 million) occur in developing countries. As per World Health Organisation (WHO), the death due to cancer is expected to increase 104% worldwide by the year 2020 with largest increase (70%) predicted to occur among people living in developing countries. Cancer rates in India is rising due to increase in life expectancy, changes in lifestyle and increased migration from rural areas to the cities. India is a vast country with diverse lifestyle and therefore varying cancer patterns and incidence rates. The world population is projected to increase by the rate of 80 million each year, and the population will be 8.9 billion in the year 2050. Further, due to increase in life expectancy, the proportion of elderly persons in developing countries is going to rise to 15% in the year 2050 from 5% in 20003. The present load of cancer cases is going to increase almost 1/3rd in each of the next few decades. By 2050, there will be 17 million new cancer cases in the developing world. (excerpt)
An unusual presentation of extrapulmonary tuberculosis.
Tuberculosis can affect any organ in the body. The most common presentation is pulmonary, but extrapulmonary disease is also an important manifestation. The diagnosis of tuberculosis in extrapulmonary site is established by the demonstration of the acid-fast bacilli (AFB) by culture of the material obtained surgically or by aspiration of the lymph nodes. Tuberculosis of the postauricular dermoid cyst is a very rare presentation and has not been reported elsewhere, so far the knowledge of the author is concerned. The presentation of right supraclavicular solitary lymph node of considerable size raises the suspicion of intrathoracic or intra-abdominal malignancy. Fine needle aspiration cytology (FNAC) is the ideal method to arrive at the diagnosis of such cases of lymphadenopathy. Here one case of extrapulmonary tuberculosis presented with a dermoid cyst over left postauricular region is reported. (excerpt)
Plasmodium malariae malaria - a case report.
The tropical zone is the endemic home for all malarial parasites. Plasmodium vivax and Plasmodium falciparum are the species that are prevalent commonly in India. Plasmodium malariae is a parasite of both the tropical and subtropical areas, especially the West and East Africa, Guiana and parts of India, but its presence in various zones tends to be patchy. It exhibits a local and clustered pattern, its proportion is usually low and Plasmodium malariae is not as prevalent as Plasmodium vivax or Plasmodium falciparum. It is said to be responsible for less than 1% of the infections in India. In India, Plasmodium malariae malaria has been reported in the coastal belt of Orissa. (excerpt)
The Post-YoKohama Mid-Term Review of the East Asia and the Pacific Regional Commitment and Action Plan against Commercial Sexual Exploitation of Children (CSEC) was held in Bangkok from 8 to 10 November 2004. Three of the priorities identified as instrumental to region's progress in combating this egregious form of violence against children were the development of national plans of action, research on CSEC and the implementation of the CSEC info database system. In response to this specific need, ESCAP has compiled the present toolkit, with the support of fellow inter-agency Group members United Nations Children's Fund (UNICEF) and ECPAT International/1, for key actors working against CSEC in the region. The toolkit is composed of three chapters: 1. Tools for Developing National Plans for Action against Commercial Sexual Exploitation of Children; 2. Situational Analysis Research on CSEC: Basic approaches and tools; 3. Piloting CSEC Info: Experiences from East Asia. By sharing experiences, good practices and practical tools in the areas of research, development of national plans of action and the piloting of CSEC Info, the present toolkit can serve as a user-friendly and functional reference for key actors seeking to learn from past practice and adapt such lessons to fit local and national contexts. The promotion of this knowledge and these experiences during this critical juncture in the region, as new forms of sexual exploitation and abuse of children emerge, will ideally help equip countries in taking sound and practical steps to work toward the elimination of the phenomenon. (excerpt)
Epididymal genomics and the search for a male contraceptive.
This report represents the joint efforts of three laboratories, one with a primary interest in understanding regulatory processes in the epididymal epithelium (TTT) and two with a primary interest in identifying and characterizing new contraceptive targets (DSJ and SAJ). We have developed a highly refined mouse epididymal transcriptome and have used it as a starting point for determining genes in the human epididymis, which may serve as targets for male contraceptives. Our database represents gene expression information for approximately 39,000 transcripts, of which over 17,000 are significantly expressed in at least one segment of the mouse epididymis. Over 2000 of these transcripts are up- or down-regulated by at least four-fold between at least two segments. In addition, human databases have been queried to determine expression of orthologs in the human epididymis and the specificity of their expression in the epididymis. Genes highly regulated in the human epididymis and showing high tissue specificity are potential targets for male contraceptives. (author's)
Hormonal approaches to male contraception: approaching reality.
The 'pre-testicular' suppression of gonadotrophins is the most likely approach for reversible therapeutic male fertility control to reach imminent clinical application. Maintenance of spermatogenesis depends on adequate gonadotrophin and intratesticular testosterone concentrations. Hormonal contraception for men interrupts this physiological axis by various means of gonadotrophin suppression; this interferes with spermatogonial differentiation and meiosis entry resulting in reversible azoospermia or severe oligozoospermia in virtually all men. Clinical trials have confirmed that high contraceptive efficacy, similar to female hormonal contraceptives, can be reliably attained with few side effects. However, the simultaneous suppression of Leydig cell steroidogenesis mandates the requirement for testosterone replacement in hormonal male contraception. Combination regimens of new synthetic progestins and androgens at various stages of development are being investigated with the lead products poised to go into phase III trials. Heterogeneity in response to spermatogenesis suppression has been observed within and between population; the mechanisms are unclear. This new method of reversible and effective contraception has registered high acceptability in surveys of both men and women. The recent entry of pharmaceutical companies into this area of research and development has considerably enhanced the prospects of translating years of academic efforts into new products which provide added family planning choice for many couples. (author's)
Our studies have focused on understanding how the initial segment is regulated, in particular, by testicular luminal fluid factor(s). Our working hypothesis is that testicular luminal fluid growth factors, e.g. FGFs, regulate initial segment function via activation of signal transduction pathways and PEA3 family transcription factors. These, in turn, regulate downstream genes that are important for providing an appropriate fluid milieu for the protection and survival of sperm and the initial segment. To test this hypothesis and to look for potential contraceptive targets, we used an in vivo electroporation technique to introduce dominant-negative plasmids of FGF Receptor 1 and ERM into the initial segment of the rat epididymis. The levels of several putative downstream genes were estimated using quantitative-PCR (q-PCR). Data suggests that initial segment genes are regulated by 5a-reductase-dependent and -independent pathways and that multiple growth factor pathways are activated to coordinate the expression of these genes. (author's)
New approaches for male fertility control: HE6 as an example of a putative target.
Reversible contraceptive methods for males are still not available. During the last few years several marketing studies have clearly shown that men and women would welcome a situation where men could assume responsibility for family planning. Schering AG and Organon are currently collaborating to develop a hormonal method for male fertility control based on the combination of etonogestrel as gestagenic component and testosterone undecanoate. To further optimize male contraceptives in terms of improved efficiency, rapid onset, reversibility, fewer side effects and a convenient method of application, a search for innovative non-hormonal approaches was started. During the last few years, numerous proteins were identified which play a specific role in male fertility. These proteins have first to fulfill a set of indication-specific criteria before a drug discovery process can be initiated. The most important criteria for a putative target protein are tissue-selective expression, crucial biological function in fertility, drugable properties and feasibility of assay development for high-throughput-screening and lead optimization. The G-protein-coupled receptor HE6 was selected as target and the above selection criteria were applied. HE6 displays a preferred epididymis-specific expression pattern and belongs to the super-family of GPCRs, which are well known to be drugable with small molecules. A knockout mouse was generated which revealed an infertility phenotype with the onset occurring 6 weeks after initiation of spermatogenesis at the latest. Surprisingly, no epididymis-specific phenotype was observed. Instead, the reabsorption of testicular fluid along the efferent ducts was strongly affected. No further obvious side effects were observed in male or female mice. This study with HE6 exemplifies how targets for male contraception have to be validated before drug development can start. (author's)
Oxidative stress, sperm survival and fertility control.
The human spermatozoon is highly susceptible to oxidative stress. This process induces peroxidative damage in the sperm plasma membrane and DNA fragmentation in both the nuclear and mitochondrial genomes. Such stress may arise from a variety of sources including a lack of antioxidant protection, the presence of redox cycling xenobiotics, infiltrating leukocytes and excess reactive oxygen species production by the spermatozoa. Whenever the levels of oxidative stress in the male germ line are high, the peroxidation of unsaturated fatty acids in the sperm plasma membrane ensures that normal fertilization cannot occur. However, at lower levels of oxidative stress, spermatozoa may retain their capacity for fertilization while carrying significant levels of oxidative damage in their DNA. Epidemiological evidence suggests that subsequent aberrant repair of such damage in the zygote may result in the creation of mutations associated with pre-term pregnancy loss and a variety of pathologies in the offspring, including childhood cancer. Thus, while the induction of oxidative stress in spermatozoa is causally involved in the aetiology of male infertility, the prospects of using such a strategy for male contraception is fraught with potential problems, should the suppression of fertility be incomplete and DNA-damaged spermatozoa gain access to the oocyte. (author's)
Utility of infertile male models for contraception and conservation.
Epididymal defects in infertile domestic species and transgenic mice demonstrate the role of the epididymis in influencing sperm function. Spermatozoa from these males cannot negotiate the female tract as they fail to regulate their volume. The latter is necessary to counter the osmotic stresses encountered in the female tract. Reduced epididymal provision of osmolytes or their premature loss is discussed as probable causes of failed volume regulation. Measuring cell volume regulation for diagnosis of male infertility and blocking it as a means to male contraception are briefly considered. Unchecked human population growth is destroying habitats supporting vulnerable and endangered species. Genome resource banks have been established to preserve spermatozoa of genetically valuable individuals. As cryopreservation stresses spermatozoa osmotically, this process could jeopardise volume regulation with consequences for fertility. Knowledge of sperm volume regulation and the uptake of organic solutes may permit improvement in sperm storage and prevent osmolyte-related cryodamage. (author's)
The voices of teen mothers: the experience of repeat pregnancy.
The purpose was to explore the insights of young mothers with regard to their life aspirations, the changes in their lives as a result of parenting, and their beliefs of the impact of repeat pregnancy on their aspirations and life course. Ethnographic, descriptive research with a purposive sample of key informants (n = 16), using semistructured interviews to solicit rich qualitative data. Iterative methods, recursive data sifting, and Ethnograph 5.0 were used in data analysis. Young mothers were asked questions about four domains of their lives: (a) their existing life context, including support and background characteristics, (b) their relationships, including family, friends, and intimate others, (c) their vocation, including education, work, and money, and (d) their personal characteristics and parenting. Young mothers' perceptions reflected costs, rewards, and neutral aspects associated with young mothering and repeat pregnancies. The three themes that emerged from the interview data included Looking for or finding a better life, Making a hard life harder, and No big difference in my life. Nurses may use these results to understand better the young mothers with whom they work, to develop intervention programs, and to support policies that attend to the needs of young mothers. By responding to young mothers' issues and challenges from their perspective, nurses may be more effective in preventing or delaying repeat pregnancy in the teen years. (author's)
Making a difference: goals for improving the health of women and children globally.
Each year more than 500,000 women die from pregnancy-related causes, and 11 million children aged less than 5 years die from causes that are mostly preventable. Are you aware of the work being done worldwide to change this? Is there anything you can do to help? In 2004, the World Health Organization (WHO) introduced millennium development goals for health priorities and included a focus on infectious diseases such as malaria, tuberculosis, and HIV/AIDS. Cardiovascular health, cancer, and diabetes were also targeted as health priorities, as were environmental issues such as toxins, tobacco, poor sanitation, and unsafe water supplies. Lifestyle issues such as hypertension, malnutrition, childhood obesity, high-risk sexual behaviors, and substance abuse were noted to be responsible for 33% of deaths worldwide. (excerpt)
Remote consultations and HIV / AIDS continuing education in low-resource settings.
Telemedicine is a way to support physicians working in resource-poor settings, providing remote consultations and continuing medical education on HIV/AIDS care. A hybrid E-mail/web support telemedicine service was created in 2003 at the Institute of Tropical Medicine, Antwerp, Belgium, with a discussion forum hosting more than 170 healthcare professionals from 40 different countries, generally resource constrained. Interesting posts and recurring questions from this discussion forum have been elaborated as case studies or frequently asked questions, available on the website for consultation. Education and support are also provided through interactive quizzes, user-friendly guidelines, and policy documents with a particular focus on HIV/AIDS care in developing countries. From April 2003 to March 2005, 342 questions were sent from over 17 countries in Africa, Asia, and South America. The vast majority of these questions (93%) were patient-oriented, with only 7% being general questions. Of the patient-oriented questions, 49%were related to antiretroviral therapy, and 44% were related to the diagnosis and treatment of opportunistic infections. Telemedicine is a cheap and effective method of providing clinical support and continuing education to healthcare workers treating HIV-positive patients in resource-poor settings. (author's)
AIDS in 2006 -- moving toward One World, One Hope?
For the past two decades, AIDS experts -- clinicians, epidemiologists, policymakers, activists, and scientists -- have gathered every two years to confer about what is now the world's leading infectious cause of death among young adults. This year, the International AIDS Society is hosting the meeting in Toronto from August 13 through 18. The last time the conference was held in Canada, in 1996, its theme was "One World, One Hope." But it was evident to conferees from the poorer reaches of the world that the price tag of the era's great hope -- combination antiretroviral therapy -- rendered it out of their reach. Indeed, some African participants that year made a banner reading "One World, No Hope." Today, the global picture is quite different. The claims that have been made for the efficacy of antiretroviral therapy have proved to be well founded: in the United States, such therapy has prolonged life by an estimated 13 years -- a success rate that would compare favorably with that of almost any treatment for cancer or complications of coronary artery disease. In addition, a number of lessons, with implications for policy and action, have emerged from efforts that are well under way in the developing world. During the past decade, we have gleaned these lessons from our work in setting global AIDS policies at the World Health Organization in Geneva and in implementing integrated programs for AIDS prevention and care in places such as rural Haiti and Rwanda. (excerpt)
Changing the paradigm for HIV testing -- the end of exceptionalism.
The Centers for Disease Control and Prevention (CDC) is poised to issue new recommendations for testing for HIV in adults, adolescents, and pregnant women. Frustrated that more than 25 percent of Americans with HIV infection are unaware of their status and that almost 40 percent of those with newly diagnosed AIDS discover that they are infected less than a year before diagnosis, officials have proposed that HIV screening be routinely offered in all health care settings. The CDC already recommends routine testing among high-risk groups and in high-prevalence settings. The radical departure is the extension of routine testing to the entire population and the reconceptualization of the requirements for consent. Patients would be told that HIV testing was a routine part of care and given the opportunity to opt out. According to the CDC, specific signed consent would no longer be required, because "general consent for medical care is sufficient to encompass consent for HIV testing." (excerpt)
Mutagenesis as an unbiased approach to identify novel contraceptive targets.
To accommodate diverse personal needs in family planning, diverse contraceptive approaches are desirable. This goal requires identification of new contraceptive targets. Phenotype-driven mutagenesis is an unbiased approach to identify novel genes and functions in reproductive processes. The ReproGenomics Program at The Jackson Laboratory is a United States National Institutes of Health resource for production, identification and distribution of mutant mouse models of infertility that can be used for identification of potential targets for contraception. The strategy of this program is whole genome, random ENU mutagenesis, coupled with a phenotype screen for breeding failure as the only phenotype. A three generation breeding scheme selects recessive mutations affecting reproductive functions. G3 males and females that fail to reproduce by natural mating to wild-type animals undergo secondary phenotype screens to assess gonad and accessory organ histology, hormone production, gamete production and gamete function in fertilization. The genetic transmission of the infertility trait in each family is confirmed and each mutation is genetically mapped to a defined chromosome region, facilitating identification of candidate genes from sequence and expression databases. Genes essential for fertility in both males and females and acting both meiotically and post-meiotically have been identified by this strategy. Phenotypes include male infertility with normal sperm count, but failure in fertilization of oocytes. These unique reproductive mutant mouse resources will lead to new discoveries in andrology (and gynecology) research, as well as reproductive medicine. Dissection of gene function in known and newly discovered reproductive pathways will expand our focus to reveal novel targets for contraception. (author's)
The National Food Consumption Survey (NFCS) -- children aged 1-9 years, South Africa, 1999.
Against the background of prevailing under-nutrition and its coexistence with micronutrient malnutrition, the Directorate of Nutrition of the Department of Health, within the scope of its Integrated Nutrition Programme (INP), has included the development of guidelines for a national micronutrient food fortification programme as part of its strategic and operational plans. However, the formulation of such a national food fortification programme requires information regarding nutrient intake as well as the identification of suitable food fortification vehicle(s) which are consumed sufficiently frequently and in sufficient quantities by the target population, and which do not pose risks for toxicity. Additionally, it is well recognised that the successful implementation of any intervention programme depends, among other factors, on appropriate nutrition education. The paucity of such data on a national basis has, therefore, necessitated the proposed survey. (excerpt)
The aim was to investigate the feasibility, coverage and cost of a national vitamin A fortification programme using maize meal and sugar. Key components of a national fortification programme using maize meal and sugar were identified. Only added sugar and not sugar earmarked for industrial use was considered for fortification. The proportion of households consuming maize meal and sugar was determined from the Household Expenditure Survey (1994) of the South African Labour Development Research Unit (SALDRU). Consumption patterns of children aged under 6 years were obtained from two previous surveys and a food consumption survey done in the Northern Province. Different levels of fortification were selected to simulate the impact of vitamin A fortification using the raw data from these three surveys. Maximum safe intake of vitamin A was determined from data on the consumption of maize meal and sugar in the Risk Factor Study (BRISK) conducted among black peri-urban women. Key industry representatives were interviewed to determine the technological requirements needed in a fortification programme. Cost estimates were determined for the various inputs of the programme. The proportion of households consuming maize meal and sugar were 78% (range 57 - 93%) and 91% (range 78 - 97%), respectively. The maximum safe intake of vitamin A was 4 µg retinol equivalents per gram (RE/g) and 44 µg RE/g for fortified dry maize meal and added sugar, respectively. A higher level of vitamin A adequacy was achieved in rural children when fortified maize meal compared with fortified sugar was consumed (84% compared with 48%). Conversely, a higher level of vitamin A adequacy was achieved in peri-urban children with consumption of fortified sugar compared with fortified maize meal (79% compared with 56%). There are seven sugar-refining mills: six in Kwazulu-Natal, where 90% of the sugar is produced, and one in Mpumalanga, where 10% of the sugar is produced. Six main maize millers process 70% of the maize meal while 100 - 150 small mills process at least 20% of the maize meal. Based on 100% of the RDA, the cost of fortifying sugar would be greater than that of maize meal (R23.2 million compared with R59.1 million). This study shows that fortifying maize meal or sugar with vitamin A would be technically feasible and could achieve wide coverage. The costs would be lower for fortifying maize meal and could result in higher levels of vitamin A adequacy in rural children, who are at greatest risk of vitamin A deficiency. However, the impact would be less in peri-urban children, and in reaching the latter group another food vehicle such as wheat flour, in addition to maize meal, would probably need to be fortified. Fortifying sugar will result in higher levels of vitamin A adequacy in peri-urban children but may have less impact on rural children. The centralised nature of the sugar industry compared with the maize meal industry will facilitate monitoring of the fortified product. The final choice of food vehicles for fortification, however, would need to be guided by the results of the national food consumption survey that was conducted by the National Food Consumption Survey Group. Vitamin A deficiency (serum retinol < 20 µg/dl) affects one-third of South African children under the age of 6 years, and has been identified as a significant public health problem, according to a national survey conducted by the South African Vitamin A Consultative Group (SAVACG). SAVACG recommended a range of interventions aimed at addressing the problem sequentially. Vitamin A supplementation was suggested as an interim strategy, while food fortification and dietary diversification were recommended as medium to long-term interventions. (author's)
The objective of the study was to establish hygiene and health-seeking practices most likely to be predictors of nutritional insecurity among children living in slums. A cross-sectional study was conducted from March to May 1997 comparing 192 households with and 192 without malnourished children. All the households with children in the 3 - 36-month age group were identified. Using underweight (weight-for-age) as an indicator of nutritional insecurity, the households were classified into two groups, namely nutritionally secure and insecure households. Subsequently, sampling frames for each set of households were established and used to select the study households randomly. Four slums in Addis Ababa, Ethiopia, constituted the study sites. The results indicated that there was not a significant difference between secure and insecure households with regard to prevalence of immunisation and dietary (food withholding) habits during episodes of diarrhoea. After adjusting (by means of logistical regression) for covariates, six household behaviours were established as having the power to predict exposure to childhood nutritional insecurity in urban slums of Ethiopia. The presence of children's faeces inside the house, failure to have diarrhoea treated at a health facility, prolonged storage of cooked foods (beyond 24 hours), feeding children with unwashed hands, and poor handling of drinking water and foods are risk factors that can predict nutritional insecurity. Advice with a view to achieving sustainable behaviour change in households, namely good personal and household hygiene practices and increased utilisation of health facilities is recommended as being essential in addressing challenges to nutritional insecurity and in optimising the success of public health programmes. (author's)
South African food-based dietary guidelines -- guidelines for whom?
Since the international meetings of the World Health Organisation and the Food and Agriculture Organisation held in Cyprus in 1995, 'food-based dietary guidelines' have become the nutrition buzzwords of the decade. To put it simply and in context, these organisations recommended the use of food-based guidelines in education programmes mainly because the man in the street thinks in terms of foods and not in terms of nutrients. After decades of promoting 'food groups', nutritionists have now 'succumbed' to food guidelines. In fact, the objective of 'food groups' originally was also to relate to foods and not to nutrients. How will the public relate to these new food-based dietary guidelines, how will they interpret them, and what will we as health educators tell them? (excerpt)
The aim was to assess the appropriateness of the preliminary South African food-based dietary guidelines (FBDGs) as a nutrition education tool for women in KwaZulu-Natal (KZN) and the Western Cape (WC) in terms of comprehension, interpretation and implementation. This was a qualitative study using focus group discussions. Focus groups were held in five magisterial districts within KZN, and the Cape Town metropolitan area of the WC, to evaluate the comprehensibility and applicability of the FBDGs. Groups were randomly selected according to settlement type (non-urban, urban informal, urban formal) and ethnicity (black, coloured (of mixed origin), Indian, white) to reflect the KZN and WC population. Focus groups were conducted in the home language of the participants, namely, English, Zulu, Xhosa and Afrikaans. Participants included 137 women aged 19 - 63 years, with no formal nutrition training and who were responsible for food purchasing and food preparation decisions in the household. In general, women understood many of the FBDGs and the suggested food categories, and could construct a day's meals using the FBDGs. Areas of confusion were identified regarding certain terminology and concepts, such as the terms 'legumes', 'foods from animals', and 'healthier snacks'. Primary constraints to implementation of the FBDGs included cost and availability of food, household taste preferences, routine food purchasing habits, habitual or traditional food preparation and cooking methods, time constraints, accessibility (primarily transport difficulties) and underlying attitudes towards health and nutrition. The findings from this study have been used to revise the preliminary FBDGs, in order to provide an appropriate tool for effective nutrition education, for the purpose of improving nutrition knowledge, attitudes and dietary behaviours of South Africans. (author's)
The objective of this preliminary study was to determine the effect of exercise, diet, menstrual status and anthropometry on the bone mineral density (BMD) of the spine, hip and forearm of young Caucasian female athletes aged 20 - 30 years. Nine female athletes and a control group (N = 9) were recruited within the same range for age and body mass index (BMI). Weight, height and skinfolds were measured. Dietary intakes were assessed using a validated food frequency questionnaire. An activity and a medical questionnaire were also completed. BMD was measured using dual energy X-ray absorptiometry (DEXA) at the lumbar spine, left hip and forearm. No significant difference between reported nutrient intakes of athletes and controls was found. Significant negative correlations were found between spine BMD of the whole group (N = 18) and total calcium intake, as well as between forearm BMD and luteal phase, menstrual cycle and number of active exercise hours per week. Athletes had a significantly lower forearm BMD, lower percentage body fat and longer active exercise time per week. Women with a history of amenorrhoea (N = 3) had a lower average BMD and exercised significantly more than the eumenorrhoeic women. It is suggested that active weekly exercise, menstrual status and percentage body fat may all have a direct or indirect effect on the forearm BMD of white female athletes. Exercising, premenopausal women are advised to lower lifestyle risk factors that may lead to a low BMD at a young age, to maintain a percentage body fat of > 12 - 14%, and if amenorrhoea is present, to undergo medical examination to identify the cause. However, because of the limited number of subjects in the study, no definite recommendations can be made. (author's)
The needs and objectives of the various groups affected by nutritional labelling illustrate the complex and controversial nature of nutritional labelling and the problems in formulating a simple and easily understood system. Twenty homogeneous white middle-income suburbs were chosen at random from a total of 39 strata. The multistage cluster method of sampling was used to divide each suburb into smaller clusters. One area was chosen at random from each suburb. Twenty homes were then systematically selected to bring the total sample number of respondents to 400. White middle-income women completed a questionnaire analysing consumer attitudes towards and knowledge of nutritional labelling in order to identify the objectives needed for the formulation of an educational programme concerning the nutritional labelling of food containers. The results of the survey suggest that although white middle-income women (N = 388) lacked nutritional labelling knowledge (pass rate < 20%), they had a positive attitude towards nutritional labelling (mean 18.29 ± 4.8). As knowledge scores increased, the following factors became more positive: attitudes towards nutritional labelling (R = 0.2905, P = 0.0000), nutritional education (c2 = 40.9273, P = 0.01), and the use of nutritional labelling in the purchase of food (r = 0.2230, P = 0.0258). The results of this survey suggest a definite need for a nutritional labelling education programme in South Africa. Although the subject group could be considered representative of the top end of the South African market, a comprehensive needs assessment of the relevant target markets that make up South Africa's diverse population should be undertaken for the formulation of a national nutritional education programme. (author's)
Heterogeneity of Mycobacterium tuberculosis isolates in Sunamganj district, Bangladesh.
A total of 111 Mycobacterium tuberculosis isolates from new pulmonary tuberculosis patients, living in the rural Sunamganj district in northern Bangladesh were characterized with IS6110 restriction fragment length polymorphism analyses and spoligotyping. Only 3 of the isolates belonged to the W-Beijing genotype of M. tuberculosis. A high degree of diversity indicated that the spread of M. tuberculosis, in this rural area, was not caused by closely related genotypes. The tuberculosis cases in the current study were less likely to represent recent transmission than what is commonly observed in urban parts of south-east Asia. It was indicated that the tuberculosis cases of this isolated area, of a high-incidence country, represented those of an established epidemic, not yet influenced by recently disseminated strains. (author's)
This study investigated anti-malarial prophylaxis during pregnancy and children's malaria care-seeking behaviour by mothers with children 5 y of age and below drawn from 2 rural communities in southern Nigeria. Findings showed that 37% of mothers said they had used anti-malarial prophylaxis (chloroquine, 50%) during pregnancy, while only 30% of them had bed net (untreated) at home, with 44% of the bed net damaged. Over half (59%) of the respondents reported that their children had had fever/malaria in the forth-night recall period, and a majority of them (44%) were treated in medicine shops. Injections accounted for 33% of the medications received by them. Of the 74% of children who were given treatment, there were delays of 2 or more d in seeking care for a quarter of them. Only 21% of the mothers attributed malaria to bites from infected mosquitoes, despite the high prevalence of childhood malaria. Low coverage of anti-malarial intervention during pregnancy and inappropriate children's malaria care-seeking behaviour has been identified. An appropriate mechanism for delivery of insecticide-treated bed nets in addition to educational interventions is recommended in order to reduce the burden of malaria among pregnant women and children in these communities. (author's)
Perspectives of midwives and doctors on adolescent sexuality and abortion care in Vietnam.
Vietnam has one of the highest abortion rates in the world and adolescent abortions are thought to constitute at least one-third of all cases. Lack of balanced reproductive health information and services to adolescents and negative social attitudes towards adolescent sexuality are contributing factors to the high abortion rates. Health providers are important in guiding and counselling adolescents on how to protect their reproductive health. There is a lack of studies on health providers' perspectives on their work in adolescent reproductive health care. The aim was to explore the perspectives of midwives and doctors on adolescent sexuality and abortion, and what they considered to be quality abortion care for adolescents and the barriers to it, as well as to their own training needs. Observations of care in abortion clinics and focus-group discussions (FGD) were used to collect data. Doctors and midwives from three healthcare facilities in Quang Ninh province in Northern Vietnam participated in a total of eight FGDs. Data were analysed using latent content analysis. Major barriers identified for quality abortion care were of technical and managerial nature. Participants considered that counselling unmarried clients in connection with abortion should focus on warning against the risks and dangers of abortion and pre-marital sexual relations, which they strongly disapproved of. However, they also expressed a pragmatic and caring attitude towards the unmarried girls and couples coming for abortion. Adolescent sexuality and abortion are morally sensitive issues in the Vietnamese culture. The contradictions between cultural norms and the reality facing health providers while counselling unmarried adolescents need to be addressed in education and training programmes. (author's)
The objective was to determine the prevalence trends of HIV-1 infection among pregnant women seen between 1995 and 2003 at public antenatal clinics (ANC) in the city of Dar es Salaam. Cross-sectional studies among pregnant women at selected antenatal clinics who were offered HIV testing as part of research and service programmes to prevent vertical transmission of HIV infection and improve pregnancy outcomes. Subjects and methods: Consenting women gave blood for HIV antibody testing using a sequential ELISA protocol. Sociodemographic information was collected using structured interviews. In total, 62% of women attending the antenatal clinics gave informed consent for HIV testing and 51,076 had final confirmed results available for this analysis. Women below 20 years of age had the lowest HIV seroprevalence. The HIV-1 prevalence declined from 14.2% in 1995 to 10.6% in 2003. There is a definite substantial decline in prevalence of HIV-1 infection among pregnant women in Dar es Salaam following ongoing interventions, which have been carried out in Tanzania. There is a need to further strengthen these interventions. (author's)
Current status of inpatient HIV care at a tertiary care center in Nepal.
The success of the WHO's '3 by 5' programme will depend on the ability of developing countries to provide antiretroviral therapy. The purpose of this study was to determine the current status of HIV care at a major teaching hospital in eastern Nepal. A retrospective cohort study was conducted of admitted HIV-infected patients at BPKIHS between 1993 and 2003, evaluating reasons for admission and the care received. There were 2, 2, 2, 3, 5 and 18 admissions, respectively, from 1998 to 2003. Only 4 were female patients. Two were children, both admitted in the last y studied. 10 admissions (31% of the total) were for opportunistic infections (OIs). Seven patients were prescribed OI prophylaxis, with incorrect dosages in 6. Four patients were prescribed antiretroviral therapy, all in inappropriate dosages or combinations. 13 patients were rapidly discharged without further care as soon as a diagnosis of HIV was made. Hospital admissions of HIV-infected individuals are increasing rapidly. Important segments of the HIV-infected population such as women and children are not receiving medical services. Most admissions are not due to OIs. The care of HIV-infected patients even at a major tertiary care teaching hospital in Nepal is sub-optimal. (author's)
Evidence on the relationship between childhood socioeconomic position (SEP) and adult mortality risk is mounting, but is sparse in regions outside Europe and North America. The present study aimed to examine this relationship in South Korea. Study design: Prospective cohort study. First-round data from the Korea Labour and Income Panel Study were linked to data on mortality. Childhood SEP indicators were father's education, own education, father's occupational class at age 14, own first occupational class after age 15, birth place, and residence at age 14. Adulthood SEP indicators included current occupational class, family income, perceived economic hardships, and current residence. Mortality differentials according to current occupational class, economic hardship and current residence were statistically significant. Mortality risk tended to increase as household income decreased. For all childhood SEP indicators, inverse relationships between childhood SEP and mortality risk were found. These inverse relationships were attenuated but did not disappear with adjustment for each adulthood SEP indicator. However, the statistically significant association between childhood SEP and mortality risk did not persist after full adjustment for four adulthood SEP indicators. Both early- and later-life markers of SEP were related to an increased risk of death in South Korea. Future studies need to examine the relationship between childhood SEP and cause-specific mortality. (author's)
The objective of this study was to determine household food security and coping strategies of an informal settlement in the Vaal Triangle. Study design: A survey study design was used. Pre-tested socio-demographic questionnaires were administered to 357 randomly selected caregivers and 149 children aged 9--13 years old. A validated quantified food frequency questionnaire (QFFQ) and 24-h recall were used to measure dietary intake and food consumption patterns and the Cornell hunger scale to determine coping strategies. Data were statistically analysed for means and standard deviations. The results indicated that the majority of caregivers (68.8%) had an income of < R500 (77 US$) per month, 70.5% (n = 190) indicated a frequent shortage of money and 58.3% spent less than R100 (15 US$) per week on food. The coping strategies used were: limiting the variety of foods served (74.7%), limiting portion sizes (80%), skipping of meals (68.4%) and maternal buffering (75.8%). It can be concluded that this is a poverty-stricken community with household food insecurity where the caregivers changed their food consumption patterns to cope, resulting in compromised nutrition. (author's)
Improving immunization services under the armed conflict in rural Nepal.
Progress of the Expanded Programme on Immunization (EPI) has been hindered by armed conflicts in many countries, such as Nicaragua, Afghanistan, Sudan, Angola, Democratic Republic of the Congo, Liberia, Sierra Leone, Somalia and Tajikistan. It is reported that immunization coverage is very low in areas affected by armed conflicts. As a result, many children become victims of a war-related upsurge in malnutrition and vaccine-preventable diseases. Since 1989, there have been more than 116 major armed conflicts in 78 countries, most of which have been civil wars in developing countries, including Nepal. (excerpt)
Preferred skeletal site for osteoporosis screening in high-risk populations.
The current World Health Organization (WHO) definition of osteoporosis, which is based on densitometry of lumbar and femoral regions, is extensively used for decision-making in clinical practice. Discordance in diagnosis of osteoporosis using this definition is a known phenomenon. The aim of this study was to evaluate the impact of such discordance and to assess the diagnostic value of using one skeletal site for screening purposes as opposed to the two sites required in the WHO criteria. Data was collected from 4188 individuals (3848 female); mean age = 53.4 years (standard deviation 11.8) referred to a community-based outpatient osteoporosis testing centre in Tehran, Iran. Methods: Dual-energy X-ray absorptiometry (DXA) was performed on L1--L4 lumbar spine and total hip for all cases. The DXA results were categorized according to WHO criteria. Sensitivity for each site was calculated as number of cases with T-score < -2.5 at that site divided by the total number of cases with T-score < -2.5 at any site. Prevalence of osteoporosis diagnosis using lumbar DXA, femoral DXA, and WHO criteria (either of the sites) were 24.7%, 12.4%, and 27.8%, respectively. Sensitivity of lumbar DXA for diagnosis of osteoporosis (88.9%) was significantly higher than femoral DXA (44.6%, P< 0.001); but this difference became nonsignificant for men = 60 and women = 70 (P = 0.615 and P = 0.077, respectively). Agreement of the procedures in different sites (k) was 0.40 (0.37 to 0.43). When proximal femur was considered as the reference, positive likelihood ratios of lumbar DXA to detect cases were 4.7 and 2.0 in younger and older groups, respectively. Concerning the high rate of discordance and low agreement between DXA results, the data obtained from each anatomical site cannot predict the condition of the other site. However, if use of a single assessment is intended for screening programs, public health authorities can develop different strategies for different age groups of their population. We propose lumbar DXA for the younger group (men < 60 and women < 70) and femoral densitometry for the older. (author's)
At the most recent meeting of the Standing Committee on Nutrition of the UN system in Geneva in March of this year (2006), there was a dramatic shift in the tenor of the opening plenary session. Three very high-ranking officials of three of the largest implementing UN agencies (WHO, UNICEF, World Bank), along with WFP and FAO, produced -- independently of one another -- a clear, consistent message focusing on the importance of nutrition for development. In each case this was couched within the comparative advantage of each agency. It was also striking that none of the speakers came from a background of nutrition training -- one economist, one public health physician, one health economist and one development expert. All had been converted by enthusiastic nutrition colleagues within their particular agency, and by long experience in many countries, and an expanding evidence base. All referred to the same evidence base -- the Bellagio Child Survival Study Group and subsequent papers, published not in nutrition or even public health journals but in medical journals (the Lancet and the British Medical Journal in particular), although the significance of this will not be discussed here. But all were somewhat perplexed as to why nutrition issues were not an automatic component of all national health and development programmes, including within each agency. They had clearly used their considerable experience in the public sector to think this through, especially the importance of having a common and consistent message. (excerpt)
Responding to the crisis in sub-Saharan Africa: the role of nutrition.
In the chapter dealing with education and health, the report of the influential Commission for Africa prioritises basic health systems, HIV/AIDS, malaria and tuberculosis. In contrast, nutrition is given less than half a page and is reduced to parasite control and micronutrient support. Such neglect of nutrition is hard to understand in the context of increasing hunger and malnutrition across the continent. Sub-Saharan Africa is the only region in the world where the proportion of underweight children has stagnated and the absolute numbers have actually increased in the last decade. It has been pointed out that if current trends continue sub-Saharan Africa will achieve the Millennium Development Goal for child mortality around 2115 -- one century after the target date. Quite clearly those concerned with nutrition need to more powerfully advocate the role of nutrition in lifting Africa out of the spiral of poverty. The present paper argues that to achieve this requires an understanding not just of the critical role of nutrition for health and development (both individual and national), but also of how recent global changes are interacting with changes in food production and supply, other determinants of maternal and child health, and the role and capacity of the state to tackle malnutrition in Africa. It concludes by suggesting some responses that nutritionists could now be making. (author's)
The objective was to describe the case of Congo as an example of the assessment and appropriateness of donor operational and sectoral strategies in a complex emergency. The paper reports the findings of an external evaluation of operations financed by the European Commission Humanitarian Office in the Democratic Republic of Congo (DRC). The Congolese health system is suffering from severe deterioration. What is functioning in the public health context is donor-dependent with high costs and limited coverage. Despite a relatively favourable agro-climatic situation, food shortage and famine severely affect the nutritional status of large population groups. In this context, humanitarian programmes have generally improved access to health care and the nutritional status of beneficiaries. The reduction of malnutrition in project areas is often demonstrated even though the context did not permit consolidation of these results. Malnutrition continues to claim a massive cost of lives owing to the effect of widespread food insecurity that follows a circular cause-and-effect pattern of very low food production and extreme poverty. The current context in DRC does not correspond yet to 'post-crisis': neither at population level with regard to indicators of poverty, malnutrition, disease and death, nor at institutional level, with regard to state support to institutions. In these situations, the international community is often called upon to replace the state as service provider. Integrated humanitarian actions should be the future of relief projects in DRC. Health, nutrition and food security components should be considered a standard public health intervention strategy representing the most sensible approach to address the needs of the affected population. (author's)
The objectives were to explore the nutritional quality of supplementary foods and additional energy consumption by the recipients in a pilot nutrition initiative of BRAC. Design: In-depth interviews, observations during feeding at feeding centres, and laboratory analyses of supplementary foods for nutrient contents performed at the Institute of Nutrition and Food Science, University of Dhaka, Bangladesh. Setting: Muktagacha thana (sub-district) in Mymensingh district, a rural area of Bangladesh. Subjects: Pregnant and lactating mothers and children below 2 years of age. Analysis revealed that supplementary food, if taken completely, could provide daily energy equivalent to 752 kcal to a mother and 212 kcal to a child below 2 years of age. Mothers consumed about 75% of the food provided (~564 kcal day/-1). The food was shared mostly with young children and husbands. In-depth interview with mothers also suggested that they usually skipped breakfast if the food was given in the morning. The children liked the taste of food, and unless the child was sick or had some food before coming to the centre, she/he ate all the food provided. Although the main purpose of the project was to provide nutrition education, it was observed that activities at feeding centres were limited to food distribution with little time devoted to the communication of nutritional messages. Training should be given to service providers to communicate nutritional messages effectively as part of understanding the goal of the initiative. It is important to explore whether the regular diets of the recipients are replaced by the food supplementation or not. (author's)
The objective was to describe the infant feeding practices and attitudes of women who used prevention of mother-to-child transmission of HIV (PMTCT) services in rural Zimbabwe. Design: A cross-sectional study including structured interviews and focus group discussions was conducted between June 2003 and February 2004. Setting: The study took place in Murambinda Mission Hospital (Buhera District, Manicaland Province), the first site offering PMTCT services in rural Zimbabwe. Subjects: The interviews targeted HIV-infected and HIV-negative women who received prenatal HIV counselling and testing and minimal infant feeding counselling, and who delivered between 15 August 2001 and 15 February 2003. The focus groups were conducted among young and elderly men and women. Overall, 71 HIV-infected and 93 HIV-negative mothers were interviewed in clinics or at home. Most infants (97%) had ever been breast-fed. HIV-negative mothers introduced fluids/foods other than breast milk significantly sooner than HIV-infected mothers (median 4.0 vs. 6.0 months, P = 0.005). Infants born to HIV-negative mothers were weaned significantly later than HIV-exposed infants (median 19.0 vs. 6.0 months, P = 1025). More than 90% of mothers reported that breast-feeding their infant was a personal decision, a third of whom also mentioned having taken into account health workers' messages. The HIV-infected mothers interviewed were gradually implementing infant feeding practices recommended in the context of HIV. Increased infant feeding support capacity in resource-limited rural populations is required, i.e. training of counselling staff, decentralised follow-up and weaning support. (author's)
Food insecurity, weight control practices and body mass index in adolescents.
We investigated whether experienced food insecurity was associated with weight control behaviour of adolescents. Design: A national survey of 16-year-old students with the six-item food security scale, questions concerning intentions of trying to change weight, physical activity patterns, and measurement of height and weight. Setting: Representative sample of 29 schools in Trinidad, West Indies. Subjects: Data analysed for 1903 subjects including 1484 who were food-secure and 419 who were food-insecure. In the whole sample, food security status did not vary by body mass index (BMI) category. 'Trying to gain weight' and 'spending most free time in activities involving little physical effort' were each associated with lower BMI. 'Trying to gain weight' was more frequent in food-insecure subjects (135, 32%) than in food-secure subjects (369, 25%, P = 0.012). After adjustment for BMI, age, sex, ethnicity and socioeconomic variables, the adjusted odds ratio (OR) of 'trying to gain weight' for food-insecure subjects was 1.39 (95% confidence interval (CI) 1.07--1.82, P = 0.014). Food-insecure subjects (197, 47%) were more likely than food-secure subjects (575, 39%) to report that most of their free time was spent doing things that involved little physical effort (P = 0.003). This association was not explained by adjustment for BMI, age, sex and ethnicity (OR = 1.41, 95% CI 1.13--1.76, P = 0.002) or additional socioeconomic variables (OR = 1.27, 95% CI 1.02--1.57, P = 0.033). Adolescents who experience food insecurity are more likely to intend to gain weight but engage in less physical activity than food-secure subjects with the same BMI. (author's)
We estimate attributable fractions, deaths and years of life lost among infants and children = 2 years of age due to suboptimal breast-feeding in developing countries. We compare actual practices to a minimum exposure pattern consisting of exclusive breast-feeding for infants = 6 months of age and continued breast-feeding for older infants and children = 2 years of age. For infants, we consider deaths due to diarrhoeal disease and lower respiratory tract infections, and deaths due to all causes are considered in the second year of life. Outcome measures are attributable fractions, deaths, years of life lost and offsetting deaths potentially caused by mother-to-child transmission of HIV through breast-feeding. Setting: Developing countries. Subjects: Infants and children = 2 years of age. Attributable fractions for deaths due to diarrhoeal disease and lower respiratory tract infections are 55% and 53%, respectively, for the first six months of infancy, 20% and 18% for the second six months, and are 20% for all-cause deaths in the second year of life. Globally, as many as 1.45 million lives (117 million years of life) are lost due to suboptimal breast-feeding in developing countries. Offsetting deaths caused by mother-to-child transmission of HIV through breast-feeding could be as high as 242 000 (18.8 million years of life lost) if relevant World Health Organization recommendations are not followed. The size of the gap between current practice and recommendations is striking when one considers breast-feeding involves no out-of-pocket costs, that there exists universal consensus on best practices, and that implementing current international recommendations could potentially save 1.45 million children's lives each year. (author's)
Food insecurity, malnutrition and mortality in Maewo and Ambae Islands, Vanuatu.
This paper reports on findings from the ex-post evaluation of the Maewo Capacity Building project in Maewo Island, Vanuatu, which was funded by World Vision Australia. The objectives were to examine the extent to which the infrastructure and systems left behind by the project contributed to the improvement of household food security and health and nutritional outcomes in Maewo Island, using Ambae Island as a comparator. Setting: Two-stage cluster survey conducted from 6 to 20 July 2004, which included anthropometric measures and 4.5-year retrospective mortality data collection. Participants: A total of 406 households in Maewo comprising 1623 people and 411 households in Ambae comprising 1799 people. Main outcome measures: Household food insecurity, crude mortality rate (CMR), under-five mortality rate (U5MR) and malnutrition prevalence among children. The prevalence of food insecurity without hunger was estimated at 15.3% (95% confidence interval (CI): 12.1, 19.2%) in Maewo versus 38.2% (95% CI: 33.6, 43.0%) in Ambae, while food insecurity with hunger in children did not vary by location. After controlling for the child's age and gender, children in Maewo had higher weight-for-age and height-for-age Z-scores than children of the same age in Ambae. The CMR was lower in Maewo (CMR = 0.47/10 000 per day, 95% CI: 0.39, 0.55) than in Ambae (CMR = 0.59/10 000 per day, 95% CI: 0.51, 0.67) but no difference existed in U5MR. The major causes of death were similar in both locations, with frequently reported causes being malaria, acute respiratory infection and diarrhoeal disease. Project initiatives in Maewo Island have reduced the risks of mortality and malnutrition. Using a cross-sectional 'external control group' design, this paper demonstrates that it is possible to draw conclusions about project effectiveness where baseline data are incomplete or absent. Shifting from donor-driven evaluations to impact evaluations has greater learning value for the organisation, and greater value when reporting back to the beneficiaries about project impact and transformational development in their community. Public health nutritionists working in the field are well versed in the collection and interpretation of anthropometric data for evaluation of nutritional interventions such as emergency feeding programmes. These same skills can be used to conduct impact evaluations, even some time after project completion, and elucidate lessons to be learned and shared. These skills can also be applied more widely to projects which impact on the longer-term nutritional status of communities and their food security. (author's)
The objective was to assess the effectiveness of a behaviour change approach, with or without financial support, in improving vitamin A (VA) intake and serum retinol concentration through mango and liver consumption by children. Design: A parallel design (no control area) was used to assess changes in VA intake and serum retinol over a 15-week period. Setting and subjects: A pilot study was implemented in the Department of Kokologho, a rural area in central west Burkina Faso. One hundred and fifty children aged 2--3 years were randomly selected and assigned to two treatment groups: PA$$ (promotional activities and financial support) and PA (promotional activities). The intervention significantly increased (P < 0.001) total VA intake by 56% in PA$$ and by 50% in PA. VA intake from liver increased significantly (P < 0.001) from 12.7 ± 23.5 to 155.3 ± 56.3 mg retinol activity equivalents (RAE) in PA$$ and from 21.6 ± 29.7 to 135.3 ± 44.9 mg RAE in PA. Changes in VA intake from liver were significantly higher (P = 0.004) in PA$$ compared with PA. Mean serum retinol concentration increased significantly by 26% (P < 0.001) in PA$$ and 30% (P < 0.001) in PA. Changes in serum retinol concentration (0.13 mmoll/-1 in PA$$ vs. 0.17 mmoll/-1 and in PA) did not differ significantly (P = 0.455) between groups over the intervention. Promotional activities on mango and liver intake effectively increased VA intake and serum retinol concentrations. Although an additional beneficial effect of financial support on liver intake was observed, this did not translate into a further increase in serum retinol concentration. (author's)
Contraceptive care for the adolescent.
Jessica, a 16-year old female, presents to your office for a sports physical. When you explain your confidentiality policy and interview her alone using an adolescent risk assessment, she reports that she has been having sexual intercourse with her 17-year-old boyfriend for about 5 months, has been using condoms ''most of the time,'' and is interested in beginning hormonal contraception. Her best friend is using the contraceptive ''patch.'' Jessica does not want to tell her mother that she is sexually active, but she has talked with her cousin, who encouraged her to request birth control pills or ''the shot.'' She expects her period next week. She does not want a gynecological examination at this visit. As primary care providers, we frequently have the opportunity to assist our adolescent patients with reproductive health issues. Teens who come to our offices for acute medical concerns or physical examinations may also be participating in sexual activities that could result in unintended pregnancy or sexually transmitted infections (STIs). Those who are not engaging in sexual intercourse may begin to do so before their next encounter with a medical provider, and therefore could benefit from the provision of information about reproductive decision-making and contraceptive choices in advance. (excerpt)
Office practice of adolescent medicine.
Many providers find working with adolescents enjoyable and rewarding. Others find dealing with the hormonal, cultural, and developmental influences that color teenagers' lives to be confusing and difficult. Health care professionals realize that health is more than physical wellness or absence of disease, and at no time is this more apparent than during adolescence. However, it is difficult to address acute needs, to discuss important prevention issues, and to connect with teenagers as a concerned adult--all in the course of a routine office visit. Fortunately, with a strategy and some effort, the teenager clinic visit can make a difference in the life of a young person. (excerpt)
Attitudes to and practices regarding sex selection in China.
This paper explores the problem of China's 'missing' girls--estimated to run into many millions. It considers the impact of the underpinning Confucian value system in China that has produced a culture of son preference and which, together with China's compulsory family planning program and 'one child policy', has effectively established a 'one son policy'. Discussion of the various means by which the birth or survival of daughters have traditionally been prevented provides the context for identifying the contribution of new sex selection procedures to the maintenance of son preference in contemporary Chinese society. The paper concludes that China's son preference is not simply a personal problem for the millions of 'missing girls' who were destined to live a shorter life and for the surviving girls who continue to face considerable discrimination simply because they are of the 'wrong' sex; it heralds a social and demographic disaster of major proportions for which neither the government nor the people of China appear to have the will or the means to forestall. (author's)
Millions of missing girls: from fetal sexing to high technology sex selection in India.
The morality and acceptability of using prenatal diagnosis for sex selection is being extensively debated around the world as advances in assisted reproductive technologies (ART) and embryology have enabled selective implantation of embryos of the desired sex. Sophisticated methods of separation of semen, originally developed for cattle breeding, are being used for human sex selection. Recently, non-invasive methods of fetal sex determination in the first trimester (from 6 weeks) of pregnancy have also emerged. Market forces that promote sex selection along with libertarian ideologues have assisted in blurring the ethical limits. The widespread misuse of sex selection for eliminating girls before birth in India and among the Indian diaspora needs to be brought into the global 'intellectual discourse'. It is imperative that Western ethicists recognize the genocidal nature of sex selection taking place in certain Asian countries. Even if they believe that these trends will not affect mainstream Western societies, the promotion or tolerance of sex selection amounts to a 'crime of silence' against this ongoing genocide in China and India. I have been concerned with issues of the girl child in India for over two decades and sex selection among Asian Indians in North America. This article examines the missing millions of girls, but will not consider the 1980s campaign against fetal sex determination, Indian feminists' recognition of sex selection as violence against women (unlike several Western feminists, Moazam, 2004), or the Government's response to regulate prenatal diagnostic techniques in 1994. (author's)
Child mortality and environment in developing countries.
This paper studies child mortality and fertility in 61 developing countries including the Central Asian Republics (CARs). To control for simultaneity, an estimated value of fertility was used in the mortality equation and a final specification included only exogenous socio-economic, health and environmental variables. We confirm the importance of female literacy in explaining both fertility and mortality, and also find a measure of consumption for the poorest share of the population to be significant, while controlling for nutrition, health expenditure, and income distribution. Incidence of tuberculosis and female agricultural population proxy for environmental impacts, but in spite of these controls, approximately 41% additional mortality was estimated due to living in the CARs. The results fill gaps in the literature: we use a wider range of socio-economic and environmental health variables than previously in an encompassing analysis of mortality and fertility, and find evidence of excessive mortality in the CARs most likely linked to environmental degradation in the region. (author's)
Two adolescents with ectopic pregnancies: experience with methotrexate.
An ectopic pregnancy is a life-threatening form of pregnancy that is increasing in frequency especially in adolescents. Whenever a woman of childbearing age, including adolescents, presents with abdominal pain, the diagnosis of ectopic pregnancy must be considered as a possibility because if it is not diagnosed and treated expediously and appropriately, there will be considerable morbidity and mortality. Methotrexate has been shown to be effective in the management of ectopic pregnancy, but few reports are described in the literature regarding its use in teenagers. We report the cases of 2 adolescents with ectopic pregnancies who were treated successfully with methotrexate. (author's)
Lack of risk of adverse birth outcomes after deworming in pregnant women.
Pregnant women who live in hookworm-endemic areas may benefit from deworming during their pregnancy. The benefit derives from reducing anemia, primarily iron-deficiency anemia caused by hookworm infection-attributable blood loss. Where the prevalence of hookworm is more than 20% to 30%, the World Health Organization recommends that pregnant women receive anthelminthic treatment (mebendazole, albendazole, levamisole or pyrantel) after their first trimester. The objective of this study is to report, describe and compare the occurrence of adverse birth outcomes in a large randomized, controlled trial of antenatal mebendazole (500 mg single dose) plus iron supplements versus placebo plus iron supplements conducted between April 2003 and June 2004 in the Amazon region of Peru. Physician-recorded data on adverse birth outcomes occurring during the trial (N = 1042) were obtained. Proportions were compared using x/2 analysis. No statistically significant difference (P = 0.664) was found between the mebendazole group and the placebo group in terms of numbers of miscarriages, malformations, stillbirths, early neonatal deaths and premature babies (28 versus 31, respectively). The evidence provided by this large randomized, controlled trial of mebendazole administered during pregnancy indicates that deworming with mebendazole can be safely included in antenatal care programs in hookworm-endemic areas. (author's)
Advice from a medical expert on concerns and queries expressed anonymously through the Internet by patients and later posted on the Web, offers a new type of patient--doctor relationship. The aim of the current study was to perform a descriptive analysis of questions about AIDS and hepatitis made to an infectious disease expert and sent through the Internet to a consumer-oriented Web site in the Spanish language. Questions were e-mailed and the questions and answers were posted anonymously in the ''expert-advice'' section of a Web site focused on AIDS and hepatitis. We performed a descriptive study and a temporal analysis of the questions received in the first 12 months after the launch of the site. A total of 899 questions were received from December 2003 to November 2004, with a marked linear growth pattern. Questions originated in Spain in 68% of cases and 32% came from Latin America (the Caribbean, Central America, and South America). Eighty percent of the senders were male. Most of the questions concerned HIV infection (79%) with many fewer on hepatitis (17%). The highest numbers of questions were submitted just after the weekend (37% of questions were made on Mondays and Tuesdays). Risk factors for contracting HIV infection were the most frequent concern (69%), followed by the window period for detection (12.6%), laboratory results (5.9%), symptoms (4.7%), diagnosis (2.7%), and treatment (2.2%). Our results confirm a great demand for this type of ''ask-the-expert'' Internet service, at least for AIDS and hepatitis. Factors such as anonymity, free access, and immediate answers have been key factors in its success. (author's)
Cost-effectiveness of treating multidrug-resistant tuberculosis.
Despite the existence of effective drug treatments, tuberculosis (TB) causes 2 million deaths annually worldwide. Effective treatment is complicated by multidrug-resistant TB (MDR TB) strains that respond only to second-line drugs. We projected the health benefits and cost-effectiveness of using drug susceptibility testing and second-line drugs in a lower-middle-income setting with high levels of MDR TB. We developed a dynamic state-transition model of TB. In a base case analysis, the model was calibrated to approximate the TB epidemic in Peru, a setting with a smear-positive TB incidence of 120 per 100,000 and 4.5% MDR TB among prevalent cases. Secondary analyses considered other settings. The following strategies were evaluated: first-line drugs administered under directly observed therapy (DOTS), locally standardized second-line drugs for previously treated cases (STR1), locally standardized second-line drugs for previously treated cases with test-confirmed MDR TB (STR2), comprehensive drug susceptibility testing and individualized treatment for previously treated cases (ITR1), and comprehensive drug susceptibility testing and individualized treatment for all cases (ITR2). Outcomes were costs per TB death averted and costs per quality-adjusted life year (QALY) gained. We found that strategies incorporating the use of second-line drug regimens following first-line treatment failure were highly costeffective compared to strategies using first-line drugs only. In our base case, standardized second-line treatment for confirmed MDR TB cases (STR2) had an incremental cost-effectiveness ratio of $720 per QALY ($8,700 per averted death) compared to DOTS. Individualized second-line drug treatment for MDR TB following first-line failure (ITR1) provided more benefit at an incremental cost of $990 per QALY ($12,000 per averted death) compared to STR2. A more aggressive version of the individualized treatment strategy (ITR2), in which both new and previously treated cases are tested for MDR TB, had an incremental cost-effectiveness ratio of $11,000 per QALY ($160,000 per averted death) compared to ITR1. The STR2 and ITR1 strategies remained cost-effective under a wide range of alternative assumptions about treatment costs, effectiveness, MDR TB prevalence, and transmission. Treatment of MDR TB using second-line drugs is highly cost-effective in Peru. In other settings, the attractiveness of strategies using second-line drugs will depend on TB incidence, MDR burden, and the available budget, but simulation results suggest that individualized regimens would be cost-effective in a wide range of situations. (author's)
The Botswana government recently implemented a policy of routine or ''opt-out'' HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults. We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1--1.9), higher education (AOR = 2.0, 95% CI = 1.5--2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3--2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1--2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2--2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5--0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45--0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%). Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing. (author's)
The potential impact of male circumcision on HIV in sub-Saharan Africa.
A randomized controlled trial (RCT) has shown that male circumcision (MC) reduces sexual transmission of HIV from women to men by 60% (32%-76%; 95% CI) offering an intervention of proven efficacy for reducing the sexual spread of HIV. We explore the implications of this finding for the promotion of MC as a public health intervention to control HIV in sub-Saharan Africa. Using dynamical simulation models we consider the impact of MC on the relative prevalence of HIV in men and women and in circumcised and uncircumcised men. Using country level data on HIV prevalence and MC, we estimate the impact of increasing MC coverage on HIV incidence, HIV prevalence, and HIV-related deaths over the next ten, twenty, and thirty years in sub-Saharan Africa. Assuming that full coverage of MC is achieved over the next ten years, we consider three scenarios in which the reduction in transmission is given by the best estimate and the upper and lower 95% confidence limits of the reduction in transmission observed in the RCT. MC could avert 2.0 (1.1-3.8) million new HIV infections and 0.3 (0.1-0.5) million deaths over the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7 (1.9-7.5) million new HIV infections and 2.7 (1.5-5.3) million deaths, with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa. We show that a) MC will increase the proportion of infected people who are women from about 52% to 58%; b) where there is homogenous mixing but not all men are circumcised, the prevalence of infection in circumcised men is likely to be about 80% of that in uncircumcised men; c) MC is equivalent to an intervention, such as a vaccine or increased condom use, that reduces transmission in both directions by 37%. This analysis is based on the result of just one RCT, but if the results of that trial are confirmed we suggest that MC could substantially reduce the burden of HIV in Africa, especially in southern Africa where the prevalence of MC is low and the prevalence of HIV is high. While the protective benefit to HIV-negative men will be immediate, the full impact of MC on HIV-related illness and death will only be apparent in ten to twenty years. (author's)
Uptake of workplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe.
HIV counselling and testing is a key component of both HIV care and HIV prevention, but uptake is currently low. We investigated the impact of rapid HIV testing at the workplace on uptake of voluntary counselling and testing (VCT). The study was a cluster-randomised trial of two VCT strategies, with business occupational health clinics as the unit of randomisation. VCT was directly offered to all employees, followed by 2 y of open access to VCT and basic HIV care. Businesses were randomised to either on-site rapid HIV testing at their occupational clinic (11 businesses) or to vouchers for off-site VCT at a chain of free-standing centres also using rapid tests (11 businesses). Baseline anonymised HIV serology was requested from all employees. HIV prevalence was 19.8% and 18.4%, respectively, at businesses randomised to on-site and off-site VCT. In total, 1,957 of 3,950 employees at clinics randomised to on-site testing had VCT (mean uptake by site 51.1%) compared to 586 of 3,532 employees taking vouchers at clinics randomised to off-site testing (mean uptake by site 19.2%). The risk ratio for on-site VCT compared to voucher uptake was 2.8 (95% confidence interval 1.8 to 3.8) after adjustment for potential confounders. Only 125 employees (mean uptake by site 4.3%) reported using their voucher, so that the true adjusted risk ratio for on-site compared to off-site VCT may have been as high as 12.5 (95% confidence interval 8.2 to 16.8). High-impact VCT strategies are urgently needed to maximise HIV prevention and access to care in Africa. VCT at the workplace offers the potential for high uptake when offered on-site and linked to basic HIV care. Convenience and accessibility appear to have critical roles in the acceptability of community-based VCT. (author's)
Nosocomial tuberculosis in India.
Most high-income countries implement tuberculosis (TB) infection control programs to reduce the risk for nosocomial transmission. However, such control programs are not routinely implemented in India, the country that accounts for the largest number of TB cases in the world. Despite the high prevalence of TB in India and the expected high probability of nosocomial transmission, little is known about nosocomial and occupational TB there. The few available studies suggest that nosocomial TB may be a problem. We review the available data on this topic, describe factors that may facilitate nosocomial transmission in Indian healthcare settings, and consider the feasibility and applicability of various recommended infection control interventions in these settings. Finally, we outline the critical information needed to effectively address the problem of nosocomial transmission of TB in India. (author's)
Risk for tuberculosis among children.
Contacts of adults with tuberculosis (TB) are at risk for infection. Tests based on interferon- (IFN- ) expression in response to Mycobacterium tuberculosis antigens may be more sensitive than the tuberculin skin test (TST). Risk for infection was assessed by using TST and an IFN- -based assay (QuantiFERON Gold in Tube [QFT-IT] test) for 207 children in Nigeria in 1 of 3 groups: contact with adults with smear-positive TB, contact with adults with smear-negative TB, and controls. For these 3 groups, respectively, TST results were >10 mm for 38 (49%) of 78, 13 (16%) of 83, and 6 (13%) of 46 and QFT-IT positive for 53 (74%) of 72, 8 (10%) of 81, and 4 (10.3%) of 39 (p<0.01). Most test discrepancies were TST negative; QFT-IT positive if in contact with TB-positive persons; and TST positive, QFT-IT negative if in contact with TB-negative persons or controls. TST may underestimate risk for infection with TB in children. (author's)
Multidrug-resistant tuberculosis management in resource-limited settings.
Evidence of successful management of multidrugresistant tuberculosis (MDRTB) is mainly generated from referral hospitals in high-income countries. We evaluate the management of MDRTB in 5 resource-limited countries: Estonia, Latvia, Peru, the Philippines, and the Russian Federation. All projects were approved by the Green Light Committee for access to quality-assured second-line drugs provided at reduced price for MDRTB management. Of 1,047 MDRTB patients evaluated, 119 (11%) were new, and 928 (89%) had received treatment previously. More than 50% of previously treated patients had received both first- and second-line drugs, and 65% of all patients had infections that were resistant to both first- and second-line drugs. Treatment was successful in 70% of all patients, but success rate was higher among new (77%) than among previously treated patients (69%). In resource-limited settings, treatment of MDRTB provided through, or in collaboration with, national TB programs can yield results similar to those from wealthier settings. (author's)
In order to determine the prevalence and risk factors for Chlamydia trachomatis infection in adolescent females and young women in central Brazil, 296 subjects attending two public health services were evaluated. The overall prevalence of C. trachomatis infection, as determined using polymerase chain reaction, was 19.6% (95% confidence interval [CI], 15.3--24.7). In multivariate analysis, young age (odds ratio [OR]/adjusted 2.32, 95% CI 1.1-- 4.8, p < 0.05) and having 2--3 (OR/adjusted 3.41, 95% CI 1.6-- 6.3, p < 0.05) or = 4 sexual partners in life (OR/adjusted 3.10, 95%CI 1.1--6.3, p < 0.05) were factors significantly associated with chlamydial infection. In conclusion, the prevalence of C. trachomatis infection was high in the studied population and risk factors were related to age and sexual behavior. (author's)
The objective was to assess the maternal sociodemographic, anthropometric, dietary and micronutrient status in apparently healthy pregnant women in order to determine their associations with intrauterine growth retardation (IUGR). Design: Prospective observational study. Setting: Bangalore City, India. Subjects: A total of 478 women were recruited at 12.9 ± 3.3 weeks of gestation and followed up at the first, second and third trimesters of pregnancy and at delivery. The dropout rate was 8.5%. Interventions: None. Main outcome measures: Birth weight was measured at hospital delivery. The mean birth weight was 2.85 ± 0.45 kg. In all, 28.6% of newborns were IUGR. There was a strong inverse relationship between maternal educational level and risk of IUGR. A low body weight at baseline was also associated with a high risk of IUGR. Compared with women in the highest quartile for second trimester weight gain, those in the lowest quartile had a significantly higher adjusted odds ratio (AOR: 3.98; 95% CI: 1.83, 8.65) for IUGR. Women in the lowest tertile for serum vitamin B12 concentration during each of the three trimesters of pregnancy had significantly higher risk of IUGR (AOR: 5.98, 9.28 and 2.81 for trimesters 1--3, respectively). The present study demonstrates associations between educational status, maternal weight and gestational weight gain with IUGR. Importantly, in a subsample, there were strong associations of vitamin B12 status with IUGR, suggesting that better socioeconomic conditions, improved nutritional status and early detection of vitamin B12 deficiency in pregnancy combined with appropriate interventions are likely to play an important role in reducing IUGR. (author's)
Duration of breast feeding and cognitive function: population based cohort study.
Some evidence suggests that breast feeding is weakly but positively associated with cognitive function. This association has been robust to adjustment for various confounders. The aim of this paper is to determine if duration of breast feeding is associated with cognitive function in late childhood. Data was abstracted from the 1970 British Cohort Study. 11004 liveborn white singletons born during 5--11 April 1970 in the United Kingdom were followed from birth to 10 years. Cognitive function at 10 years is the dependent variable, a latent construct composed of one ability test and three performance measures. Estimates derived from multiple linear regression and structural equation modeling were compared. Effect sizes were estimated using standardized coefficients (SC). Differences in cognitive function according to breast feeding duration were estimated to be small by multiple linear regression (SC = 0.07) and much smaller and non-significant as estimated by structural equation modeling (SC = 0.02) after adjusting for parental socioeconomic status (SES), birth weight, parity, gestational age, maternal age and maternal smoking. Differences in cognitive function according to duration of breast feeding appear to be small and of little clinical importance as estimated by structural equation modeling. (author's)
Vitamin B12 deficiency in infancy may cause failure to thrive, severe neurological disorders and megaloblastic pancytopenia. It is well known that infants born with deficient vitamin B12 storage have increased the risk of vitamin B12 deficiency. Vitamin B12 deficiency is more prevalent in infancy in Sanliurfa province (at the southeast region of Turkey). The aim of this study was to determine the frequencies of vitamin B12, folic acid and iron deficiencies in pregnants and their babies at birth and to what extend the mothers' deficiency becomes effective on babies' deficiencies. The study groups were constituted by 180 pregnant women and their single and term babies. Venous blood samples of pregnants were obtained 1--3 h before delivery and babies' cord bloods were collected at birth. Vitamin B12 and folic acid levels were measured with electro chemiluminiscence method; serum iron and iron binding capacities were measured by colorimetric method and complete blood counts were performed by automatic blood counter. Mean vitamin B12 levels in maternal and cord blood serum were 130 ± 61.7 pg/ml and 207 ± 141 pg/ml; mean folic acid levels were 8.91 ± 6.46 ng/ml and 17.8 ± 11.8 ng/ml; mean serum iron levels were 56.9 ± 37.5 lg/dl and 147 ± 43.2 lg/dl; and mean transferrin saturations were 11.8 ± 8% and 65.6 ± 24%, respectively. There were vitamin B12 deficiency (< 160 pg/ml) in 72% of the mothers and 41% of the babies, and severe deficiency (< 120 pg/ml) in 48% of the mothers and 23% of the babies. Folic acid deficiency was found in 12% of the mothers, but was not found in the babies. There were iron deficiency in 62% of the mothers and 1% of the babies. There were statistically significant correlation between maternal and cord blood serum vitamin B12 levels (r = 0.395, P < 0.001) and folic acid levels (r = 0.227, P = 0.017), while there were no correlation between maternal and cord blood iron levels and transferrin saturations. The study results showed that vitamin B12 deficiency is prevalent in pregnants in this region and that 41% of infants have born with deficient vitamin B12 storages. Therefore, prophylactic use of vitamin B12 by pregnant women in Sanliurfa and other poor communities could have considerable benefits to prevent vitamin B12 deficiency and its complications in infants. (author's)
The aim of this study was to determine the vaginal douching habits and associated factors of women attending two different healthcare clinics. This cross-sectional study was conducted between 1 and 31 May 2004. All participants were women (n = 635) who attended either a university hospital gynecology clinic or a primary health care center family planning unit. One-way ANOVA, chi-squared test, and binary and multiple logistic regression analyses were used for the statistical evaluation of data. The mean age of the participants was 36.90 ± 10.72 years (range: 18--75). Half of the participants believed vaginal douching had a positive effect on health. They believed vaginal douching demonstrates cleanliness, prevents infections and pregnancy, removes sperm following intercourse, a necessity of Islamic doctrine, and reduces symptoms like discharge, unpleasant odor, etc. Of the women, 50.2% performed vaginal douching. Vaginal douching was associated with age, education level, type of dwelling, working outside of the home, age at marriage, age at birth of first child, parity, spontaneous abortion, history of pelvic inflammatory disease, use of contraceptives, and attending a healthcare clinic. Douching is a common habit among Turkish women. Many women are not aware of the harmful effects of douching. Public health and health professionals should monitor more closely this traditional habit in Turkey. (author's)
Body mass index and risk for oral contraceptive failure: a case-cohort study in South Carolina.
Studies have suggested that obesity is associated with an increased risk for oral contraceptive (OC) failure. We conducted a case--cohort study in South Carolina to examine the association between body mass index (BMI) and OC failure by using population-based data sources. Our cohort sample from the source population consists of 205 women who reported using OCs to prevent pregnancy on the 1999 Behavioral Risk Factor Surveillance System survey. The 153 women who reported using OCs at the time of conception on the 2000 Pregnancy Risk Assessment Monitoring System survey represent the case sample that arose from the source population. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs). In unadjusted models with normal BMI (20 to 24.9 kg/m2) as the comparison, greater BMI was associated significantly with OC failure (overweight [25 to 29.9 kg/m2],OR = 2.54; 95% CI, 1.18--5.50; and obese [= 30 kg/m2], OR = 2.82; 95% CI, 1.05--7.58). After adjustment for education, income, and race/ethnicity, associations were attenuated and no longer statistically significant. In this heterogeneous population, we found a suggestion that overweight and obese women may be at increased risk for OC failure. However, long-term prospective studies are needed to study this association in diverse populations. (author's)
Biologic and social determinants of sequelae and long-term survival of pediatric HIV in Romania.
The aim of the study is to investigate the effect of social context and clinical factors on survival in a cohort of 333 children to identify issues useful in the treatment and care of human immunodeficiency virus (HIV)-infected youth in developing countries. A prospective cohort study design was used, and data were gathered at baseline and 1-year follow-up. The study cohort consisted of children given a diagnosis of HIV between 1995 and 1999 and receiving medical care in Constanta, Romania. Data were examined by means of multivariate Cox regression analysis models. The majority of the cohort were in the moderate (41%) or severe (40%) stages of HIV at baseline. Multivariate analysis indicated that social-context factors were the most significant determinants of HIV survival. The hazard for death for those with mothers or fathers with a higher level of education was approximately one quarter (relative hazard, 0.3--0.4; confidence interval, 0.1--1.0) that for a parent with a lower level of education. Subjects with employed mothers were four times more likely to survive than subjects with unemployed mothers. Results suggest that recognition of social-context risk factors for HIV disease progression and survival is important in developing countries, as it is in developed countries. (author's)
Argentina’s return to constitutional rule on December 10, 1983 also represented its definitive incorporation into the international systems for the protection of human rights. On issues specifically relating to women, of special significance is the crucial decision that resulted in the ratification, in 1985 by Law No. 23,179, of the Convention on the Elimination of All Forms of Discrimination Against Women. This treaty, pursuant to the 1994 constitutional reform, acquired constitutional rank, along with other human rights instruments, as provided in Article 75 (22) of the Constitution. The treaty thus became part of what Bidart Campos calls “the bloc of federal constitutional law.” Several legislative measures were adopted for the implementation of this convention, due in large part to the active participation of women’s groups, which represented significant progress. These include laws regarding joint custody, equal rights for children born out of wedlock and civil marriage. The so-called “quota law,” Law No. 24,012, is especially notable. This law guarantees the participation of at least thirty percent women on the lists of candidates for national elective offices. (excerpt)
‘Kusvika taparadzaniswa nerufu' (Until death do us part).
A cross-sectional study of 7 667 non-virgins between 15 and 54 years of age was carried out to assess the protective effect of marriage against HIV acquisition in a rural population in Zimbabwe, whilst taking into account gender-differentials in risk factors for seroconversion. Persons in stable first marriages and long-term consensual cohabiting unions had higher odds of HIV infection than never-married people but a lower risk than those who had been divorced or widowed, even after adjusting for known confounders and significant risk factors for infection. Partner-related risk factors appear to play a more pivotal role in determining HIV prevalence in females than for males, for whom personal sexual behaviour risk factors are more dominant. (author's)
This paper employs syndemics theory to explain high rates of sexually transmitted disease among inner city African American and Puerto Rican heterosexual young adults in Hartford, CT, USA. Syndemic theory helps to elucidate the tendency for multiple co-terminus and interacting epidemics to develop under conditions of health and social disparity. Based on enhanced focus group and in-depth interview data, the paper argues that respondents employed a cultural logic of risk assessment which put them at high risk for STD infection. This cultural logic was shaped by their experiences of growing up in the inner city which included: coming of age in an impoverished family, living in a broken home, experiencing domestic violence, limited expectations of the future, limited exposure to positive role models, lack of expectation of the dependency of others, and fear of intimacy. (author's)
Consistent condom use is critical to efforts to prevent sexually transmitted infections among adolescents, but condom use may decline as relationships and contraceptive needs change. The purpose of this research is to assess changes in condom non-use longitudinally in the context of changes in relationship quality, coital frequency and hormonal contraceptive choice. Participants were women (aged 14--17 years at enrollment) recruited from three urban adolescent medicine clinics. Data were collected at three-month intervals using a face-to-face structured interview. Participants were able to contribute up to 10 interviews, but on average contributed 4.2 interviews over the 27-month period. Independent variables assessed partner-specific relationship quality (five items; scale range 5--25; a = .92, e.g., this partner is a very important person to me); and, number of coital events with a specific partner. Additional items assessed experience with oral contraceptive pills (OCP) use and injected depomedroxy-progesterone acetate (DMPA). The outcome variable was number of coital events without condom use during the past three months. Analyses were conducted as a three-level hierarchical linear growth curve model using HLM 6. The Level 1 predictor was time, to test the hypothesis that condom non-use increases over time. Level 2 predictors assessed relationship quality and coital frequency across all partners to assess hypotheses that participants' condom non-use increases over time as a function of relationship quality and coital frequency. Level 3 predictors assessed the participant-level influence of OCP or DMPA experience on time-related changes in condom non-use. A total of 176 women reported 279 sex partners and contributed 478 visits. Both average coital frequency and average condom non-use linearly increased during the 27-month follow-up. At any given follow-up, about 35% reported recent OCP use, and 65% reported DMPA use. HLM analyses showed that condom non-use increased as a function of time (ß = .12; p = .03, Level 1 analysis). Increased condom non-use over time was primarily a function of increased coital frequency (ß = .01; p = .00), although higher levels of relationship quality were associated with increased condom non-use at enrollment (ß = .44; p = .00, Level 2 analysis). The temporal rise in condom non-use significantly increased among DMPA users (ß = .06; p = .00) but not OCP users (Level 3 analysis) (ß = -.04; p = .06). Developmentally, relationship characteristics and coital frequency appear to have increasing weight in decisions about condom use. Hormonal contraceptive methods are not equivalently associated with the overall temporal decline in condom use. Future research associated with dual contraceptive/condom use should address differential factors associated condom use in combination with different hormonal methods. (author's)
Aspects of the social environment, including social conditions (socio-economic status, household situations, chronic illnesses) and social relations (attitude and behaviors of relations) are major determinants of depression among women. This study evaluates the relative power of social relations and social conditions in predicting depression among pregnant women in Pakistan. In the qualitative phase of the study, social environmental determinants were identified through literature search, and experts' opinions from psychologists, psychiatrists, gynecologists, sociologists and researchers. Along with this, 79 in-depth interviews were conducted with pregnant women drawn from six hospitals (public and private) and two communities in Karachi, Pakistan. Identified determinants of depression were grouped into themes of social conditions and social relations and pregnancy-related concerns. In the study's quantitative phase, the relative power of the identified themes and categories, based on their scores for predicting depression (determined by the Center for Epidemiological Studies--Depression Scale (CES-D scale)), was determined through multivariate linear regression. Social environmental determinants of pregnant women were described under the themes and categories of (1) social relations: involving husband, in-laws and children; (2) social conditions: involving the economy, illness, life events, household work, environmental circumstances and social problems; and (3) pregnancy-related concerns i.e. symptoms of pregnancy, changes during pregnancy, dependency and concern for unborn baby. Multivariate analysis found that among these themes, social relations and pregnancy-related concerns were significantly associated with total CES-D scores. Among the categories besides increasing age and less education, husband, in-laws, household work and pregnancy symptoms were significantly associated with total CES-D scores. The study highlights the importance of social relations compared to social conditions for determining depression in pregnant women. (author's)
Erectile dysfunction and Viagra use: what's up with college-age males?
We surveyed 234 sexually active males aged 18--25 years about erectile dysfunction (ED). Thirteen percent reported ED, but rarely discussed this with medical providers; 25% reported ED occurring with condom use, which was associated with risky sex. Six percent used ED medications, rarely under medical supervision, and often mixed with recreational drugs. (author's)
Among adolescent women, having older sexual partners has been associated with initial Chlamydia trachomatis (Ct) infection and high-risk behaviors. This study evaluates the role of older partners in the risk of three outcomes: recurrent Ct, lack of condom use, and nonadherence with partner management (PM) strategies. Female participants aged 14 to 18 years enrolled in a randomized clinical trial of patient-delivered partner treatment (PDPT) with at least one follow-up visit were included in this secondary analysis. Patient- and partner-level data were collected at baseline, one, and four months follow-up. Generalized estimating equations (GEE) and logistic regression were used to examine unadjusted and adjusted associations. The majority of the 496 women were African-American (63.3%), aged 16 to 18 years (62.3%), and asymptomatic for Ct (66.7%). At baseline, all of the women had laboratory-demonstrated Ct and were treated; they had 622 partners during the last 60 days, 21.4% reported having more than one partner with a mean (SD) of 1.5 (.78) partners per woman, and 46.3% of the partners were at least three years older than the woman. Over follow-up, 16.1% of the women experienced Ct recurrence, in 41.9% of the partnerships a condom was not used at last sex, and 80.6% of women reported giving PM. After adjusting for confounders, having a partner at least three years older was not associated with increased risk of Ct recurrence, lack of condom use, or nonadherence to PM strategies. Risk of Ct recurrence, lack of condom use, and nonadherence to PM strategies was not higher among adolescent women with older partners. (author's)
The purpose was to understand the prospective relationship between depressive symptoms and sexual risk behavior among a community sample of African American adolescents. African American adolescents (n = 415) who participated in a larger multi-site human immunodeficiency virus (HIV) prevention program provided baseline data on demographics, psychosocial context and depressive symptoms. At six-month follow-up, data were collected regarding sexual activity in the past 90 days. Multivariate logistic regression was conducted to determine the prospective relationship between depressive symptoms and proportion of condom use while controlling for relevant demographic and contextual factors. The odds that African American adolescents who reported depressive symptoms at baseline would report inconsistent condom use at six-month follow-up was approximately four times greater than that of their peers who did not report depressive symptoms. Older adolescents and females were less likely to use condoms consistently and certain contextual factors, such as less pleasurable expectations about condom use, and living with a partner also heightened HIV/STI risk. Clinicians should assess for depression symptoms in African American adolescent patients as an indicator of future sexual risk. Prevention interventions that address depressed mood could have a significant impact on later HIV/STI sexual risk behaviors. Further research is needed to understand the effect of depressive symptoms on sexual risk among adolescents of other race/ethnicities and to examine the potential cultural forces that affect this relationship. (author's)
Newly homeless youth STD testing patterns over time.
The purpose was to use the Behavioral Model for Vulnerable Populations to examine the predisposing and need characteristics of newly homeless youth that are associated with sexually transmitted disease (STD) testing over time. A longitudinal cohort of newly homeless youth from Los Angeles County (n = 261; ages 12--20 years) were followed for 24 months. Youth were interviewed at baseline, 3, 6, 12, 18, and 24 months, and asked about their background, housing situation, emotional distress (using the Brief-Symptom Inventory), substance use, sexual risk behaviors, and their STD testing rates. We modeled our longitudinal data using logistic random effects models. Characteristics of homeless youth that were associated with STD testing in our multivariate model included time in study (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1--1.6), age at baseline (OR 1.2, 95% CI 1.1--1.4), being African-American ( OR 2.7, 95% CI 1.4 --5.3), being from a mixed race/ethnic group (OR 2.8, 95% CI 1.3--5.8), self-identifying as a gay/bisexual male (OR 2.9, 95% CI 1.2-- 6.9), self-identifying as a heterosexual female (OR 2.2, 95% CI 1.3--3.7), using amphetamines (OR 1.7, 95% CI 1.1--2.6), and history of having gotten someone/becoming pregnant (OR 2.3, 95% CI 1.4 --3.9). Youth who lived in an apartment were less likely to have received an STD test than youth who lived in other types of housing (OR .4, 95% CI .2--.9). Sexual risk behaviors such as inconsistent condom use (OR 1.0, 95% CI .6 --1.4) and number of sexual partners over past 3 months (OR 1.1, 95% CI 1.0 --1.1) were not predictive of STD testing over time. A need exists for interventions to target young newly homeless youth who engage in high-risk sexual behaviors to increase their STD testing rates and thereby decrease their risk for HIV infection. (author's)
Condom use with "casual" and "main" partners: what's in a name?
This study examined adolescents' attitudes about and behaviors toward condom use with "casual" vs. "main" sexual partners. Participants were sexually active adolescents aged 15--21 years (n = 1316) recruited from primary care clinics and through outreach activities in three major cities in the United States. Assessment of condom use within the past 90 days, relevant attitudes, substance use, and demographic data were obtained via audio computer-assisted self-interview (ACASI). Participants were divided into two groups: the 65% who reported main partners only (MP group) and the 35% who had at least one casual partner (CP group). Adolescents in the MP group were more likely to be female, whereas males were significantly more likely to report casual partners. Race/ethnicity, age, education level, household income, and sexually transmitted infection (STI) history were unrelated to group status (i.e., sexual partner type). Greater substance use and riskier attitudes were reported by teens in the CP group. The number of unprotected sex acts in the past 90 days was substantial and equivalent between the main and casual partner groups (19.2 vs. 21.5, respectively). Regression analyses revealed that perceptions of main partner attitudes toward condom use and condom use expectations were significantly related to condom use with MPs, but that attitudes were not related to condom use with CPs. Adolescents with either casual or main partners may be at continued risk for contracting human immunodeficiency virus (HIV) and STIs, given high rates of unprotected sex. Interventions that do not target attitudes and practices related to casual partners as compared with main partners may miss an opportunity to change risk behaviors. This study demonstrates the importance of understanding an adolescent's perception of partner types in order to design effective interventions. (author's)
Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass.
The purpose was to evaluate the patterns of surgical care among pediatric and adolescent females undergoing operative intervention for an adnexal mass with particular attention toward factors associated with ovarian-conserving surgery and access to gynecologic care. All female patients aged = 18 years undergoing surgery for an adnexal mass between January 1, 1991 and December 31, 2002 were retrospectively identified and demographic, operative, and pathologic data abstracted. Logistic regression analyses were used to identify factors independently associated with ovarian-conserving surgery and access to gynecologic care. Eighty-two consecutive cases were identified. The median age at surgery was 15 years, and 91.7% of patients were = 12 years of age. A malignant ovarian neoplasm was present in 14.6% of cases. Oophorectomy was performed in 52.4% of cases, while 47.6% of patients underwent ovarian-conserving surgery. Multivariate regression analysis revealed that ovarian-conserving surgery was significantly less likely in the setting of malignancy, torsion, and an ovarian size of = 6 cm. The presence of a gynecologic surgeon, compared to other surgical specialties, was statistically significantly and independently associated with ovarian-conserving surgery (odds ratio [OR] 8.71, 95% confidence interval [CI] 2.12-- 41.41, p = .001). Post-menarchal status and age = 16 years were the characteristic most predictive of access to gynecologic surgical care. In pediatric and adolescent patients, operative intervention for an adnexal mass is significantly more likely to result in ovarian conservation when performed by a gynecologic surgeon. For such patients, improved access to gynecologic consultation prior to surgical intervention may reduce the number of patients subjected to oophorectomy for benign conditions. (author's)
This study estimates the relative importance to child health (indicated by weight and height for age) of economic development level [gross domestic product (GDP) converted to international dollars using purchasing power parity (PPP) rates: GDP-PPP], household wealth and maternal education and examines the modifying influence of national contexts on these estimates. It uses information collected from mothers aged 15--49-years participating in Demographic Health Surveys (DHS) conducted in 42 developing countries. In multilevel regression models, the three study variables exhibited strong independent associations with child health: GDP-PPP accounted for the largest amount of unique variation, followed by maternal education and household wealth. There was also substantial overlap (shared variance) between maternal education and the other two study variables. The regressions of child health on household wealth and maternal education exhibited substantial cross-national variation in both strength and form of association. Although higher education levels were associated with disproportionately greater returns to child health, the pattern for household wealth was erratic: in many countries there were diminishing returns to child health at higher levels of household wealth. We conclude that there are inextricable links among different strategies for improving child health and that policy planners, associating benefits with these strategies, must take into account the strong moderating impact of national context. (author's)
Connecting the adolescent male with health care.
Starting in adolescence, males use health care services less than females. Younger adolescent males who use existing services rely on access to their primary clinician: pediatricians, adolescent medicine physicians, family physicians, internists, or nurse practitioners. Older adolescent and young adult males obtain medical care from hospital emergency departments more often than primary care clinicians. Many adolescent males who do have contact with clinicians receive limited medical examinations, whether for injuries or for sports physicals. There are few opportunities for preventive health messages or discussions with male adolescents; only one third report talking with a clinician about a reproductive health topic. Unfortunately, utilization of health services decreases further as males leave high school and become increasingly disconnected from traditional venues that provide preventive health care services and education to young people. (excerpt)
Providing anticipatory guidance and counseling to the adolescent male.
During a clinical day, a health care provider may find it refreshing to see an adolescent male because he will be quick and easy to see, with an uncomplicated physical examination and clinical history. This attitude may be in part due to the fact that adolescent males have the reputation of being nontalkative, difficult to engage, or not interested when it comes to clinical care. Yet adolescent males experience many preventable health issues that place them at significant risk for morbidity and mortality (see earlier article). Also, despite their reputation, adolescent males do want to discuss their health. The primary care provider should not shortchange the adolescent male during his medical encounter but instead should take the time to engage him in anticipatory guidance and counseling. The fact that adolescent males are seen in a variety of clinical settings, including ambulatory care, emergency department, school-based, and juvenile detention, makes it important for all types of care providers to become familiar with how to counsel adolescent males and to use counseling approaches that work. To provide a rationale for effective counseling, a framework is first presented to enhance the understanding of the adolescent male in context of his development, family, friends, and community/school. Equipped with the right set of tools, clinicians of either gender can have much success communicating with and counseling adolescent male patients. (excerpt)
Not all adolescents are the same: addressing the unique needs of gay and bisexual male youth.
Adolescent males who self-identify as gay or bisexual come from all walks of life, all socioeconomic backgrounds, all religious denominations, and all racial and ethnic groups. They live in urban centers, suburban communities, and small rural towns. Providing health care to this subpopulation of youth can be challenging to health care providers because of a pervasive societal stigma surrounding same gender sexual activity and sexual minority youth. Although gay and bisexual male youth share many of the same adolescent struggles as their heterosexual peers, growing up in a society that often rejects and disapproves of them creates unique challenges to healthy physical and psychological development. Here we discuss the role of sexual identity formation in the lives of gay and bisexual male adolescents, review some of the greatest challenges to their overall health and well-being, and provide guidance for clinicians wishing to improve the delivery of health care services to this vulnerable population of youth. (excerpt)
Anogenital human papillomavirus infection in males.
Human papillomaviruses (HPVs) are members of the Papillomaviridae family of DNA viruses. More than 100 types have been identified; some HPV types cause nongenital cutaneous infection, and other HPV types cause anogenital mucocutaneous infection. Based on their association with cervical cancer, anogenital HPV types have been classified further: low-risk types (e.g., 6, 11) are associated with anogenital warts and mild dysplasias, and high-risk types (e.g., 16, 18, 31, 45), are associated with anogenital cancers and high-grade dysplasias. In contrast to other sexually transmitted pathogens, HPV cannot be cultured and no serologic test is available for clinical use. HPV infection is assessed clinically and by detection of HPV DNA. Anogenital HPV infections are estimated to be the most common sexually transmitted infection; an estimated 5.5 million adults are infected with HPV annually. In one study, cumulative annual incidence in young women was 43%. It is unclear whether the high prevalence of genital HPV infection is because the virus is easily transmitted, remains infectious on the genital mucosa for long periods, or both. (excerpt)
Genitourinary problems in adolescent males.
In most aspects of life, the adolescent is at an awkward transition between childhood and adult life. In medicine, and especially urology, this gray zone pertains often to the disadvantage of these individuals--too big to consider themselves children, but clearly not adults. The genitourinary problems of adolescent males, perhaps a unique species unto themselves, span a wide range from undetected congenital anomalies to developmental and environmentally acquired problems. Most genitourinary anomalies are detected in infancy, if not before, by virtue of antenatal ultrasonography and careful newborn examination. Many children do not receive these examinations, however, and only later in childhood are the problems identified. (excerpt)
Since its introduction in the 1970s, depot medroxyprogesterone acetate (DMPA) has endured medical and political controversy, causing its delayed approval as a contraceptive agent in the United States for almost 20 years. Its continued use and success, despite such controversy, are because of its unique features and strengths as a contraceptive agent. DMPA is a progestin-only contraceptive given intramuscularly every 3 months. It is extremely effective (less than 1% annual failure rate), obviates the need for daily pill compliance, and can be used privately. As such, DMPA has many features that are clinically appealing for use in adolescents. It is estimated that 1 million adolescent girls between the ages of 15 and 19 use DMPA as their contraceptive method. The decreased incidence of adolescent pregnancy over the past decade has been attributed, in part, to the increased use of DMPA. (excerpt)
In the United States, adolescent pregnancy rates have declined by 30% since 1991, with a record low of 43 births per 1000 women ages 15 to 19 in 2002. Although this is a positive trend, the United States still has a higher adolescent pregnancy rate than many other developed countries. The use of contraceptives by adolescent women has been increasing, but adolescents as a group have higher rates of contraceptive failure compared with older women. No contraceptive method is 100% effective, and even with perfect use and good technique, adolescents still may experience times of inadequate protection. Despite improvements in the accessibility and range of contraceptive options available, 8 of 10 adolescent pregnancies are unintended. Timely use of emergency contraception (EC) could reduce the risk of pregnancy by as much as 89% to 99%, depending on the type used, and could prevent as many as 1.5 million unintended pregnancies each year. (excerpt)
Among consumers and health professionals, complementary and alternative medicine (CAM) has become sought after and integrated into mainstream provision of medical services. CAM, known as nonallopathic, unconventional, holistic, or natural therapy, encompasses many types of healing practices From the Cochrane Collaboration, CAM is a ''a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems in a particular society or culture in a given historical period''. (excerpt)
Current contraceptive research and development.
It is important that the level of contraceptive research be maintained or expanded and that new products continue to be brought to market. It is known that in terms of contraception, one size does not fit all. Women respond differently to combined oral contraceptive formulations; some will do well on a particular progestin, while others may have intolerable adverse effects. There is a need for a wide variety of contraceptive options. The average age of menarche in the United States is approximately 12 years, and the average age of menopause is approximately 51 years. Modern trends toward delayed childbearing, decreased parity, and decreased duration of lactation mean that many women may require some method of contraception for 30 years or more, and the particular method or formulation that may be optimal or preferred for a woman at the age of 18 may be different than the method she chooses to use or can medically use at the age of 40. The choice of a contraceptive method is influenced not only by a woman's medical history, but also by her current social or family situation, frequency of intercourse, desire for children and spacing of pregnancies, fecundity, preferred dosing frequency, level of effectiveness, noncontraceptive benefits, and cost of the method. Because of these influencing factors that vary throughout a woman's reproductive life, it is crucial that women have access to numerous safe and effective contraceptive options. (excerpt)
Contraceptive choices for chronically ill adolescents.
All adolescents, including those with a disability or chronic medical condition, experience psychosocial and physiological changes during adolescence and have the need to be regarded as sexual beings. Chronic illness affects about 10% of children and adolescents by the age of 18. Youth with disabilities experience the same psychosocial development as do their healthy peers. Adolescents with chronic illness have sexual interests that also parallel those of their healthy peers. A study from 1996 showed no differences between adolescents with and without disability in those ever having intercourse, age of sexual debut, or pregnancy. Sexual behaviors in boys and girls with visible compared with nonvisible medical conditions showed no differences in sexual behavior. This implies that physical disability does not interfere with sexuality and the social needs of the adolescent. (excerpt)
In 2000, there were about 1.15 billion adolescents, comprising about 20% of the world's population. The proportion of adolescents in the population varies little from region to region in the developing world, from about 19% in Asia to 23% in Africa. By 2020, there will be 65 million more adolescents, with Africa and Asia projected to contribute most to this rapidly growing segment of the population. Eighty-seven percent of adolescents live in developing countries where poverty is deep and pervasive. Almost 25% (238 million) subsist on less than $1 a day, and most face the prospects of inadequate education, continued gender inequality, early marriage and childbearing, and the threat of HIV. Diverse factors contribute to this worrying situation. These include a declining age at menarche, an older age at marriage, improved levels of literacy, and a change in cultural values brought about by the effects of globalization, urbanization, and widespread use of communication technologies, high migration rates, and a decline in the prevalence of the extended family. In the 1990s, 294 million adolescents lived in urban centers; in 2025, it is estimated that the number will double to 634 million. (excerpt)
Practical approaches to prescribing contraception in the office setting.
Many adolescents will not seek contraceptive services until well after their first sexual intercourse. Most adolescents do not seek contraceptive services until they have been sexually active for 6 months, yet 50% of adolescents will conceive within these first 6 months of unprotected intercourse. In other words, many sexually active adolescents will be not seek care until it is too late. Initial access to care becomes crucial for preventing unintended adolescent pregnancy. Early (12--14 years) and often middle (15--17 years) adolescents, are concrete thinkers; their inability to think abstractly limits their ability to make decisions and choices for future benefit. The use of all types of contraceptives requires some advance planning. This may become a barrier in delivering care to early and middle adolescents. To plan in advance requires acknowledging that sexual activity may occur in the near future. Many adolescents describe being swept away and not having planned intercourse. (excerpt)
The business of HIV / AIDS [editorial]
For the first time in its 183 year history, this week's issue of The Lancet is black and white and (RED) all over. The journal also contains, rather unusually, advertisements for a Motorola mobile phone, an American Express card, and clothing by GAP. This is because The Lancet has joined (PRODUCT) RED, which was launched at the World Economic Forum earlier this year to provide additional money for the Global Fund to Fight AIDS, Tuberculosis and Malaria. This issue, devoted entirely to the predicament of HIV/ AIDS, coincides with the International AIDS Society meeting that will be held in Toronto, Aug 13--18; some of the papers included in the pages that follow will be presented at the conference. (excerpt)
Betting on HIV prevention [editorial]
Deciding how to give away US$3 billion a year effectively cannot be easy, but that is the task facing the Bill and Melinda Gates Foundation now that Warren Buffett, the world's second richest man, has pledged to give the charity $37 billion of his fortune. The Gates Foundation has to give away 5% of its assets each year to keep its tax status as a charity, and some insiders say that it is already struggling to find suitable projects to fund. Philanthropists in the past have found it easy to waste their hard-earned cash. Is there a risk that the Gates Foundation might do the same? On July 20, the Foundation announced that it had awarded 16 grants, totalling $287 million over 5 years, to fund the development of an HIV vaccine. So far, the Foundation has invested $528 million and the US National Institutes of Health has spent $3.4 billion to try to develop a vaccine. (excerpt)
AIDS anniversaries in 2006 mark the time to deliver.
The XVI International AIDS Conference (AIDS 2006), to be held on Aug 13--18 in Toronto, Canada, will mark two important moments in the history of the epidemic. 25 years ago the first reports of a disturbing new illness that defied medical classification began circulating in the Center for Disease Control's Morbidity and Mortality Weekly Report. Little could have prepared the medical community--or the world--for the human catastrophe that followed. Yet, AIDS 2006 will mark another important anniversary: the stunning breakthroughs in clinical re search that led to highly active antiretroviral therapy (HAART), which were first reported 10 years ago at the XI International AIDS Conference in Vancouver, the last time the conference was held in Canada. HAART revolutionised HIV treatment and, amidst the unbridled optimism coming out of that conference, held the tantalising promise not only of effective treatment but also of hopes for a cure. (excerpt)