Volume 8, Number 12
24 March 2008

World Tuberculosis Day, held annually on 24 March, is intended to raise public awareness that tuberculosis remains an epidemic in many areas of world, made worse by co-infection with HIV. World TB Day commemorates the date in 1882 when Dr Robert Koch presented his discovery of the TB bacillus to a group of doctors in Berlin. In recognition of World TB Day, today's issue of The Pop Reporter includes resources and news about the state of tuberculosis eradication, including a recent report by the World Health Organization. To add your own comments about World TB Day, visit INFOforhealth.org's blog at: http://www.infoforhealth.org/blog/.

ADOLESCENT HEALTH NEWS

Iraqi refugee women and girls in Jordan: Desperate and alone
(Press Release; Middle East)
18 Mar 2008
Women's Commission for Refugee Women and Children, ReliefWeb

ADOLESCENT HEALTH RESEARCH

Appropriate use of cervical cancer vaccine
(Abstract; subscription needed for full text; North America)
Annual Review of Medicine. 2008 Feb;59:223-236.
Zimet GD | Shew ML | Kahn JA
Human papillomavirus (HPV) is a necessary, though not sufficient, cause of cervical cancer. Two vaccines have been developed that prevent two HPV types associated with 70% of cervical cancers. One of the vaccines (a quadrivalent vaccine) also prevents two HPV types associated with 90% of genital warts. Both HPV vaccines have shown very good efficacy and safety. This review summarizes the guidelines for use of the quadrivalent vaccine published by the Advisory Committee on Immunization Practices, presents data on vaccine efficacy and safety, and gives an overview of the findings of cost-effectiveness studies. In addition, we summarize the research on the attitudes of parents and health care providers toward HPV vaccine and critically evaluate controversial and challenging issues surrounding HPV vaccination, including concerns about sexual disinhibition and potential obstacles to vaccine distribution and uptake.

Longitudinal study of depot medroxyprogesterone acetate (Depo-Provera) effects on bone health in adolescents: Study design, population characteristics and baseline bone mineral density
(Abstract; subscription needed for full text; Global)
Contraception. 2008 Apr;77(4):239-248.
Johnson CC | Burkman RT | Gold MA | Brown RT | Harel Z
This analysis was conducted to assess the baseline data and design methodology within an observational longitudinal comparison of use vs. nonuse of the injectable (intramuscular) contraceptive depot medroxyprogesterone acetate (DMPA-IM) and its effect on bone mass in adolescent women. A prospective, observational, open-label, unmatched-cohort, safety study in females aged 11-18 years. Participants either self-selected DMPA-IM (Depo-Provera) 150 mg to be administered every 12 weeks for up to 240 weeks with a 120-week post-treatment follow-up or were nonusers (users of nonhormonal contraception or sexually abstinent) who were to be followed up for up to 360 weeks. As each participant entered the study, bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine, hip and femoral neck regions, along with total body bone mineral content; serum and urine specimens were obtained for assay of bone metabolism markers and participants' histories of parity and tobacco and alcohol use were obtained. A total of 389 participants were enrolled: 169 elected to begin DMPA-IM; 26 chose nonhormonal methods and 194 were abstinent. The baseline characteristics indicated significant disparities between DMPA-IM users and nonusers: compared with the nonusers, DMPA-IM users had more advanced chronologic and gynecologic ages, were more likely to have smoked, been pregnant and included more blacks. These factors would likely influence bone accretion rates independent of DMPA-IM exposure. Comparison of participant BMDs with standard reference data revealed that the study cohorts did not match reference populations closely enough to make a direct between-cohort comparative analysis feasible. The baseline differences in cohort characteristics preclude a meaningful comparison of mean BMD changes over time between DMPA-IM users and nonusers cohorts, and comparisons of changes in Z-scores between cohorts were also not appropriate. Therefore, within-participant BMD decreases from baseline were established as safety thresholds, and the proportion of individuals crossing those thresholds on a persistent or progressive basis was identified as the revised primary end point.

Childhood abuse as a risk factor for adolescent pregnancy in El Salvador
(Abstract; subscription needed for full text; Central America and the Caribbean)
Journal of Adolescent Health. 2008 Mar;
Pallitto CC | Murillo V
The purpose was to determine whether having been abused as a child increases the risk of adolescent pregnancy in El Salvador and whether intimate partner violence during adolescence affects the association. Using data from 3753 women between the ages of 15 and 24 from a nationally representative household health survey of Salvadoran women (FESAL 2002/2003), the association between history of childhood abuse (emotional, physical, or sexual abuse, and witnessing abuse of one's mother) and adolescent pregnancy was explored using multiple logistic regression analyses. The effect of intimate partner violence during adolescence on the relationship was explored among a subgroup of 15-19-year-olds. The risk of adolescent pregnancy was significantly higher among women abused as children. Women who were sexually abused, physically abused, or who experienced any type of abuse had a 48%, 42%, and 31% higher risk, respectively, of adolescent pregnancy than those without a history of abuse, after adjusting for confounding factors. Intimate partner violence during adolescence was also strongly and significantly linked with adolescent pregnancy risk. This is the first study from a Latin American country to demonstrate a relationship between childhood abuse and adolescent pregnancy. Greater efforts are needed to promote detection of abuse, expand knowledge about sexual and reproductive health, protect vulnerable youth, and to advocate for greater rights and social protections to Salvadoran children and adolescents.

FAMILY PLANNING NEWS

India offers firearms permits for vasectomies
(News Article; Asia)
21 Mar 2008
Blakely R, The Times

Uganda: MPs demand more funding for reproductive health
(News Article; Sub-Saharan Africa)
The Monitor (Kampala). 14 Mar 2008
Nandutu A

FAMILY PLANNING RESEARCH

Provision of injectable contraception services through community-based distribution: Implementation handbook
(Programming Guide; Global)
Research Triangle Park, NC, Family Health International, 2008.
Weil B | Krueger K | Stanback J | Hatzell Hoke T
Produced in collaboration with Save the Children USA, this step-by-step guide explains how to introduce injectable contraceptives — such as Depo Provera (or DMPA) — into an existing community-based distribution (CBD) program. According to the World Health Organization, 36 of 46 African countries currently face critical shortages of doctors, nurses, and midwives. This deficit comes at a time when there is a growing demand for family planning services throughout Sub-Saharan Africa. This is especially true in rural areas, where modern contraceptive methods are scarce, and few trained personnel can provide these services. Providing injectable contraception to women through community-based distribution (CBD) programs is one way to meet this demand. Based on the experience of two recent pilot projects in Uganda and Madagascar, the Implementation Handbook introduces a nine-step process and provides some helpful tools for the CBD of injectables. Program managers, policy-makers, and others interested in providing greater access to family planning will appreciate the guidance offered by this handbook.

The effects of Implanon on menstrual bleeding patterns
(Abstract; subscription needed for full text; Global)
European Journal of Contraception and Reproductive Health Care. 2008 Jun;13 Suppl 1:13-28.
Mansour D | Korver T | Marintcheva-Petrova M | Fraser IS
The objectives were to evaluate an integrated analysis of bleeding patterns associated with use of the subdermal contraceptive implant Implanon (etonogestrel, Organon, part of Schering-Plough) and to provide physician guidance to optimize patient counselling. Data from 11 clinical trials were reviewed (N = 923). Assessments included bleeding-spotting records, dysmenorrhoea, and patient-perceived reasons for discontinuation. Bleeding patterns were analysed via reference period (RP) analyses. Implanon use was associated with the following bleeding irregularities: amenorrhoea (22.2%) and infrequent (33.6%), frequent (6.7%), and/or prolonged bleeding (17.7%). In 75% of RPs, bleeding-spotting days were fewer than or comparable to those observed during the natural cycle, but they occurred at unpredictable intervals. The bleeding pattern experienced during the initial phase predicted future patterns for the majority of women. The group of women with favourable bleeding patterns during the first three months tended to continue with this pattern throughout the first two years of use, whereas the group with unfavourable initial patterns had at least a 50% chance that the pattern would improve. Only 11.3% of patients discontinued owing to bleeding irregularities, mainly because of prolonged flow and frequent irregular bleeding. Most women (77%) who had baseline dysmenorrhoea experienced complete resolution of symptoms. Implanon use is associated with an unpredictable bleeding pattern, which includes amenorrhoea and infrequent, frequent, and/or prolonged bleeding. The bleeding pattern experienced during the first three months is broadly predictive of future bleeding patterns for many women. Effective preinsertion counselling on the possible changes in bleeding patterns may improve continuation rates.

Tolerability and clinical safety of Implanon
(Abstract; subscription needed for full text; Global)
European Journal of Contraception and Reproductive Health Care. 2008 Jun;13 Suppl 1:29-36.
Blumenthal PD | Gemzell-Danielsson K | Marintcheva-Petrova M
The objectives were to evaluate the tolerability and clinical safety of the subdermal, long-acting hormonal contraceptive Implanon. This integrated safety analysis included 11 international studies concerning Implanon (68 mg etonogestrel) of which 10 had a duration of at least two years. Assessments included reports of adverse events (AEs), reasons and rates of discontinuation, insertion/removal complications, and the condition of the implant site. Metabolic and coagulation parameters are briefly discussed to fully describe the clinical safety profile. In total 942 women were exposed to Implanon for 24,679 cycles over the course of one to five years. The overall discontinuation rate was 32.7%; the most frequently reported reasons for discontinuation were adverse events (13.9%), bleeding irregularities (10.4%), and planning pregnancy (4.1%). The most commonly reported drug-related AE was headache (15.3%); however, headache was reported in only 1.6% of women as a reason for discontinuation. Insertion and removal times for Implanon were short with few complications, none of which were major. From earlier studies it is known that treatment with Implanon has little effect on metabolic and coagulation parameters. Implanon is a well-tolerated and safe method of long-acting hormonal contraception for women.

New perspectives in non-hormonal male contraception
(Abstract; subscription needed for full text; Global)
Trends in Endocrinology and Metabolism. 2008 Mar;19(2):57-64.
Mruk DD
As the world's population continues to soar, contraception has become increasingly important. Recently, men have expressed willingness to share the burden of family planning. Thus, safe, effective and reversible male contraceptives would satisfy an urgent need among couples. Currently, there are several promising non-hormonal contraceptives at various stages of research and development. In addition, major advances in genomic and proteomic research have been instrumental in identifying and characterizing genes and proteins expressed uniquely in the testis or other male reproductive organs, which might become 'druggable' targets for non-hormonal male contraceptive development in the future. Through committed research, advocacy and support, male contraceptives are likely to become a valuable addition to the current choices of family planning.

Effects of the progestagen-only contraceptive implant Implanon on cardiovascular risk factors
(Abstract; subscription needed for full text; Europe)
Clinical Endocrinology. 2008 Mar;68(3):355-360.
Merki-Feld GS | Imthurn B | Seifert B
Epidemiological studies on the cardiovascular risk of progestagen-only contraceptives are rare. With the present study we aimed to investigate the effect of the low-dose etonogestrel-releasing contraceptive implant Implanon on cardiovascular risk factors, including markers of inflammation. The design was a longitudinal study. The setting was a family planning centre of a University Hospital. The subjects were thirty-six healthy, nonsmoking women with regular cycles (n = 18 controls without hormonal contraception; n = 18 cases requesting the insertion of Implanon). Blood samples for the determination of C-reactive protein (CRP), nitric oxide (NO), sex hormones and plasma lipids were taken in the early follicular phase of the cycle in both groups. A second sample was taken 12 weeks after Implanon insertion or in the controls during the early follicular phase of cycle 4. Implanon treatment caused a 36% decrease in CRP (P less than 0.06) and a significant decrease in high density lipoprotein (HDL) (P less than 0.007), low density lipoprotein (LDL) (P less than 0.001), cholesterol (P less than 0.001), testosterone (P less than 0.05) and SHBG (P less than 0.002). Levels of NO, oestradiol and progesterone were not affected in either group. The cholesterol/HDL ratio did not change in Implanon carriers. There was a significant correlation between the cardiovascular risk factors CRP, cholesterol/HDL ratio and NO. The progestagen-only implant Implanon does not exert a negative effect on the cardiovascular risk factors CRP, cholesterol/HDL ratio and NO. These results suggest that the use of a progestagen-only contraception does not increase cardiovascular risk factors in healthy young women.

Fertility choices and management for HIV-positive women
(Abstract; subscription needed for full text; Global)
Current Opinion in HIV and AIDS. 2008 Mar;3(2):186-192.
Coll O | Lopez M | Hernandez S
It is becoming increasingly important to address the issue of reproductive counseling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review. Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method. Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

Contraceptive trends in developing countries
(Technical Report; Global | Global)
Calverton, Maryland, Macro International, MEASURE DHS, 2007 Dec. [80] p. (Array)
Khan S | Mishra V | Arnold F | Abderrahim N
This study examines trends and differentials in key family planning indicators in 35 developing countries. The data are for countries with a Demographic and Health Survey (DHS) conducted between 2000 and 2005. Trends are provided for countries with at least one previous DHS survey. The study investigates how knowledge of contraception and use of contraception have changed; whether public-private, urban-rural, and other differentials in contraceptive use have narrowed, and whether women are making informed decisions about the use of contraception. It also examines discontinuation and switching rates, and decision-making about family planning. Results indicate that knowledge of contraception is almost universal in most countries, yet knowledge of multiple methods of contraception, despite increases over time, remains considerably lower, particularly in sub-Saharan Africa. The most commonly used modern methods are the pill, injectables, and the male condom. Current contraceptive use has increased steadily in most countries, but levels remain lower in sub-Saharan Africa, and particularly among rural and less-educated women. While modern methods account for the large majority of contraceptive use, and a growing share of all use, considerable proportions of women in several countries continue to rely on traditional methods. Unmet need has declined in many countries, but remains substantial in sub-Saharan Africa.

GENDER and HEALTH NEWS

Congo-Kinshasa: National campaign against sexual violence launched
(News Article; Sub-Saharan Africa)
19 Mar 2008
Lukoki A, United Nations Mission in the Democratic Republic of Congo (Kinshasa)

Liberia: Rape highest reported crime in country
(News Article; Sub-Saharan Africa)
18 Mar 2008
The NEWS (Monrovia)

Botswana: Shelter focuses on gender based violence
(News Article; Sub-Saharan Africa)
18 Mar 2008
Chwaane T, Mmegi/The Reporter (Gaborone)

GENDER and HEALTH RESEARCH

From PMTCT to a more comprehensive AIDS response for women: A much-needed shift
(Abstract; subscription needed for full text; Global)
Developing World Bioethics. 2008 Apr;8(1):33-42.
Eyakuze C | Jones DA | Starrs AM | Sorkin N
Half of the 33.2 million people living with HIV today are women. Yet, responses to the epidemic are not adequately meeting the needs of women. This article critically evaluates how prevention of mother-to-child transmission (PMTCT) programs, the principal framework under which women's health is currently addressed in the global response to AIDS, have tended to focus on the prevention of HIV transmission from HIV-positive women to their infants. This paper concludes that more than ten years after their inception, PMTCT programs still do not successfully ensure the adequate treatment, care and support of HIV-infected women. Of particular concern is the continued widespread use of single-dose nevirapine despite World Health Organization recommendations to employ more effective combination therapies that do not potentially jeopardize women's future treatment outcomes. In response, the article calls for a more comprehensive approach that places women's health needs at the centre of AIDS responses. This is critical in settings where the pandemic is generalized and there is a push to greatly expand PMTCT programs, as a more effective and equitable way of meeting the needs of women in the context of HIV. Without such a comprehensive approach, women will continue to be impacted disproportionately by the pandemic, and current strategies for prevention, including PMTCT, and treatment will not be as effective and responsive as they need to be.

Human papillomavirus type-distribution in the cervix of Chinese women: A meta-analysis
(Abstract; subscription needed for full text; Asia)
International Journal of STD and AIDS. 2008 Feb;19(2):106-111.
Bao YP | Li N | Smith JS | Qiao YL
The aim of the study was to determine human papillomavirus (HPV) type-distribution in the cervix of Chinese women, and to estimate the potential future impact of HPV prophylactic vaccines for cervical cancer prevention in China. A total of 32 studies using polymerase chain reaction for HPV detection were included in the meta-analysis, including 2844 invasive cervical cancer (ICC), 820 high-grade squamous intraepithelial lesions (HSIL), 432 low-grade squamous intraepithelial lesions (LSIL) and 2902 women with normal cytology/histology. The overall and type-specific HPV prevalence of 18 HPV types (HPV 6, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 70, 73 and 82 of different cervical stages) were estimated. Overall HPV prevalence was 83.7%, 66.2%, 61.3% and 11.2% in ICC, HSIL, LSIL and normal, respectively. HPV 16 was the predominant type in all cervical stages. Estimated HPV 16/18-positive fractions in ICC, HSIL, LSIL and normal were 69.7%, 45.5%, 32.23% and 4.6%, respectively. HPV-16/18 vaccine has the 69.7% potential prevention in ICC. HPV 58 and 52 were the priority HPV types in Chinese women.

Differences in characteristics among 1,000 women with endometriosis based on extent of disease
(Abstract; subscription needed for full text; Europe)
Fertility and Sterility. 2008 Mar;89(3):538-545.
Sinaii N | Plumb K | Cotton L | Lambert A | Kennedy S
The objective was to determine the relationship between disease severity and patient characteristics in endometriosis. The design used was a cross-sectional study of self-reported survey data. The setting used was an academic research setting. The patient(s) used were one thousand women in the Oxford Endometriosis Gene (OXEGENE) study. Participants were assigned to one of two groups with predominantly revised AFS stage I-II (group I, n = 423) or III-IV disease (group II, n = 517). Their characteristics were compared by disease extent. Most participants were white (96%) and of reproductive age (81%). Women in group I were significantly younger on entering the study (39.9 plus or minus 0.5 vs. 44.5 plus or minus 0.4 years). Overall time to diagnosis did not differ between groups. The most common symptoms leading to a diagnosis were dysmenorrhea (79%) and pelvic pain (69%). In group II, subfertility (21.5% vs. 30.0%) and an ovarian mass (7.3% vs. 29.4%) more commonly led to a diagnosis, whereas dyspareunia (51.1% vs. 39.5%) was significantly more common in group I. Subfertility (41.5% vs. 53.4%) remained more common in group II throughout reproductive life, although birth and miscarriage rates were similar. Pelvic pain is common to all with endometriosis and those with more extensive disease report higher rates of subfertility. Remarkably, the time to diagnosis was similar among women.

The psychosocial profile of Bedouin Arab women living in polygamous and monogamous marriages
(Abstract; subscription needed for full text; Middle East)
Families in Society. 2008 Jan-Mar;89(1):139-149.
Al-Krenawi A | Slonim-Nevo V
This study examining the psychosocial profile of Bedouin Arab Women living in polygamous and monogamous marriages found that women in polygamous marriages reported lower levels of self-esteem and higher levels of somatization, depression, anxiety, hostility, paranoid ideation, more problematic family functioning, less marital satisfaction, and more problematic mother-child relationships than women in monogamous marriages. The sample consisted of 315 women, 156 from polygamous and 159 from monogamous families. The respondents completed the Self-Esteem scale (SE), The Brief Symptom Inventory (BSI), The McMaster Family Assessment Device (FAD), The Enrich questionnaire and the Index of Parental Attitudes. The polygamous family structure and the economic difficulties widespread, apparently constitutes a substantial contribution to the polygamous household's impaired family functioning.

HIV/AIDS and STIs NEWS

Rwanda: Private sector to intensify fight against HIV/Aids
(News Article; Sub-Saharan Africa)
17 Mar 2008
Focus Media (Kigali)

China: Students take up AIDS challenge
(News Article; Asia)
18 Mar 2008
Xu B, China Daily

Nigeria: World Tuberculosis Day - Containing ravages of a pandemic
(News Article; Sub-Saharan Africa)
This Day (Lagos)

HIV/TB features in World TB Day events
(Feature Article; Sub-Saharan Africa)
30 Mar 2008
UNAIDS

Rwanda: Tuberculosis infections up 20 percent
(News Article; Sub-Saharan Africa)
Rwanda News Agency/Agence Rwandaise d'Information (Kigali)
Related Report: WHO Report 2008: Global tuberculosis control - surveillance, planning, financing

HIV/AIDS and STIs RESEARCH

Effect of herpes simplex suppression on incidence of HIV among women in Tanzania
(Abstract; subscription needed for full text; Sub-Saharan Africa)
New England Journal of Medicine. 2008 Mar 12;:1-12.
Watson-Jones D | Weiss HA | Rusizoka M | Changalucha J | Baisley K
Infection with herpes simplex virus type 2 (HSV-2) is associated with an increased risk of acquiring infection with the human immunodeficiency virus (HIV). This study tested the hypothesis that HSV-2 suppressive therapy reduces the risk of HIV acquisition. Female workers at recreational facilities in northwestern Tanzania who were 16 to 35 years of age were interviewed and underwent serologic testing for HIV and HSV-2. We enrolled female workers who were HIV-seronegative and HSV-2-seropositive in a randomized, double-blind, placebo-controlled trial of suppressive treatment with acyclovir (400 mg twice daily). Participants attended mobile clinics every 3 months for a follow-up period of 12 to 30 months, depending on enrollment date. The primary outcome was the incidence of infection with HIV. We used a modified intention-to-treat analysis; data for participants who became pregnant were censored. Adherence to treatment was estimated by a tablet count at each visit. A total of 821 participants were randomly assigned to receive acyclovir (400 participants) or placebo (421 participants); 659 (80%) completed follow-up. Mean follow-up for the acyclovir and placebo groups was 1.52 and 1.62 years, respectively. The incidence of HIV infection was 4.27 per 100 person-years (27 participants in the acyclovir group and 28 in the placebo group), and there was no overall effect of acyclovir on the incidence of HIV (rate ratio for the acyclovir group, 1.08; 95% confidence interval, 0.64 to 1.83). The estimated median adherence was 90%. Genital HSV was detected in a similar proportion of participants in the two study groups at 6, 12, and 24 months. No serious adverse events were attributable to treatment with acyclovir. These data show no evidence that acyclovir (400 mg twice daily) as HSV suppressive therapy decreases the incidence of infection with HIV.

Syndromic approach to sexually transmitted infections in Tunisian women: Bacteriological validation
(Abstract; subscription needed for full text; North Africa)
International Journal of STD and AIDS. 2008 Feb;19(2):112-114.
Zribi M | Mansour KB | Abid F | Masmoudi A | Fendri C
The World Health Organization emphasizes an integrated primary care approach using syndromic management of sexually transmitted infections. The objective of our study was to evaluate the quality of care of the syndromic management of sexually transmitted disease in women in Rabta hospital in Tunisia. Algorithms have been developed for: cervicitis due to Neisseria gonorrhoeae or Chlamydia (algorithm 3a), vaginitis due to Trichomonas vaginalis or Chlamydia trachomatis (algorithm 3b) and vaginitis due to Candida (algorithm 3c). A total of 116 women were enrolled in the study during February 2003 to April 2004. The prevalence of each bacterium was Chlamydia (10%), N. gonorrhoeae (1%), Treponema pallidum (1%), T. vaginalis (5%) and Candida (21%). Algorithm '3a' had a sensitivity of 45%, a specificity of 42% and positive predictive value (PPV) of 11.9%. Algorithm '3b' had a sensitivity of 35.7%, a specificity of 68.9% and PPV of 20.8%. Algorithm '3c' had a sensitivity of 12%, a specificity of 88% and PPV of 33.3%. To improve the sensitivity of the syndromic approach, we suggest improving the quality of history taking.

Sexual behavior and reproductive health among HIV-infected patients in urban and rural South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Apr;47(4):484-493.
Lurie M | Pronyk P | de Moor E | Heyer A | de Bruyn G
With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission. We surveyed 3819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic. Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; x/2 odds ratio [OR] = 3.531; P less than 0.001), to have any current sexual partners (75.3% vs. 51.2%; x/2 OR = 2.908; P less than 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; x/2 OR = 3.886; P less than 0.001) and with casual partners (68.6% vs. 48.3%; x/2 OR = 2.337; P less than 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm3 as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner. HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.

The impact of monitoring HIV patients prior to treatment in resource-poor settings: Insights from mathematical modelling
(Research Article; Sub-Saharan Africa)
PLoS Medicine. 2008 Mar;5(3):e53.
Hallett TB | Gregson S | Dube S | Garnett GP
The roll-out of antiretroviral treatment (ART) in developing countries concentrates on finding patients currently in need, but over time many HIV-infected individuals will be identified who will require treatment in the future. We investigated the potential influence of alternative patient management and ART initiation strategies on the impact of ART programmes in sub-Saharan Africa. We developed a stochastic mathematical model representing disease progression, diagnosis, clinical monitoring, and survival in a cohort of 1,000 hypothetical HIV-infected individuals in Africa. If individuals primarily enter ART programmes when symptomatic, the model predicts that only 25% will start treatment and, on average, 6 life-years will be saved per person treated. If individuals are recruited to programmes while still healthy and are frequently monitored, and CD4+ cell counts are used to help decide when to initiate ART, three times as many are expected to be treated, and average life-years saved among those treated increases to 15. The impact of programmes can be improved further by performing a second CD4+ cell count when the initial value is close to the threshold for starting treatment, maintaining high patient follow-up rates, and prioritising monitoring the oldest (greater than or equal to 35 y) and most immune-suppressed patients (CD4+ cell count less than or equal to 350). Initiating ART at higher CD4+ cell counts than WHO recommends leads to more life-years saved, but disproportionately more years spent on ART. The overall impact of ART programmes will be limited if rates of diagnosis are low and individuals enter care too late. Frequently monitoring individuals at all stages of HIV infection and using CD4 cell count information to determine when to start treatment can maximise the impact of ART.

Agriculture in the time of HIV/AID: A report on the situation in sub-Saharan Africa prepared for NORAD
(Report; Sub-Saharan Africa)
Norweigian University of Life Sciences, Noragric, Department of International Environmental and Development Studies, Feb 2008. (42)
Bie SW
In November 2005 Norad asked Noragric to prepare a review on the current views on the relationships between agriculture, HIV infections and AIDS-related diseases in sub-Saharan Africa, on the basis of a limited desk study of relevant literature. Often considered unrelated, this report, drawing on review papers and original research mostly published during the last 2-3 years, suggests that agriculture both is severely affected by HIV and AIDS and that the state of agriculture significantly influences the spread of HIV. The report concludes that central to any interventions is a strong appreciation of gender issues. It is essential to strengthen the roles and position of girls and women in society, to give them freedom to choose, and to gain respect from men, families and societies for their stance. This cannot be done solely by declaring good intentions; it involves fundamental transformations in impoverished rural societies.

MATERNAL AND CHILD HEALTH NEWS

Uganda: 'Weak health systems affect child birth'
(News Article; Sub-Saharan Africa)
17 Mar 2008
Lirri E, The Monitor (Kampala)

India: Tracking maternal mortality the low-cost way
(News Article; Asia)
20 Mar 2008
Bagchi S, One World South Asia

South Africa: Experts defy minister over death figures
(News Article; Sub-Saharan Africa)
12 Mar 2008
Kahn T, Business Day

MATERNAL AND CHILD HEALTH RESEARCH

Obstetric near miss and deaths in public and private hospitals in Indonesia
(Abstract; subscription needed for full text; Asia)
BMC Pregnancy and Childbirth. 2008 Mar 12;8:10.
Adisasmita A | Deviany PE | Nandiaty F | Stanton C | Ronsmans C
Falling numbers of maternal deaths have stimulated an interest in investigating cases of life threatening obstetric morbidity or near miss. The purpose of this study was to document the frequency and causes of near miss and maternal deaths in four hospitals in West Java, Indonesia. Cross sectional study in four hospitals in two districts in Banten province, Indonesia. The authors reviewed registers and case notes to identify the numbers and causes of near miss and death between November 2003 and October 2004. Near miss cases were defined based on organ dysfunction, clinical and management criteria. Near miss were categorized by whether or not the woman was at a critical state at admission by reviewing the final signs at admission. The prevalence of near miss was much greater in public than in private hospitals (17.3% versus 4.2%, p=0.000). Hemorrhage and hypertensive diseases were the most common diagnoses associated with near miss, and vascular dysfunction was the most common criterion of organ dysfunction. The occurrence of maternal deaths was 1.6%, with non-obstetric complications as the leading cause. The majority (70.7%) of near miss in public hospitals were in a critical state at admission but this proportion was much lower in private hospitals (31.9%). This is the first study to document near miss in public and private hospitals in Indonesia. Close to a fifth of admissions in public hospitals were associated with near miss; and the critical state in which the women arrived suggest important delays in reaching the hospitals. Even though the private sector takes an increasingly larger share of facility-based births in Indonesia, managing obstetric emergencies remains the domain of the public sector.

Maternal HIV status and pregnancy outcomes in northeastern Tanzania: A registry-based study
(Abstract; subscription needed for full text; Sub-Saharan Africa)
BJOG: An International Journal of Obstetrics and Gynaecology. 2008 Apr 1;115(5):616-624.
Habib NA | Daltveit AK | Bergsjo P | Shao J | Oneko O | Lie RT
The proportion of women delivering with known HIV status in sub-Saharan Africa is not well described. Risk of HIV transmission to newborns is a major concern, but there may also be increased risks for other adverse pregnancy outcomes. The design used was a hospital registry. The setting was North East Tanzania (1999-2006). The population used was singletons (n = 14 444). Births were grouped by maternal HIV status and sociodemographic factors predicting HIV status, and associations between status and pregnancy outcomes were studied. The main outcome measures were maternal HIV status, perinatal mortality, prematurity, small for gestational age (SGA), birthweight and low Apgar score. The proportion of mothers with known HIV status increased from 7% before 2001 to 78% after 2004. Single motherhood, rural residence, low maternal education, maternal and paternal farming and higher paternal age were associated with unknown HIV status. About 7.4% (95% CI 6.7-8.1%) of women were HIV infected, with increased likelihood of infection with higher gravidity, single motherhood, rural residence, maternal business or farming occupations and paternal tribe. Compared with HIV-uninfected women, the untreated HIV-infected women had a higher risk of SGA births (adjusted risk ratio [ARR] 1.6; 95% CI 1.1-2.4), preterm birth (ARR 1.8; 95% CI 1.1-2.7) and perinatal death (ARR 1.9; 95% CI 0.95-3.8). Women with unknown HIV status had moderately increased risks. Treated HIV-infected women had a risk similar to that of the HIV-uninfected women for all outcomes, except for low Apgar score. HIV testing and infection were associated with socio-demographic factors. Untreated HIV-infected women had higher risks of adverse pregnancy outcomes, and risks were also increased for women with unknown HIV status. There is still a need to increase availability of HIV testing, education and adequate therapy for pregnant women.

Factors associated with acute postpartum hemorrhage in low-risk women delivering in rural India
(Abstract; subscription needed for full text; Asia)
International Journal of Gynecology and Obstetrics. 2008 Apr 1;101(1):94-99.
Geller SE | Goudar SS | Adams MG | Naik VA | Patel A | Bellad M | Patted S | Edlavitch S | Moss N | Kodkany B | Derman R
Related Fact Sheet: Preventing Postpartum Hemorrhage
Postpartum hemorrhage (PPH), a major cause of maternal mortality and morbidity in low-income countries, can occur unpredictably. This study examined the sociodemographic, clinical, and perinatal characteristics of low-risk women who experienced PPH. This analysis was conducted using data on 1620 women from a randomized trial testing oral misoprostol for prevention of PPH in rural India. Of the women, 9.2% experienced PPH. No maternal or sociodemographic factors and few perinatal factors differed between women with PPH and those without, other than treatment with misoprostol. Having fewer than 4 prenatal visits and lack of iron supplementation increased the risk for PPH (P less than 0.001 and P=0.037, respectively). Several factors unknown until the second stage of labor (perineal tear and birth weight) were also associated (P=0.003). Among women at low risk for PPH, there were few factors associated with further risk. Given that PPH can occur without warning, rural communities should consider ways to increase both primary prevention (iron supplementation, AMTSL) and secondary prevention of PPH (availability of obstetric first aid, availability of transport, and availability of emergency obstetric care).

Association of HIV and malaria with mother-to-child transmission, birth outcomes, and child mortality
(Abstract; subscription needed for full text; Sub-Saharan Africa)
JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Apr 1;47(1):472-476.
Brahmbhatt H | Sullivan D | Kigozi G | Askin F | Wabwire-Mangenm F | Serwadda D | Sewankambo N | Wawer M | Gray R
The objective was to assess the impact of HIV and malaria coinfection on mother-to-child HIV transmission (MTCT) and adverse birth outcomes. One hundred nine HIV-positive mother-infant pairs with a malaria diagnosis were identified in a community cohort and followed up postpartum. Maternal malaria was diagnosed by a rapid immunochromatographic test (ICT) on sera and histopathologic examination of placenta. Infant HIV was diagnosed within 6 weeks of birth using polymerase chain reaction (PCR) to capture in-utero and intrapartum HIV transmission. Log binomial models were used to assess the relative risk of MTCT, low birth weight, and preterm birth associated with malaria. Approximately 17.4% of infants were HIV positive at or around birth, and the prevalence of serologic and placental malaria were 31% and 32%, respectively. HIV-positive mothers with serological ICT malaria were significantly more likely to have low-birthweight infants, and low-birth-weight infants had significantly higher risk of MTCT compared with infants of normal birth weight. Although placental and serologic ICT malaria were significantly associated with MTCT, after adjusting for maternal HIV viral load, the risk of MTCT was significantly increased only for mothers coinfected with placental malaria (relative risk [RR] = 7.9, P = 0.025). Placental malaria increases the risk of MTCT after adjustment for viral load. Programs should focus on enhanced malaria prevention during pregnancy to decrease the risk of adverse birth outcomes and MTCT.

Reproductive health issues in rural western Kenya
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Reproductive Health. 2008 Mar 18;5(1):1-15.
van Eijk AM | Lindblade KA | Odhiambo F | Peterson E | Sikuku E | Ayisi JG | Ouma P | Rosen DH | Slutsker L
The authors describe reproductive health issues among pregnant women in a rural area of Kenya with a high coverage of insecticide treated nets (ITNs) and high prevalence of HIV (15%). The authors conducted a community-based cross-sectional survey among rural pregnant women in western Kenya. A medical, obstetric and reproductive history was obtained. Blood was obtained for a malaria smear and haemoglobin level, and stool was examined for geohelminths. Height and weight were measured. Of 673 participants, 87% were multigravidae and 50% were in their third trimester; 41% had started antenatal clinic visits at the time of interview and 69% reported ITN-use. Malaria parasitemia and anaemia (haemoglobin less than 11 g/dl) were detected among 36% and 53% of the women, respectively. Geohelminth infections were detected among 76% of the 390 women who gave a stool sample. Twenty percent of women were underweight, and sixteen percent reported symptoms of herpes zoster or oral thrush in the last two months. Nineteen percent of all women reported using a contraceptive method to delay or prevent pregnancy before the current pregnancy (injection 10%, pill 8%, condom 0.4%). Twenty-three percent of multigravidae conceived their current pregnancy within a year of the previous pregnancy. More than half of the multigravidae (55%) had ever lost a live born child and 21% had lost their last singleton live born child at the time of interview. In this rural area with a high HIV prevalence, the reported use of condoms before pregnancy was extremely low. Pregnancy health was not optimal with a high prevalence of malaria, geohelminth infections, anaemia and underweight. Chances of losing a child after birth were high. Multiple interventions are needed to improve reproductive health in this area.

POPULATION/FERTILITY/DEMOGRAPHY NEWS

No estimate of planet population by 2050
(News Article; Global)
19 Mar 2008
Hill J, Canada Free Press

Egyptian president says unrestricted rise of the population affects the quality of life
(News Article; North Africa)
17 Mar 2008
Associated Press

Russia's outdated healthcare mired in corruption
(News Article; Asia)
16 Mar 2008
Los Angeles Times

POPULATION/FERTILITY/DEMOGRAPHY RESEARCH

Managing migration: The global challenge
(Report; Global)
Population Bulletin. 2008 Mar;63(1):1-22.
Martin P | Zurcher G
The number of international migrants is at an all-time high. There were 191 million migrants in 2005, which means that 3 percent of the world's people left their country of birth or citizenship for a year or more. The number of international migrants in industrialized countries more than doubled between 1985 and 2005, from almost 55 million to 120 million. However, most of the world's 6.6 billion people never cross a national border; most live and die near their place of birth. Those who cross national borders usually move to nearby countries, for example, from Mexico to the United States, or from Turkey to Germany. The largest flow of migrants is from less developed to more developed countries. In 2005, 62 million migrants from developing countries moved to more developed countries, but almost as many migrants (61 million) moved from one developing country to another, such as from Indonesia to Malaysia. Large flows of people also move from one industrialized country to another, from Canada to the United States, for example, and much smaller flows move from more developed to less developed countries, such as people from Japan who work in or retire to Thailand. The international community believes that international migration should be voluntary, and has tried to minimize "forced migration," whether motivated by persecution or economic deprivation at home. The United Nation's 1948 Universal Declaration of Human Rights asserts that "everyone has the right to leave any country, including his own, and to return to his country." However, the right to emigrate does not give migrants a right to immigrate, and most migrants are not welcomed unconditionally into the countries to which they move.

Motives for parenthood among couples attending a level 3 infertility clinic in the public health sector in South Africa
(Abstract; subscription needed for full text; Sub-Saharan Africa)
Human Reproduction. 2008;23(2):352-357.
Dyer S | Mokoena N | Maritz J | van der Spuy Z
Most African countries are pronatalistic with high total fertility rates and a low prevalence of voluntary childlessness. At present, limited data exist relating to the reasons why men and women desire children. This study explores parenthood motives among infertile couples from an urban community in South Africa. The parenthood-motivation list, an instrument developed in the Netherlands for the assessment of parenthood motives and strength of desire for a child, was administrated to 50 couples (100 participants) who presented to an infertility clinic in a tertiary referral centre. The instrument discerns six parenthood motives comprising happiness, well-being, identity, parenthood, continuity and social control. The majority of participants endorsed most of the motives. The categories happiness and parenthood were the most frequent motives. Women endorsed more motives simultaneously when compared with men. The categories happiness, well-being and social control correlated positively with strength of desire for a child. Most men and women expressed a strong desire for a child. Men and women desired children for many reasons and with similar intensity. This diversity and intensity of parenthood motives appears to be a reflection of the value of children in our communities and further our understanding of the implications of involuntary childlessness.

SPECIAL REPORTS/PROFILES/RESOURCES

WHO Report 2008: Global tuberculosis control - surveillance, planning, financing
(Report; Global)
Geneva, Switzerland, World Health Organization, 2008. (WHO/HTM/TB/2008.393)
Tuberculosis (TB) is a major cause of illness and death worldwide, especially in Asia and Africa. Globally, 9.2 million new cases and 1.7 million deaths from TB occurred in 2006, of which 0.7 million cases and 0.2 million deaths were in HIV-positive people. Population growth has boosted these numbers compared with those reported by the World Health Organization (WHO) for previous years. More positively, and reinforcing a finding first reported in 2007, the number of new cases per capita appears to have been falling globally since 2003, and in all six WHO regions except the European Region where rates are approximately stable. If this trend is sustained, Millennium Development Goal 6, to have halted and begun to reverse the incidence of TB, will be achieved well before the target date of 2015. Four regions are also on track to halve prevalence and death rates by 2015 compared with 1990 levels, in line with targets set by the Stop TB Partnership. Africa and Europe are not on track to reach these targets, following large increases in the incidence of TB during the 1990s. At current rates of progress these regions will prevent the targets being achieved globally.

Tuberculosis and the media: The importance of communicating messages with partners
(Fact Sheet; Global)
Baltimore, MD, INFO Project, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, 2008.
Fraire M | Walton W
Planning is the key to a successful tuberculosis (TB) communication program or activity.Choose a format for contact with the media that best fits your audience and message. Identify the SOCO (“single overriding communication objective”) that you want your audience to remember.
Identify and train a spokesperson to represent your program to the media.

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Volume 8, Number 1224 March 2008