Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 32, Number 2, June 2006
UPDATE


HIV RISK ELEVATED IN EARLY SYPHILIS INFECTION

Individuals who become infected with syphilis may have a temporarily increased risk of acquiring HIV.1 According to a prospective study conducted between 1993 and 2000 in Pune, India, 172 of 2,324 men and women attending STI clinics who tested negative for HIV and syphilis at baseline tested positive for syphilis during follow-up. The risk of HIV infection was more than four times as high among participants who had contracted syphilis during the previous six months as it was among those who had had no evidence of infection during the study. The risk of HIV infection among participants who had been infected with syphilis for more than six months was no higher than it was among those who were not infected. The authors conclude that syphilis is "an important cofactor contributing to the spread of HIV among high risk individuals in India and should be targeted in the current Government of India strategy to control the spread of HIV."

1. Reynolds SJ et al., High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India, Sexually Transmitted Infections, 2006, 82(2):121–126.

MISPERCEPTIONS LEAD TO FAILED BREAST-FEEDING

Many new mothers cite insufficient breast milk as the reason for not following international recommendations to breastfeed infants exclusively for the first six months and then feed them breast milk with supplementary food until at least age two.1 According to a survey conducted in two Bolivian cities, of women who reported having an infant younger than 18 months whom they had stopped breastfeeding, 16% in Cochabamba and 25% in Santa Cruz named insufficient milk as a reason for doing so. When these women were asked why they believed that they did not have enough milk, the most common answer given was that the infant cried (36% in Cochabamba; 25% in Santa Cruz); women's most common response to perceiving that they had insufficient milk was to give infants other liquids or solid food (48% in Cochabamba; 36% in Santa Cruz). The researchers comment that merely "teaching mothers that 'breast is best'…is not enough." They suggest that public health workers should encourage women who perceive themselves as having insufficient milk "to breast-feed more frequently, as a first response, in order to stimulate the milk supply."

1. McCann MF and Bender DE, Perceived insufficient milk as a barrier to optimal feeding: examples from Bolivia, Journal of Biosocial Science, 2006, 38(3): 341–364.

TIME TO ADJUST ICPD COST ESTIMATES

The estimated annual funding required to implement the 1994 International Conference on Population and Development (ICPD) Programme of Action needs to be substantially increased, according to a research commentary published by the policy advocacy group Population Action International.1 Although the ICPD Programme of Action calls for cost estimates for reproductive health and HIV/AIDS services to be reviewed and updated, and for the addition of funds for related activities as necessary, neither has occurred thus far. The ICPD funding requirement for 2005 was originally projected to be $18.5 billion—of which $11.5 billion would go to family planning, $5.4 billion to safe maternity services, $1.4 billion to STI and HIV services and $0.2 billion to research. Developing countries agreed to provide two-thirds of the funds ($12.4 billion) and donor countries one-third ($6.1 billion). The report, however, estimates that the cost for each of the next few years will be substantially higher—between $35 billion and $45 billion—in part because of increased expenditures for HIV/AIDS prevention, treatment, care and support services. On the basis of this estimate, the amount of developing country spending would increase to $19–24 billion; donor country spending would increase to $16–21 billion, based on UNAIDS' recommendation that donor countries provide two-thirds of the AIDS-related costs.

1. Ethelston S and Leahy E, Reproductive health: How much? Who pays? Population Action International, 2006, <http://www.populationaction.org/ resources/researchCommentaries/ DonorAssistance_Jun06.htm>, accessed June 15, 2006.

GENDER NORMS AND HIV RISK AMONG DRUG USERS

Female intravenous drug users may engage in higher levels of HIV risk behaviors than their male counterparts, according to a community-based study conducted in 2003–2004 in a medium-sized city in China's Sichuan Province.1 Compared with male intravenous drug users, female users scored higher on an index of 10 HIV risk behaviors (mean score, 5.9 vs. 3.6). Greater proportions of females than of males had had multiple sexual partners (68% vs. 24%), had ever had an STI (42% vs. 16%) and had had an STI for which they did not seek treatment (32% vs. 19%), whereas a greater proportion of males than of females had used needles prepared by others (15% vs. 6%). In regression analysis, factors associated with a higher score on the HIV risk behavior index included younger age, lower family support, greater economic pressure and having a primary sexual partner who was an intravenous drug user. In separate analyses by gender, the HIV risk behavior score among male users was negatively associated with age and family support, whereas the score among women was positively associated with economic pressure and having a primary sexual partner who was an intravenous drug user. The authors suggest that HIV risk factors for Chinese intravenous drug users are "shaped by gender norms surrounding needle sharing and unsafe sex," and that prevention and intervention programs in China should promote "equality between the two sexes in decision-making in matters relating to sexual intimacy."

1. Choi SYP, Cheung YW and Chen K, Gender and HIV risk behavior among intravenous drug users in Sichuan Province, China, Social Science & Medicine, 2006, 62(7):1672–1684.

WATER ARSENIC LEVELS LINKED TO STILLBIRTHS

Exposure to high levels of arsenic during pregnancy increases a woman's risk of having a stillbirth, according to a study conducted in 2001–2003 in West Bengal, India.1 The 202 married women aged 20–40 who participated reported 660 pregnancies and 540 live births during the study period. On average, the water women drank during pregnancy contained an arsenic concentration of 102 mcg/liter, and 18% of the women had been exposed during pregnancy to water containing high levels of arsenic (at least 200 mcg/liter). Women who had been exposed to high levels of arsenic during pregnancy had elevated odds of having a stillbirth (odds ratio, 6.1); this was not the case with lower arsenic concentrations. In addition, women who were found during a physical examination to have arsenic-related skin lesions were much more likely than others to have experienced a stillbirth (13.1). The authors comment that although their findings need to be confirmed in a prospective study, "the existing evidence warrants preventative actions designed to reduce the exposure of childbearing-age women in regions with high levels of arsenic in water."

1. von Ehrenstein OS et al., Pregnancy outcomes, infant mortality, and arsenic in drinking water in West Bengal, India, American Journal of Epidemiology, 2006, 163(7):662–669.

RESISTANT HIV DETECTED AFTER NEVIRAPINE DOSE

As part of a prospective study of mother-to-child HIV transmission conducted in Soweto, South Africa, 22 pregnant HIV-positive women underwent blood tests before and 2–12 months after receiving a single dose of the antiretroviral drug nevirapine.1 At baseline, the plasma levels of HIV strains resistant to nevira-pine were negligible for all women. However, researchers using standard genotyping techniques detected nevirapine- resistant HIV variants in 68% of women two months after treatment and in 27% of women six months after treatment. Using a highly sensitive molecular biology assay, researchers detected drug-resistant strains in 91% of women two months after treatment and estimated that in 23% of women, the level of nevirapine-resistant HIV variants would persist above baseline for more than a year. The authors suggest that further study is needed to "assess the clinical significance of nevirapine-resistant variants, particularly in relation to subsequent treatment with antiretroviral therapy and subsequent pregnancies."

1. Palmer S et al., Persistence of nevira-pine-resistant HIV-1 in women after single-dose nevirapine therapy for prevention of maternal-to-fetal HIV-1 transmission, Proceedings of the National Academy of Sciences, 2006, 103(18):7094– 7099.

COST-EFFECTIVE WAYS TO REDUCE CHILD MORTALITY

Micronutrient fortification, measles immunization, case management of pneumonia and oral rehydration therapy for diarrhea are the most cost- effective interventions developing countries can use to achieve the millennium development goal of reducing mortality in young children by two-thirds by 2015, according to an analysis of the Sub-Saharan African and South East Asian regions.1 Estimates of the effectiveness and cost of each of nine child health interventions and of various combinations of those interventions at 50%, 80% and 95% coverage indicate that vitamin A and zinc fortification are the most successful in terms of the lowest cost per disability-adjusted life year averted; provision of supplementary food and nutritional counseling is the least cost-effective. In Sub-Saharan Africa, a package consisting of 95% coverage with micronutrient fortification, measles immunization, case management of pneumonia and oral rehydration therapy for diarrhea could be offered relatively inexpensively ($95 per disability-adjusted life year averted); in South East Asia; a similar package that substituted micro-nutrient supplementation for fortification could be offered for a modest increase in cost ($134 per disability-adjusted life year averted). Although the interventions found to be cost-effective have the potential to reduce child mortality, the authors point out that "reducing malnutrition in children and tackling the root causes of poverty, lack of education, and sex inequality" will be necessary to accomplish the millennium development goal.

1. Edejer TT et al., Cost effectiveness analysis of strategies for child health in developing countries, BMJ, 2006, 331(7526):1177–1180.

PARENTAL SUPPORT AND SEX

Adolescent females in El Salvador who reported feeling that their parents were not very supportive of them had elevated odds of being sexually experienced; however, the same was not true for their male counterparts.1 More than one-quarter of a sample of 930 secondary school students surveyed in the country's central region between June and August 1999 reported ever having had sex; males were more likely than females and 16–19-year-olds more likely than 12–15-year-olds to have done so. Females who felt that they could not always count on their parents for help or support had elevated odds of ever having had sexual intercourse (odds ratio, 6.4). Perceived low parental support was not associated with sexual experience among males, and perceived social support at school was not associated with sexual experience among either females or males. According to the authors, their findings suggest that "parental social support may be more important for preventing sexual activity among girls compared with boys, but that perceived social cohesion at school does not appear to influence sexual activity for either group."

1. Springer A et al., Supportive social relationships and adolescent health risk behavior among secondary school students in El Salvador, Social Science & Medicine, 2006, 62(7):1628–1640.