Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 33, Number 2, June 2007
UPDATE


MORE NEEDS TO BE DONE TO REDUCE CHILD MORTALITY

Child mortality rates in many countries have not been going in the right direction, according to a report entitled State of the World's Mothers 2007: Saving the Lives of Children Under 5.1 Each year, more than 10 million children die before the age of five—the equivalent of 28,000 child deaths per day. Of the 60 developing countries that together account for 94% of all such deaths, 20 had stable or increasing rates of child mortality between 1990 and 2005. The four countries with the largest increases in child mortality during the period were Iraq (150%), Botswana (107%), Zimbabwe (65%) and Swaziland (45%); the four countries with the largest decreases were Egypt (68%), Indonesia (60%), Bangladesh (51%) and Nepal (49%). To reduce child mortality, the report urges countries to ensure the well-being of mothers by promoting nutrition, skilled care during childbirth and access to modern contraceptives. In addition, the report recommends that countries invest in basic, low-cost solutions to save children's lives, including breast-feeding, immunizations, oral re-hydration therapy, antibiotics and insecticide-treated mosquito nets. Finally, the report urges governments, especially that of the United States, to increase funding and support for newborn, child and maternal health, especially among the women and children of the developing world who are in the most need.

1. Save the Children, State of the World's Mothers 2007: Saving the Lives of Children Under 5, 2007, <http://www.savethechildren.org/jump.jsp?path=/publications/mothers/2007/SOWM-2007-final.pdf>, accessed May 9, 2007.

MALE CONDOM FAILURE IS REDUCED BY COUNSELING

Counseling on how to properly use condoms may help reduce rates of breakage and slippage, according to a condom acceptability study conducted between July 2002 and September 2004 at an STI clinic in Kingston, Jamaica.1 Among the sample of 314 male STI clients surveyed at an initial screening visit, the reported rates of condom breakage and slippage were 19% and 4%, respectively. Clients were then given condoms and a demonstration of proper condom use using a penis model, and were asked to return for several follow-up visits over the following six months. The reported breakage rate dropped to 7% at the one-week follow-up and remained below 10% at subsequent visits; similarly, the reported slippage rate dropped to 2% at the first follow-up and remained low at each of the subsequent visits. In multivariate analyses, clients at the follow-up visits were less likely than those at the screening to report having experienced condom failure in the prior week (rate ratios, 0.4–0.5). In in-depth interviews, clients who experienced high rates of condom failure were asked why they believed they had such difficulties: Sixty percent believed it was because of improper condom storage, 50% using expired condoms, 40% improper handling of condoms while putting them on and 40% using lubricants or improper lubricants. The authors comment that although "condom failure…may be reduced through appropriate condom counseling," there is a "need to improve the quality of condom counseling," as "condom instructions are often overly complicated and may not have any scientific basis."

1. Steiner MJ et al., Decreased condom breakage and slippage rates after counseling men at a sexually transmitted infection clinic in Jamaica, Contraception, 2007, 75(4):289–293.

MEN AND WOMEN ACCURATELY ASSESS THEIR HIV STATUS

Respondents' reports of their HIV status are generally accurate, according to a study conducted between April and December 2004 among men and women aged 15 or older in rural Malawi.1 Of the 2,299 respondents who estimated their likelihood of current HIV infection and gave saliva samples for HIV testing, 71% were accurate in their response; 96% of men and 94% of women who reported no chance of infection tested negative for HIV. Some 88% of those who gave incorrect answers overestimated their chances of infection; 93% of men and 91% of women who reported some chance of infection tested negative. Overall, men were more accurate than women (77% vs. 65%). In multivariate analyses, being married was associated with increased odds of having given an incorrect positive response among both men and women (odds ratios, 33.8 and 3.7, respectively). The authors comment that "without proper information, people may continue to falsely believe that they are already infected and may believe that they no longer have any health to protect, resulting in lower incentives to use condoms."

1. Bignami-Van Assche S et al., The validity of self-reported likelihood of HIV infection among the general population in rural Malawi, Sexually Transmitted Infections, 2007, 83(1):35–40.

POSTPARTUM COUNSELING ON CONTRACEPTION WORKS, TOO

Counseling women postpartum about using lactational amenorrhea as a contraceptive method may convince them to accept the method.1 As part of a cross-sectional study conducted at a public hospital in Leon, Mexico, 1,490 women who delivered healthy babies subsequently received counseling about how lactational amenorrhea functions as a contraceptive method and its efficacy in preventing pregnancy. About half (49%) of the women reported already knowing about lactational amenorrhea, and all said that they intended to breast-feed their baby. After counseling, 54% of women declared their intention to use the method; of those, 54% reported having been convinced by the counseling. Among the women who decided not to accept the method, 62% did so because they believed that it is unreliable and 16% because they thought that it might adversely affect their health. In logistic regression analyses, adopting lactational amenorrhea was associated with holding a job outside of the home and with previous knowledge of the method. The authors comment that although international guidelines recommend counseling women about lactational amenorrhea before delivery, their results suggest that postpartum counseling is also effective.

1. Lopez-Martinez MG, Romero-Gutierrez G and Ponce-Ponce De Leon AL, Acceptance of lactational amenorrhoea for family planning after postpartum counseling, European Journal of Contraception and Reproductive Health Care, 2006, 11(4):297–301.

SMOKING LINKED TO HIV INFECTION

Smoking tobacco may increase the risk of becoming infected with HIV, but it does not appear to be related to the progression from HIV infection to AIDS.1 In a review of the research literature, researchers identified 15 articles on smoking and HIV infection and progression, most of which were conducted in developed countries. Five used HIV seroconversion as an outcome variable, nine used progression to AIDS and one used both. Five of the six articles that assessed the relationship between smoking and HIV infection found a positive association between the two (odds ratios, 1.6–3.5); the odds ratio in the other study was also positive (1.2), but was only marginally significant. Of the 10 articles in which progression from HIV infection to AIDS was the outcome variable, nine found no significant difference between smokers and nonsmokers; the researchers considered the remaining study, which did find an association, to be of poor quality. The authors note that their sample included many cross-sectional studies, which are unable to demonstrate causality and are prone to confounding. They comment that "future research must examine the effect of smoking of people living with HIV in developing countries where the AIDS epidemic has the greatest impact."

1. Furber AS et al., Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? A systemic review, Sexually Transmitted Infections, 2007, 83(1):41–46.

BLEEDING PATTERNS IN LONG-TERM RING USE ACCEPTABLE

Menstrual bleeding patterns associated with long-term use of the contraceptive vaginal ring are considered acceptable by most women, according to a study conducted at a gynecology clinic in Sao Paulo, Brazil, between April 2004 and January 2005.1 Of the sample of 75 women who adopted the 91-day contraceptive regimen (four consecutive 21-day vaginal rings, followed by a one-week ring-free period), 62 completed four cycles—representing a 83% one-year continuation rate. No pregnancies were reported during the study period. Analysis of data from women's menstrual diary showed that the proportion of women who reported their bleeding pattern as acceptable increased from 52% after the first 91-day cycle to 86% after the fourth. On average, women reported 6–8 days of bleeding per cycle; 60% of women experienced bleeding during the ring-free week. The number of irregular bleeding days decreased from an average of 6.4 during the first cycle to 3.0 by the fourth. The authors comment that "compared with daily oral regimens, [extended use of the ring] offers increased convenience and privacy, which may contribute to improved patient adherence."

1. Barreiros FA et al., Bleeding patterns of women using extended regimens of the contraceptive vaginal ring, Contraception, 2007, 75(4):204–208.

CONDOM PROGRAM NEEDED ALONG AFRICAN HIGHWAY

As many as 2,700 new HIV infections could be prevented if condom use could be raised to 90% among female sex workers and their trucker clients along the trans-African highway between Mombasa and Kampala.1 As part of a study conducted at 30 sites of transactional sex along the highway, sex workers were asked to keep 28-day diaries recording their daily number of clients, daily number of sex acts and condom use per sex act; similarly, truckers were asked to complete surveys about numbers of partners and levels of condom use. Researchers estimated that on average, the approximately 8,000 female sex workers each have 634 sex acts with 129 different partners per year; 78% of those sex acts are protected by a condom. Assuming an HIV prevalence of 30–50% among sex workers and 15–25% among truckers, as many as 4,148 new HIV infections occur along the highway per year. If condom use among sex workers and truckers could be increased from 78% to 90%, an estimated 2,713 HIV infections could be prevented each year—a decrease of nearly two-thirds. The authors comment that their findings highlight the "need for targeted prevention interventions in the HIV epidemic in East Africa."

1. Morris CN and Ferguson AG, Estimation of the sexual transmission of HIV in Kenya and Uganda on the trans-African highway: the continuing role for prevention in high risk groups, Sexually Transmitted Infections, 2006, 82(5):368–371.

HPV VACCINE FOUND EFFECTIVE IN DEVELOPING COUNTRIES

A vaccination against four types of HPV—two of which, HPV-16 and HPV-18, are associated with an estimated 70% of cervical cancers worldwide—is highly effective at preventing high-grade cervical lesions.1 As part of a double-blind trial conducted in 13 developed and developing countries, 12,167 women were followed for an average of three years after receiving the first of three doses of either vaccine or placebo. During that time, only one woman without previous HPV infection in the vaccine group received a diagnosis of a high-grade cervical lesion associated with HPV-16 or HPV-18, compared with 42 in the control group—a vaccine efficacy rate of 98%. The authors of a related viewpoint suggest that the HPV vaccine trial data "constitute sufficient evidence to support global policy recommendations" for the introduction of the vaccine.2 They add that 80% of all cervical cancers occur in the developing world and that "with every 5-year delay in bringing vaccination to developing countries, 1.5 million to 2 million more women will die."

1. FUTURE II Study Group, Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions, New England Journal of Medicine, 2007, 356(19):1915–1927.

2. Agosti JM and Goldie SJ, Introducing HPV vaccine in developing countries—key challenges and issues, New England Journal of Medicine, 2007, 356(19):1908–1910.