Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 33, Number 3, September 2007
UPDATE


POOR WOMEN IN BRAZIL FIND HOME STI TESTING ACCEPTABLE

Use of home-based STI self-collection and testing kits for chlamydia, gonorrhea and trichomoniasis is acceptable to low-income women, according to a study conducted between April and November 2004 in São Paulo, Brazil.1 A total of 818 women aged 18–40 were enrolled; half were randomized to receive a kit that they could use at home to collect and test vaginal samples for trichomoniasis, whereas the other half were given appointments to come to the clinic to perform sample collection and testing with guidance from a nurse. A marginally greater proportion of women in the home group (80%) than of those in the clinic group (76%) did as instructed within the specified two-week period. After reminders were given to nonrespondents, a greater proportion of women in the home group (93%) than of those in the clinic group (89%) did as instructed within an additional four weeks. Some 94% of women in the home group completed sample collection and testing at home on their first attempt. The authors conclude that "self-collection and rapid tests are a feasible and acceptable option for home-based STI screening in low-income populations in developing country settings and should be introduced in resource-rich and poor countries alike. "

1. Lippman SA et al., Home-based self-sampling and self-testing for sexually transmitted infections: acceptable and feasible alternatives to provider-based screening in low-income women on São Paulo, Brazil, Sexually Transmitted Diseases, 2007, 34(7): 421–428.

DIAPHRAGM ADDS NO HIV PROTECTION TO CONDOM

Women provided with a dia-phragm and lubricant gel in addition to condoms to use during sex do not have a lower risk of becoming infected with HIV than women provided with condoms only, according to a study conducted in South Africa and Zimbabwe between September 2003 and December 2006.1 Among the 2,472 sexually active, HIV-negative women aged 18–49 in the intervention group, who were given and instructed to use a latex diaphragm with lubricant gel and condoms during sex, the incidence of HIV infection over the study period was 4.1 seroconversions per 100 woman-years; HIV incidence was 3.9 seroconversions per 100 woman-years among the 2,476 similar women in the control group, who were provided with condoms only. The relative hazard of HIV infection for the intervention group compared with the control group was 1.05, a nonsignificant finding. Although there was no difference at enrollment in the proportions of women in the intervention and control groups who had used condoms at last sex, over the course of the study, a smaller proportion of women in the intervention group than of those in the control group reported using condoms at last sex (54% vs. 85%); women in the intervention group reported using the diaphragm 73% of the time. Women in the two groups did not differ in terms of pregnancy rates or proportions experiencing adverse events. The authors conclude that their results "do not support the addition of the diaphragm to current strategies to prevent HIV infection, " and thus "women who cannot convince their male partners to use condoms are still in urgent need of a female-controlled method of protection. "

1. Padian NS et al., Diaphragm and lubricant gel for prevention of HIV acquisition in southern African women: a randomised controlled trial, Lancet, 2007, 370(9583):251–261.

MONTHLY INJECTABLE DOES NOT RAISE RISK OF CANCER

One-month injectable contraceptive use does not appear to be associated with an increased risk of cancer.1 As part of a study of female textile workers in Shanghai, China, 267,400 women were interviewed between October 1989 and October 1991; of those, 3% had developed one of 12 types of cancer studied (breast, colon, gallbladder, liver, lung, ovarian, pancreatic, rectal, stomach, thyroid, cervical and uterine) by July 2000. The most common form of cancer was of the breast. Among women who had developed cancer, 4% had ever used a one-month injectable. In multivariate analyses controlling for possible confounding variables such as age and parity, no relationship was found between ever-use of a one-month injectable and the risk of all cancers combined. However, women who had ever used a monthly injectable had reduced odds of developing cancer of the uterus (risk ratio, 0.6). In additional analyses, researchers found no association between duration of one-month injectable use and all cancers combined or with cancer of the breast, colon, liver, lung or stomach; for other cancers, there were too few cases for individual analyses. Although the authors note their study investigated use of an injectable exclusive to China, they believe that their findings "are probably relevant to other estrogen-progestin combined monthly injectable contraceptives and should provide some reassurance to women who have used these products that their risk of cancer has not been increased. "

1. Rosenblatt KA et al., Monthly injectable contraceptives and the risk of all cancers combined and site-specific cancers in Shanghai, Contraception, 2007, 76(1): 40–44.

HORMONAL METHODS ARE NOT LINKED TO HIV RISK

There appears to be no association between current hormonal contraceptive use and HIV infection, according to a study of women aged 35–49 conducted in Cape Town, South Africa. Of the 4,200 HIV-negative women who were enrolled in the study between June 2000 and December 2002, 21% reported current use of any hormonal contraceptive method (14%, the three-month injectable; 5%, the two-month injectable; and 2%, the oral contraceptive pill); 86% reported ever-use of an injectable. Women were followed for an average of 14.3 months, and during that time, incident HIV infections occurred among 86 women not currently using a hormonal contraceptive method and among 25 women currently using a hormonal method (18, the three-month injectable; 5, the two-month injectable; and 2, oral contraceptives). In multivariate analyses, women who reported current use of any hormonal contraceptive method or current use of any individual type of hormonal method had the same odds of HIV infection as women who were not currently using a hormonal method. Furthermore, women's risk of HIV infection was not associated with increasing duration of three-month injectable use. The authors comment that even though they found no association between hormonal contraceptive use and HIV infection, "most women using contraceptive methods are sexually active, and in many settings the use of male or female condoms is less likely when women are using a non-barrier contraceptive method. " They suggest that "dual method use should be actively pro-moted by family planning services in populations where HIV is prevalent. "

1. Myer L et al., Prospective study of hormonal contraception and women's risk of HIV infection in South Africa, International Journal of Epidemiology, 2007, 36(1):166–174.

GENDER EQUALITY IS BETTER FOR MOTHERS AND CHILDREN

In the developing world, improving women's autonomy and household authority may also improve children's chances of survival, according to a study of 7,534 children born between 1988 and 1993 in six subdistricts of Bangladesh and their mothers.1 In hazard regression models of neonatal (first 28 days), postneonatal (28–365 days) and child (1–5 years) mortality that included measures of maternal autonomy and authority, and variables found in previous research to be associated with the mortality of children younger than five in rural Bangladesh, postneonatal mortality decreased with increased maternal autonomy (rate ratio, 0.9). In addition, child mortality decreased with mothers' increased household authority (0.8); increased maternal authority also showed a marginal association with decreased postneonatal mortality (0.9). Using a simulation model, researchers estimated that total gender equality could reduce postneonatal mortality by 36% and child mortality by 45%. The authors suggest that "policies and interventions in Bangladesh that seek to improve women's status have the additional benefit of impacting on the survival chances of their children. " They conclude that "gender bias affecting adult women is not only a social problem; it is a public health problem affecting child survival. "

1. Hossain MB, Phillips JF and Pence B, The effect of women's status on infant and child mortality in four rural areas of Bangladesh, Journal of Biosocial Science, 2007, 39(3):355–366.

PHARMACIES ARE IMPORTANT STI INTERVENTION SITES

Men and women who visit pharmacies in Lima, Peru, seeking care for urethral or vaginal symptoms have infection rates comparable to those of the country's general population, making pharmacies an important venue for STI treatment and intervention.1 As part of a study conducted in Lima between 2002 and 2003, 227 male and female pharmacy clients aged 18–55 with symptoms of reproductive tract infections (e.g., urethral discharge and dysuria for men, and abnormal discharge, bad odor or vaginal itching for women) completed a questionnaire and submitted samples for laboratory testing. The vast majority of men reported having regular sexual partners (94%) and casual partners (89%); the proportions for women were 98% and 37%, respectively. Thirty-four percent of men tested positive for gonorrhea or chlamydia, and 49% of women tested positive for bacterial vaginosis, trichomoniasis, candidiasis, gonorrhea or chlamydia—proportions comparable to those from previous studies in the general Peruvian population. Reasons given by pharmacy clients as to why they were seeking care at the pharmacy included trust of pharmacy staff (39%), convenient location (14%), cost and waiting time (8% each). The authors comment that "symptomatic men and women seeking care in pharmacies seem to have specific STIs as often as those seeking care from clinicians. " They conclude that "pharmacies are important sources for treatment and intervention for control of sexually transmitted diseases in developing countries. "

1. Garcia PJ et al., Sexually transmitted and reproductive tract infections in symptomatic clients of pharmacies in Lima, Peru, Sexually Transmitted Infections, 2007, 83(2):142–146.

NIGERIAN STUDENTS UNDERESTIMATE THEIR HIV RISK

Undergraduates in Nigeria do not accurately perceive their true risk of acquiring HIV, according to a study of students of two colleges in the southwest of the country.1 Of the 405 male and female undergraduates who completed a questionnaire that asked about the students' sexual history, STI history and perceived level of HIV risk, 85% believed themselves to be at little or no risk of acquiring HIV, and only 15% believed that they were at moderate or high risk of infection. However, according to a scale based on students' number of lifetime partners and histories of unprotected sex and STI symptoms, researchers estimated that 77% of the students were at high risk of HIV, and only 23% were at low risk. In addition, researchers estimated that a student who believed himself or herself to be at little or no risk of HIV had only a 16% probability of truly having such low risk. In multivariate analyses, having had recent STI symptoms was associated with students' higher perceived HIV risk; no associations were found between perceived risk and students' past history of STI, recent history of unprotected sex or number of lifetime partners. The authors comment that "this 'optimism bias'…has grave implications for the control of HIV infection in Nigeria, as young people aged less than 25 years have the highest sero-prevalence…and represent over 60% of existing cases of HIV/AIDS in the country. "

1. Ijadunola KT et al., College students in Nigeria underestimate their risk of contracting HIV/AIDS infection, European Journal of Contraception and Reproductive Health Care, 2007, 12(2):131–137.