Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 35, Number 1, March 2009
UPDATE


CALL FOR MORE U.S. FUNDS FOR FAMILY PLANNING WORLDWIDE

Five former directors of the Population and Reproductive Health Program of the United States Agency for International Development (USAID) have released a report recommending that the Obama administration more than double USAID's international family planning assistance, to $1.2 billion in 2010, up from $457 million in 2008.1 According to the report, entitled Making the Case for U.S. International Family Planning Assistance, the United States once led the world in supporting family planning education and services to people in the developing world—efforts that have simultaneously improved the health and lives of millions of women worldwide, slowed population growth and encouraged economic development. USAID funding for such services, however, peaked in 1995 and has declined ever since, even though demand for family planning and related services has continually increased. The former directors suggest that increasing the USAID population budget to $1.2 billion in 2010 and then gradually to $1.5 billion by 2014 would represent "an appropriate American contribution to international efforts to achieve the global consensus Millennium Development Goal target of universal access to reproductive health services, including family planning, by 2015."

1. Speidel JJ et al., Making the Case for U.S. International Family Planning Assistance, 2009, http://www.jhsph.edu/gatesinstitute/_pdf/policy_practice/Papers/Making theCase. pdf, accessed Jan. 28, 2009.

POOR PREVENTIVE PRACTICES AMONG HIV-POSITIVE YOUTH

Many Ugandan adolescents born with HIV are sexually active but do not engage in safer-sex practices, according to a 2007 study conducted in four of the country's districts.1 Of the 732 perinatally infected males and females aged 15–19 interviewed, one-third reported ever having had sex; of these (37%) reported preferring a HIV-negative partner. Among the sexually experienced youth, only 37% had used a method at first sex to prevent HIV infection (either of their partner or of themselves with a different HIV strain), and even fewer were currently doing so (30% and 25%, respectively). Just 44% of sexually experienced HIV-positive youth currently using condoms reported consistent use. Of youth currently in a relationship, only 33% knew their partner's HIV status, and 38% had disclosed their status to their partner. The authors comment, "There is a need to provide preventive sexual and reproductive health information and services to HIV-positive adolescents in order to prevent further HIV transmission and unwanted pregnancies. This should entail empowering these adolescents with skills to negotiate disclosure and consistent condom use."

1. Birungi H et al., Sexual behavior and desires among adolescents perinatally infected with human immunodeficiency virus in Uganda: implications for programming, Journal of Adolescent Health, 2009, 44(2):184–187.

EVALUATION OF YOUTH-FRIENDLY CLINICS IN SOUTH AFRICA

Health clinics in Cape Town, South Africa, participating in an initiative to improve services for adolescents succeeded in providing youth with greater access to HIV testing than did other clinics, but were no different in terms of acceptability or confidentiality.1 According to study conducted between May and August 2005 in which 10 adolescent volunteers acting as simulated clients made 137 clinic visits for HIV testing, a smaller proportion of youth were denied an HIV test at clinics participating in the National Adolescent-Friendly Clinic Initiative (NAFCI) than at nonparticipating clinics (19% vs. 37%). However, there were no differences between clinics in terms of youth's perceptions of the attitudes of health workers and the confidentiality of services. Youth spent between 30 and 335 minutes for a clinic visit, with the median time being 120 minutes. To make an impact on service acceptability and confidentiality, the authors comment that "youth-friendly initiatives need to impact clinic work organization and clinic culture."

1. Flisher AJ et al., The quality of HIV testing services for adolescents in Cape Town, South Africa: Do adolescent-friendly services make a difference, Journal of Adolescent Health, 2009, 44(2): 188–190.

TARGETED MALE CIRCUMCISION MAY BE EFFECTIVE AGAINST HIV

In Sub-Saharan countries with a low level of male circumcision, a circumcision intervention targeting high-risk males and those aged 20–30 would produce the most substantial decrease in HIV prevalence for the smallest number of surgical procedures.1 According to a mathematical model simulating the spread of HIV through heterosexual transmission from 2007 to 2020, providing circumcision to all males would reduce the prevalence of HIV from 12% to 6%. Interventions targeting males aged 20–25 or 25–30 would each reduce HIV prevalence by about 2%; targeting younger or older age-groups had smaller effects. Similarly, an intervention that focused on high-risk males (i.e., those who changed sexual partners 2–4 times more frequently than the rest of the population) had one-third of the benefit of circumcising every male, even though it targeted only about 10% of the population. The authors conclude that "circumcision has the potential to be an effective intervention against the HIV epidemic in Sub-Saharan Africa even if such intervention is limited to a subset of the young male population.

1. Londish GJ and Murray JM, Significant reduction in HIV prevalence according to male circumcision intervention in Sub-Saharan Africa, International Journal of Epidemiology, 2008, 37(6): 1246–1253.

FEMALE GENITAL MUTILATION LINKED TO SEXUAL DYSFUNCTION

Women who have experienced female genital mutilation report lower sexual function than other women, according to a pilot study to assess sexual dysfunction associated with genital cutting.1 As part of the study conducted in Jeddah, Saudi Arabia, between February 2007 and March 2008, 260 sexually active women—half of whom had experienced genital mutilation—were given an Arabic translation of the female sexual function index (FSFI) questionnaire developed by Rosen et al., which includes questions about libido, arousal, lubrication, orgasm, satisfaction and pain. Of the women who had experienced genital mutilation, 41% characterized their mutilation as type I (the least severe) or type II, 42% as type III (the most severe) and 17% as unknown. There were no differences between the women with genital mutilation and those without in terms of their scores on the libido or pain indexes; however, women with genital cutting had lower scores on the indexes for arousal, lubrication, orgasm and satisfaction. The authors comment that "efforts by local religious and medical authorities in countries where [female genital mutilation] is common to demonstrate that…all types of [female genital mutilation] including type I are associated with a long list of health consequences, will help toward abandoning the procedure."

1. Alsibiani SA et al., Sexual function in women with female genital mutilation, Fertility and Sterility, 2008, doi:10.1016/ j.fertstert.2008.10.035.

PRESIDENT BARACK OBAMA RESCINDS GLOBAL GAG RULE

On Jan. 23, 2009, President Barack Obama signed an executive order reversing the global gag rule (also known as the Mexico City Policy)—implemented by President Ronald Reagan in 1984, rescinded by President Bill Clinton in 1993 and reinstated by President George W. Bush in 2001—which prohibited international nongovernmental organizations that receive U.S. funding from providing or promoting abortion, even with other funds.1 In a statement released the following day, President Obama said "It is clear that the provisions of the Mexico City Policy are unnecessarily broad and unwarranted under current law, and for the past eight years, they have undermined efforts to promote safe and effective voluntary family planning in developing countries."2 He continued, "it is right for us to rescind this policy and restore critical efforts to protect and empower women and promote global economic development." And to conclude, the President gave even more good news to reproductive health advocates by expressing his support for restoring U.S. funding to the United Nations Population Fund, withheld by the Bush Administration since 2002.

1. The White House, Mexico City policy and assistance for voluntary population planning, <http://www.whitehouse.gov/ the_press_office/ Mexico_ City_Policy_ and_Assistance_for_Voluntary_ Population_ Planning/>, accessed Jan. 28, 2009. 2. The White House, Statement released after the President rescinds "Mexico City Policy," <http://www. whitehouse.gov/ statement-released-after-the- president- rescinds/>, accessed Jan. 28, 2009.

MALE CIRCUMCISION AND HPV PREVALENCE

Young men who have been circumcised are less likely than those who have not to be infected with the human papillomavirus (HPV), according to a study of data from a male circumcision trial conducted in Orange Farm, South Africa.1 Of the 3,274 uncircumcised men aged 18–24 recruited between February 2002 and July 2004, half were randomly assigned to the intervention group to be circumcised and half were assigned to the control group; urethral swab samples from 1,264 participants were collected at the 21-month follow-up visit and analyzed for HPV and gonorrhea. In univariate intention-to-treat analyses, HPV prevalence was lower for men in the intervention group than for those in the control group (15% vs. 22%), and the prevalence rate ratio was 0.66, suggesting that circumcision is negatively associated with HPV infection. Controlling for social, demographic and sexual behavior characteristics and HIV status did not significantly change the prevalence rate ratio (0.68). Similar analyses for gonorrhea found no difference between circumcised and uncircumcised men. Because the researchers did not test men's HPV status at baseline, they were not able to determine what proportions of circumcised and uncircumcised men became infected over the study period, only the proportions of the two groups with HPV at the 21-month endpoint. The authors remark, however, that given the sample randomization, the controlled analyses and the lack of difference in gonorrheal prevalence between the two groups, it is likely that the difference in HPV prevalence at 21 months was due to the protective effect of the circumcision intervention on HPV infection.

1. Auvert B et al., Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa, Journal of Infectious Diseases, 2009, 199(1):14–19.

GENDER VIOLENCE OVERLOOKED BY AFRICAN GOVERNMENTS

Sub-Saharan African governments are not appropriately acknowledging and addressing gender-based violence, according to a report released by USAID's Africa's Health in 2010 project.1 The report, which reviewed Demographic and Health Survey (DHS) findings and national planning documents from Cameroon, Kenya, Malawi, Rwanda, Uganda, Zambia and Zimbabwe, found that the prevalence of violence against 15–49-year-old women was high in all seven countries, ranging from about 30% to 60%. Between 70% and 80% of ever- married women who had experienced gender-based violence reported their husband as the perpetrator; across countries, there were strong associations between violence and husband's controlling behavior and drunkenness. Although the topic of gender-based violence is included in most countries' planning documents, it is often not included in overall priorities. Furthermore, despite the richness of DHS data, the findings seem not to be used to inform policies and programs in the planning documents. The authors make recommendations for national governments, including the need to "acknowledge that domestic violence is a public health problem" that "needs to be officially recognized and addressed, via public policy and appropriate budget allocation."

1. Borwankar R, Diallo R and Sommerfelt AE, Gender-Based Violence in Sub- Saharan Africa: A Review of Demographic and Health Survey Findings and Their Use in National Planning, 2008, <http:// africahealth2010.aed.org/PDF/GBV.pdf>, accessed Feb. 23, 2009.