Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 37, Number 2, June 2011
UPDATE


IUD USE RATES WORLDWIDE

The rates of IUD use and discontinuation vary widely around the world, according to an analysis of data from Demographic and Health Surveys of 14 developing Asian, Latin American and Caribbean, and North African countries conducted between 1993 and 2007.1 The proportion of currently married women aged 49 or younger who reported using the IUD at the time of survey ranged from 2% in Bangladesh and the Dominican Republic to 38% in Viet Nam and 42% in Kazakhstan; across all of the study countries, the median prevalence of IUD use among those women was 9%. IUD discontinuation was consistently low in Indonesia, Kazakhstan and Turkey (10–31%) and consistently high in Bangladesh, the Dominican Republic and Nicaragua (24–66%). The main reason women gave for discontinuing use of the IUD was health concerns or side effects (16% of episodes); rates of discontinuation for this reason ranged from 8% in Indonesia to 40% in Bangladesh. The median cumulative probability of discontinuing use of the IUD for method-related reasons increased from 9% at 12 months to 27% at 36 months; In regard to the large variability in IUD prevalence across developing countries, the authors comment, "It is most unlikely that any biological or cultural factor can account for this variability. Rather, it reflects the policy choices about which methods to promote and biases in family planning services." The authors add that "The reasons for variation in the willingness or ability of women to persist with the [IUD] are unclear."

1. Ali MM et al., Long-Term Contraceptive Protection, Discontinuation and Switching Behavior, London: World Health Organization and Marie Stopes International, 2011.

GLOBAL PREVALENCE OF HPV AMONG MEN

More studies about the prevalence of HPV among men—especially among young men—are needed, according to a systematic review of the research literature.1 Of the 6,600 articles published between Jan. 1, 1989, and June 30, 2009, that concern HPV and men, 62 studies met the inclusion criteria (having been peer-reviewed and including a methodology in which polymerase chain reaction or hybrid capture methodology was used to detect HPV). Of these, 38 were from populations at high risk of HPV infection (e.g., male STI clinic clients and men with HPV-infected partners). Overall, the data from the included studies were from 14,800 men in 23 countries; most studies included only males older than 18. The prevalence of HPV varied widely, from 2% to 93% among high-risk men and from 1% to 84% among men not considered at high risk. The prevalence of all HPV types associated with an elevated risk of cancer ranged from 1% to 79%; the prevalence of specific HPV types 16 and 18—the two types associated with 70% of cervical cancer cases in women—ranged from 1% to 52% and 0% to 28%, respectively. Overall, HPV prevalence did not change greatly among men, regardless of risk, from age 20 to at least age 50. The authors comment that "Few data on HPV-16/18 prevalence are available among young men for whom current HPV prophylactic vaccines are approved. These data would be useful to estimate the proportion of young men negative for both HPV-16/18…who may obtain optimal benefits from HPV vaccination."

1. Smith JS et al., Age-specific prevalence of human papillomavirus infection in males: a global review, Journal of Adolescent Health, 2011, 48(6):540–552.

EXTRA TRAINING OF BIRTH ATTENDANTS SAVES LIVES

Traditional birth attendants trained to manage several common perinatal conditions can reduce neonatal mortality in rural settings.1 As part of a community-based field effectiveness study conducted in Lafwanyama, Zambia, between June 2006 and November 2008, 127 traditional birth attendants were randomly selected into either an intervention group or a control group. The intervention group received additional training and equipment associated with a modified neonatal resuscitation protocol and with administration of amoxicillin for infants showing signs of sepsis, as well as training on record-keeping and reporting aspects of the trial, whereas controls received additional training only in record-keeping and reporting. Over the study period, 3,497 infants were delivered by participating birth attendants; of the 102 live-born infants who died within 28 days of birth, 43 were delivered by intervention attendants and 59 by control—a 45% lower neonatal mortality rate among those delivered by intervention attendants. The intervention had the greatest reduction in mortality on the day of birth: Infants delivered by intervention attendants had a 60% lower 24-hour mortality rate than those delivered by control attendants. Most neonatal deaths were attributed to serious infections or birth asphyxia; there was no difference between groups in deaths from infection, but the rate of death by birth asphyxia was 63% lower among infants delivered by intervention attendants. The authors comment that "traditional birth attendants were able to master a set of skills that allowed them to significantly reduce neonatal mortality. This was accomplished in a population of women birth attendants with low rates of formal education and under austere conditions, making this example highly generalisable."

1. Gill CJ et al., Effect of training birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study, BMJ, 2011, 342:d346 doi: 10.1136/bmj.d346.

IMPACT OF CIRCUMCISION REVISED WITH NEW DATA

Male circumcision in settings with a high HIV prevalence can substantially reduce the rate of HIV transmission, even after accounting for recent findings that the procedure is associated with a short-term increase and a delayed reduction in the risk of transmission.1 To examine the impact of research that suggests a 3–3.5 fold increase in the risk of female-to-male and male-to-female HIV transmission associated with sex during the postcircumcision wound healing period, researchers altered two previously published mathematical models: one based on Zimbabwe (HIV prevalence, 20%; adult male circumcision prevalence, 0%), and one based on Kisumu, Kenya (HIV prevalence, 15%; adult male circumcision prevalence, 25%). Using these models, the researchers estimated that an intervention in which half of uncircumcised men undergo the procedure within 10 years would be associated with a reduction in the HIV incidence rate of 19–21% in Zimbabwe and of 6–7% in Kisumu over 20 years, depending on the duration of the wound healing period and on the level of sexual activity during that period. On the basis of other research findings, the models were adjusted to reduce the risk of male-to-female transmission by 46% beginning two years after circumcision, which yielded a HIV incidence rate reduction of 28% in Zimbabwe and of 17% in Kisumu over 20 years. The authors comment that their "synthesis of new data about the effect of circumcision on female-to-male and male-to-female HIV transmission provides an even greater imperative to increase scale-up of circumcision interventions to prevent HIV."

1. Hallett TB et al., Will circumcision provide even more protection from HIV to women and men? New estimates of the population impact of circumcision interventions, Sexually Transmitted Infections, 2011, 87(2):88–93.

WOMEN'S DECISION MAKING PRE- AND POST-MARRIAGE

Women in Pakistan who have some involvement in the selection of their husbands prior to marriage are more likely than others to be involved in family planning decisions within their marriage.1 Of a sample of 1,803 married Pakistani women aged 15–24 drawn from a 2001–2002 nationally representative survey of adolescents and youth, 12% reported having some input into the selection of their husband; 27% had met their husband prior to marriage and 52% were related to their husband. Some 55% reported ever discussing their wanted number of children with their husband, and 44% reported agreeing with their husband about how many children they wanted. Ten percent of women were currently using a contraceptive method, and 51% intended to use a method in the future. In multivariate analyses controlling for socioeconomic characteristics, levels of mobility outside of the home and decision-making ability within the home, women who had had input into whom they were to marry had greater odds than those who had not had such input of agreeing with their husband about how many children they wanted and of intending to use contraceptives (odds ratios, 1.7 and 1.6, respectively); involvement in spouse selection was not associated with women's current contraceptive use. The authors conclude that "If young women are brought up in their parental home with more involvement in decision making, they are more likely to be involved in decision making once married. Promoting an environment in the parental home where young women are encouraged to participate in decision making about their marriage has positive future implications on their reproductive life."

1. Hamid S, Stephenson R and Rubenson B, Marriage decision making, spousal communication, and reproductive health among married youth in Pakistan, Global Health Action, 2011, Vol. 4, <http://www.globalhealthaction.net/index.php/ gha/article/viewArticle/5079/ 6659: 5079- DOI: 10.3402/gha.v4i0. 5079>, accessed Feb. 15, 2011.

LONGER ANTI-HIV THERAPY IS WORTH THE COST

Implementation of a new antiretroviral therapy (ART) regimen recommended by the World Health Organization (WHO) for the prevention of mother-to-child transmission of HIV (PMTCT) would be cost-effective, according to an analysis based on a target population of pregnant Nigerian women living with HIV.1 Each year, there are an estimated 240,000 pregnancies among women in Nigeria living with HIV. At Nigeria's current level of PMTCT coverage (10% of all HIV-infected women), the mother-to-child HIV transmission rate would be 23.7% with the new intervention (i.e., a regimen of three antiretroviral medications for the mother from as early as 14 weeks' gestation through the end of breast-feeding, plus six weeks of ART for the infant), compared with 24.3% with the current standard of care (i.e., a regimen of two antiretroviral medications for the mother from 34 weeks' gestation through seven days postpartum, plus a single dose of ART for the mother and infant during delivery). The difference in rates would amount to 1,440 fewer HIV-infected infants per year and 0.16 fewer disability adjusted life years (DALYs) among infants per pregnancy. If the interventions were implemented at Nigeria's current level of antenatal care coverage (58% of HIV-infected women), the transmission rates would decrease to 13% and 16%, respectively—resulting in 7,680 fewer HIV-infected infants per year and 0.96 fewer DALYs per pregnancy. And if all HIV-infected Nigerian women received PMTCT coverage, the rates would fall to 3% and 9%, which would translate to 14,400 fewer HIV-infected infants per year and 1.65 fewer DALYs per pregnancy. Relative to the current standard of care, the WHO-recommended regimen would be associated with an increase in program costs ranging from $274 per pregnancy (10% coverage) to $30 per pregnancy (100% coverage). In terms of cost-effectiveness, at the 10% coverage level, the WHO-recommended regimen would be associated with an increased cost of $127 per DALY averted; at full coverage, the figure would fall to $111 per DALY averted. At either level, the newly recommended regimen would be substantially lower than the WHO-recommended willingness-to-pay threshold for Nigeria of $1,191 per DALY averted—the threshold under which an intervention would be considered cost-effective.

1. Shah M et al., Cost-effectiveness of new WHO recommendations for prevention of mother-to-child transmission of HIV in a resource-limited setting, AIDS, 2011, 25(8):1093–1102.