Advancing Sexual and Reproductive Health and Rights
 
International Perspectives on Sexual and Reproductive Health
Volume 39, Number 3, September 2013
UPDATE


NEW WHO GUIDELINES FOR ANTIRETROVIRAL THERAPY

The World Health Organization (WHO) has released revised guidelines for the use of antiretroviral therapy (ART) recommending that individuals who have received an HIV diagnosis be given therapy earlier than previously suggested.1 Among the many new recommendations—formulated on the basis of the most recent evidence and practice—are guidelines for the expansion of ART to all HIV-positive adults, adolescents and children aged five or older with a CD4 count of 500 cells/mm3 or less; the previous guidelines suggested an ART initiation threshold of 350 cells/mm3. In addition, ART is now recommended, regardless of CD4 count, for certain HIV-positive populations, including people in HIV-serodiscordant couples, pregnant and breast-feeding women, and children younger than five. Furthermore, the new guidelines suggest that all individuals initiating ART take a simple fixed-dose combination pill once per day. In all, WHO estimates that nearly 10 million more people living with HIV in low- and middle-income countries will be eligible for ART under the new guidelines than under the previous ones, and that the guideline change will avert an additional three million AIDS-related deaths and 3.5 million new HIV infections between 2013 and 2025.

1. World Health Organization (WHO), Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection, 2013, Geneva: WHO, <http://apps.who.int/iris/bitstream/10665/85321/1/9789241505727_eng.pdf>, accessed Aug. 21, 2013.

EXPANDED METHOD MIX LEADS TO INCREASED METHOD USE

Modern contraceptive use within a country increases with the number of available methods, according to an analysis of nearly three decades of data from Demographic and Health Surveys and other national surveys, as well as Family Planning Effort Index data from 113 developing countries.1 Overall, the estimated average proportion of married women using modern methods in the developing world increased between 1982 and 2009, from 23% to 37%. During that time, the average number of modern methods available—defined as being accessible to at least 50% of a country’s population—increased from about two to more than 3.5. Under the same definition of availability, the addition of one modern method to a country’s method mix was associated with an eight-percentage-point increase in its overall contraceptive prevalence. The authors comment that “there is significant potential to increase contraceptive use by expanding access to existing methods and by making new or modified methods widely available….Improving method availability would simultaneously expand benefits to individual women and to couples through wider contraceptive choice.”

1. Ross J and Stover J, Use of modern contraception increases when more methods become available: analysis of evidence from 1982–2009, Global Health: Science and Practice, 2013, 1(2):203–212.

PARTICIPATORY LEARNING AND ACTION SAVES NEWBORN LIVES

Participatory learning and action—a health education approach that uses dialogue and problem solving—appears to be an effective and cost-effective strategy to improve maternal and neonatal survival in low-resource settings, according to a meta-analysis of randomized controlled trials in low- and middle-income countries.1 In a systematic literature review, seven studies conducted between 1999 and 2011 in four countries (Bangladesh, India, Malawi and Nepal) met the researchers’ inclusion criteria for participatory learning and action interventions in groups of women of reproductive age to reduce maternal and neonatal mortality. Meta-analyses of the 119,428 births to women in the combined sample found that exposure to such interventions was associated with lower odds of maternal and neonatal mortality (odds ratios, 0.6 and 0.8, respectively). In metaregression analyses, the likelihood of both maternal and neonatal mortality decreased as the proportion of pregnant women participating in groups increased. A subgroup analysis of the four studies with at least 30% of pregnant women participating in groups showed a reduction in the odds of both maternal and neonatal mortality (0.5 and 0.7, respectively); analyses among studies with lower levels of participation found no reduction in outcomes. Participatory learning and action interventions were cost-effective according to World Health Organization standards, and researchers estimated that such programs, if implemented in rural areas of Countdown to 2015 countries, could save an estimated 283,000 newborns and 41,100 mothers each year.

1. Prost A et al., Women’s groups practicing participatory learning and action to improve maternal and newborn health in low-resource settings: a systemic review and meta-analysis, Lancet, 2013, 381(9879):1736–1746.

YOUNG WOMEN IN AFRICA MISREPORT SEXUAL HISTORY

Underreporting of sexual activity is common among adolescent African women—a fact that could have important implications for HIV prevention efforts. According to an analysis of Demographic and Health Survey data from 5,570 never-married women aged 15–19 in four southern African countries with high HIV prevalence (Lesotho, Swaziland, Zambia and Zimbabwe), 5% reported being HIV-positive.1 Seventy-two percent of all women and 46% of those with HIV reported never having had sex; however, using a mathematical model, researchers estimated that the actual proportions of women who were sexually inexperienced were in fact 50% and 32%, respectively. That means that an estimated 44% of women who had had premarital sex misreported, but only 21% of HIV-positive women who had had premarital sex did so. Without misreporting, nonsexual modes of transmission would account for 64% of HIV infections; when misreporting is accounted for, sexual and nonsexual modes contribute equally. The authors comment that “current policies narrowly stressing sexual transmissions need to be expanded” and “more research is needed to understand the other ways HIV is passed between individuals.”

1. Tennekoon V and Rosenman R, ‘Behold, a virgin with HIV!’ Misreporting sexual behavior among infected adolescents, Health Economics, 2013, doi: 10.1002/hec.2918, accessed Aug. 21, 2013.

THE HIGH PRICE OF HPV VACCINE DELIVERY

The cost of providing young adolescent women with the human papillomavirus (HPV) vaccine may be higher than that of vaccines included in traditional Expanded Programme on Immunization (EPI) schedules. According to an evaluation of demonstration projects in Peru, Uganda and Viet Nam,1 the average cost per dose of the HPV vaccine delivered to young women by project facilities between 2008 and 2010 ranged from $1.44 in Uganda to $3.88 in Peru; vaccines in traditional EPI schedules typically cost $0.75–1.40, depending on the vaccine and country. The cost varied not only by country, but by program delivery strategy: In general, school-based HPV vaccination programs were more expensive than those based in health centers or those that utilized integrated outreach (i.e., made use of existing health services). On the basis of the costs of the demonstration projects, the researchers estimated that to implement a nationwide HPV vaccination program that would cover 80% of eligible young women, Peru would have to spend more than $14 million per year, whereas Uganda and Viet Nam would have to spend less than $3 million each; much of this difference is caused by the higher cost per dose of the vaccine for a medium-income country like Peru ($14) than for low-income countries like Uganda and Viet Nam ($0.20 each). The authors comment that “The cost of delivering HPV vaccine to young adolescent girls…may decline as delivery becomes integrated into immunization and school-based health services.”

1. Levin CE et al., Delivery cost of human papillomavirus vaccination of young adolescent girls in Peru, Uganda and Viet Nam, Bulletin of the World Health Organization, 2013, 91(8):585–592.

SHIFT IN CHINA’S NEWSPAPER COVERAGE OF HIV AND AIDS

The tone of print coverage of HIV and AIDS in China has become more positive over time, according to a study of the China Core Newspapers Database, in which most Chinese newspapers have been indexed since 2000.1 From the beginning of the database through 2010, some 3,648 articles were published about HIV or AIDS in 117 newspapers in China— an average of fewer than three articles per newspaper per year. The number of articles peaked in 2004–2007 at 418–559 per year; other years before and after that period had between 178 and 320 articles. Prior to 2002, the proportion of articles with a positive tone (e.g., those expressing care or sympathy for people living with HIV) was smaller than the proportion with a negative tone (i.e., those asserting that HIV or AIDS is punishment for evil behavior); however, after that year, the former increased substantially, whereas the latter decreased to close to zero. The authors conclude that “the HIV/AIDS news-reporting pattern has shifted during the past decade,” but add that “coverage…remains insufficient.”

1. Gao J et al., Newspaper coverage of HIV/AIDS in China from 2000 to 2010, AIDS Care, 2013, 25(9):1174–1178.

VIOLENCE AGAINST WOMEN: A GLOBAL HEALTH EPIDEMIC

Worldwide, 35% of women have ever been physically or sexually abused by an intimate partner or sexually abused by someone other than a partner, according to a new report by the World Health Organization (WHO).1 The report—which is the first global systematic review and synthesis of scientific data on the prevalence of violence against women—finds that 30% of the world’s women have experienced physical or sexual intimate partner violence, and 7% have experienced nonpartner sexual violence. Southeast Asia is the region of the world with the highest prevalence of violence against women (38%), followed by the Eastern Mediterranean and African regions (37% each). Women exposed to intimate partner violence are more likely than other women to have an induced abortion or a low-birth-weight baby and to experience depression. The report concludes that violence against women is a global public health epidemic that needs a stronger response from the health sector. To that end, WHO has also published new clinical and policy guidelines based on findings from the report.2

1. World Health Organization (WHO), Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence, 2013, Geneva: WHO, <http://apps.who.int/iris/bitstream/ 10665/85239/1/9789241564625_eng.pdf>, accessed Aug. 21, 2013.

2. WHO, Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines, 2013, Geneva: WHO, <http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf>, accessed Aug. 21, 2013.

IN BRIEF

Female Genital Mutilation/Cutting: A Statistical Overview and Exploration of the Dynamics of Change, a new report from UNICEF, analyzes nationally representative survey data from 29 African and Middle Eastern countries where female genital mutilation occurs. The report, which finds declines in the practice in more than half of the countries examined, is available at <http://www.unicef.org/media/files/FGCM_Lo_res.pdf>.

•President Obama’s federal budget request for the 2014 fiscal year, released in April, included an estimated $9 billion for global health programs under his Global Health Initiative—an increase of 1.6% from the 2012 budget (the last one for which data are available). Under the requested budget, funding for HIV/AIDS would be reduced by 5%, whereas funding for family planning and reproductive health would rise by 1%. The analysis, by the Henry J. Kaiser Family Foundation, is available at <http://kff.org/global-health-policy/fact-sheet/u-s-funding-for-global-health-the-presidents-fy-2014-budget-request/>.