Advancing Sexual and Reproductive Health and Rights
 
Perspectives on Sexual and Reproductive Health
Volume 40, Number 4, December 2008
FYI


STD PREVENTION: BEHAVIORAL COUNSELING GETS FEDERAL NOD

After reviewing the clinical data, the U.S. Preventive Services Task Force has found “convincing evidence” that “high-intensity” behavioral counseling can help prevent STDs among adults who are at high risk and among sexually active adolescents.1 The task force therefore recommends that high-intensity counseling—characterized by multiple sessions, which are frequently presented to small groups—be offered to all such individuals. (According to the task force, adults are at high risk if they have an STD or had one in the past year, if they have multiple partners or if they live in a community with high STD rates and they are sexually active and nonmonogamous.) Effective counseling may be delivered in primary care settings or elsewhere in the health system or community, and the task force emphasizes that collaboration between the primary care sector and the community may enhance delivery. The task force found only limited evidence supporting the effectiveness of counseling teenagers who are not sexually active and no evidence that counseling adults who are not at high risk is effective. Looking ahead, it recommends the use of biologically confirmed outcomes to measure interventions’ effectiveness, development and evaluation of interventions for particular populations, and assessment of continuity of care as a factor in effectiveness.

1. U.S. Preventive Services Task Force, Behavioral counseling to prevent sexually transmitted infections: U.S. Preventive Services Task Force Recommendation Statement, Annals of Internal Medicine, 2008, 149(7):491–497.

CAN MATERNAL DEATHS BE AVOIDED?

Of the nearly 1.5 million women obtaining obstetric care during the period 2000–2006 in this country’s largest health care delivery system, 95 died during pregnancy or soon after delivery, and only 27 of these deaths could have been avoided.1 In a study based on record reviews from a network of hospitals with a patient population that is “roughly” nationally representative, more than half of maternal deaths were attributable to four causes: complications of preeclampsia, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Eighteen percent of the deaths could have been prevented with “more appropriate medical care,” and 11% were preventable but were unrelated to medical care (for example, two women died in motor vehicle accidents, and two committed suicide). Most of the women who died would have been considered at low risk of dying during pregnancy: Preexisting medical conditions contributed to only 15% of deaths. Four deaths apparently were directly attributable to cesarean delivery, and two to vaginal delivery. “Whereas any precise figures regarding frequencies of preventable deaths must be viewed with caution,” the investigators write, “it is clear that the majority of maternal deaths in the United States are not preventable.”

1. Clark SL et al, Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery, American Journal of Obstetrics & Gynecology, 2008, 199(1):36.e1–36.e5.

NOT TELLING COULD HURT YOU

In a survey of adult men who have sex with men living in and around New York City, 39% of participants said that they had not told any health care provider that they are attracted to or have sex with men.1 A wide range of demographic, socioeconomic and behavioral characteristics were examined in multivariate analyses, but few were associated with the likelihood of disclosure. Black and Hispanic men were less likely than whites to have told a provider that they were attracted to or had sex with men (odds ratios, 0.3 and 0.5, respectively), and men who had had a female partner in the last 12 months were less likely than others to have made such a disclosure (0.1). The odds were elevated among men who had ever had an HIV test (2.1), U.S.-born men (1.9) and men reporting incomes of at least $10,000 (3.9–4.7, depending on the income group). No men who considered themselves bisexual had disclosed that to a provider. The investigators note that despite federal recommendations of universal HIV screening, many providers continue to offer HIV tests only to patients they consider to be at risk. If these providers are not aware of patients’ risk factors, the researchers conclude, high-risk individuals could be missed.

1. Bernstein KT et al., Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches, Archives of Internal Medicine, 2008, 168(13):1458–1464.

USAID TARGETS MARIE STOPES

The U.S. Agency for International Development (USAID) has instructed the governments of six African countries to stop distributing U.S.-donated contraceptive supplies to Marie Stopes International, a British charity that operates sexual and reproductive health programs in the developing world.1 USAID’s decision stems from its assessment of the role that Marie Stopes plays in the United Nations Population Fund’s family planning program in China, which the State Department contends involves “coercive abortion or involuntary sterilization” and therefore is ineligible for U.S. assistance.2 Marie Stopes claims that the move—which affects Ghana, Malawi, Sierra Leone, Tanzania, Uganda and Zimbabwe—was politically motivated and could lead to increases in abortion, maternal mortality and health problems among poor women.1 USAID says that it is “working with governments in the affected countries”2 to ensure that the supplies that would have been channeled through Marie Stopes are distributed by other groups.

1. Lee M, US cuts off family planning group in Africa, Associated Press, Oct. 2, 2008, <http://washingtonpost.com/wp-dyn/content/article/2008/10/02/AR20081002202772.html?referrer=emailarticle>, accessed Oct. 2, 2008.

2. U.S. Agency for International Development, USAID statement regarding its decision on Marie Stopes International, news release, Oct. 10, 2008, <http://www.usaid.gov/press/releases/2008/ps081010.html>, accessed Oct. 17, 2008.

NEW VACCINATION UPTAKE LOW

The first nationwide estimates of adolescent women’s receipt of the human papillomavirus (HPV) vaccine suggest that coverage is well below the federally recommended level.1 In March 2007, just a few months after the vaccine went on the market, a federal advisory committee recommended that the three-shot series routinely be administered to 11- and 12-year-old females. However, only 25% of 13–17-year-olds surveyed in the fourth quarter of that year had had at least one shot; the proportion did not differ by age within this group. Among teenagers who had had at least one shot, 24% had completed the series; 32% had received one dose, and 44% had gotten two shots. Future surveys will monitor vaccine completion rates. Proponents of the vaccine, who had hoped for much swifter uptake, speculate that several factors may contribute to the low coverage rate: parents’ uncertainty about the safety of the new vaccine, its cost and questions about whether it provides lifetime immunity against HPV.2

1. Jain N, Stokley S and Yankey D, Vaccination coverage among adolescents aged 13–17 years—United States, 2007, Morbidity and Mortality Weekly Report, 2008, 57(40):1100–1103.

2. Associated Press, Cancer vaccine used by 25% of girls 13 to 17, New York Times, Oct. 10, 2008, p. A21.

GETTING TO KNOW YOU

Women working in licensed brothels in Victoria, Australia, primarily cite financial rewards as their reason for having entered the sex industry; nevertheless, many express concerns about their line of work.1 In a 2006 survey of 97 women working in 38 of Victoria’s 92 licensed brothels, 56% said that they had gone into sex work because they had needed the money—several specified that they were trying to pay for an education or support a family—and 6% said that they could not get another job. Although the industry is regulated in Victoria, 55% of women expressed concerns about the STD risk attached to their work, 38% had other safety concerns and 47% worried about community attitudes toward them. Anonymity was important to many women; in particular, women were concerned about hurting their families, being rejected by them or having their children learn of their work. About half said that they would like to leave the industry, and nearly two-thirds said that they might be able to leave if they had an opportunity to train for a mainstream job. While acknowledging the limited generalizability of their sample, the researchers hope that their findings help to reduce stigma associated with sex work and to ensure that legal sex workers receive appropriate services and protections.

1. Groves J et al., Sex workers working within a legalised industry: their side of the story, Sexually Transmitted Infections, 84(5):393–394.

WHEN YOU CARE ENOUGH TO SEND THE VERY BEST

Individuals who learn that they have an STD now have a simple, quick way of letting recent partners know: By logging onto www.InSPOT.org, they can send a free e-card with a simple, direct message to an unlimited number of individuals, notifying them that they may have been exposed to an STD and should be tested.1 They even have the option of sending the cards anonymously. The Web site also contains a wealth of information about STD risks, symptoms and treatments; how to talk to partners about an STD diagnosis; and how to get further information. For selected cities, it helps individuals find an STD testing facility. Since the site was launched in 2004, close to 50,000 cards have been sent, but the service’s effectiveness is not yet known.

1. Alexander B, STD postcards: you’ve got mail—and more, Oct. 20, 2008, <http://www.msnbc.msn.com/id/27205681/>, accessed Oct. 23, 2008.

WITH ANTIRETROVIRAL DRUGS, LIFE, WITH HIV, GOES ON

Life expectancy of HIV-positive people receiving combination antiretroviral therapy has increased substantially since the introduction of this treatment strategy in 1996, according to results of a study conducted among 14 cohorts in developed countries.1 Analysts examined data on three cohorts of individuals beginning combination antiretroviral therapy: approximately 19,000 in 1996–1999, nearly 14,000 in 2000–2002 and close to 11,000 in 2003–2005. At age 20, individuals in the earliest cohort could expect to live another 36 years; for the latest cohort, the figure was 49 years. Similarly, life expectancy at age 35 increased by 12 years across cohorts. Men had a slightly lower life expectancy at age 20 than women (43 vs. 44 years), and individuals who had likely acquired HIV infection through injection-drug use had a dramatically lower life expectancy than those who had become infected through another means (33 vs. 45 years). Life expectancy also was related to baseline CD4 cell count (32 years at age 20 for patients with the lowest counts, compared with 50 years for those with the highest counts). The investigators comment that “the marked increase in life expectancy since 1996 is a testament to the gradual improvement and overall success of [combination antiretroviral] treatment.” Nevertheless, they urge health planners to use these findings to work toward further improvements.

1. The Antiretroviral Therapy Cohort Collaboration, Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies, Lancet, 372(9635):293–299.