Trevor Lane

First published online:


An expert group convened by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has reaffirmed that unprotected sex is the main mode of HIV transmission in Sub-Saharan Africa.1 In March 2003, WHO and UNAIDS jointly reexamined evidence on how the virus is spread, in response to three review articles suggesting that HIV infection is caused primarily by unhygienic medical procedures--particularly injections using contaminated needles--rather than by risky heterosexual behavior.2 After considering the "best available information," WHO and UNAIDS concluded that the previous WHO estimate of HIV prevalence in Sub-Saharan Africa attributable to injections (2.5%) still stands. They also maintained that "unsafe sex is by far the predominant mode of [HIV] transmission" and that "the prevention of HIV through the practice of safer sex should be the mainstay of the response to AIDS in the region."

1. World Health Organization, Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa, Geneva: WHO, Mar. 14, 2003, <http://www.who.int/mediacentre/statements/2003/statement5/en/print.html…;, accessed Mar. 28, 2003.

2. Brewer DD et al., Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm, International Journal of STD & AIDS, 2003, 14(3):144-147; Gisselquist D et al., Let it be sexual: how health care transmission of AIDS in Africa was ignored, ibid., 148-161; and Gisselquist D and Potterat JJ, Heterosexual transmission of HIV in Africa: an empiric estimate, ibid., 162-173.


The two main causes of ill health worldwide are related to maternal and reproductive health, according to an analysis of 26 risk factors that together accounted for roughly one-half of the total number of years of healthy life lost in 2000 because of illness, disability and death.1 The two leading risk factors were poor nutrition of mothers and children younger than five (responsible for 10% of the 1,456 million disability-adjusted life-years lost) and infection due to unprotected sexual intercourse (6%). In developing regions with high mortality, which include most of Africa, malnutrition and unsafe sex remained the top two risk factors (15% and 10% of disability-adjusted life-years lost, respectively), followed by unsafe water, sanitation and hygiene (6%). In contrast, tobacco use, high blood pressure, alcohol use, high cholesterol and high body mass index were the main causes of ill health in developed nations.

1. Ezzati M et al., Selected major risk factors and global and regional burden of disease, Lancet, 2002, 360(9343): 1347-1360.


Although serologic and in vitro studies have suggested that herpes simplex virus type 2 (HSV-2) helps human papillomavirus (HPV) trigger cervical cancer, DNA tests show no evidence of coinfection in cervical cancer specimens.1 Using polymerase chain reaction, researchers analyzed cervical cell specimens taken from 439 women who attended a hospital gynecology clinic between September 1998 and May 2000, including 50 women with invasive cervical cancer, 65 with high-grade squamous intraepithelial lesions and 80 with low-grade squamous intraepithelial lesions. HPV type 16 or 18 (both of which are implicated in cancer) was present in the samples from 35 women with cervical cancer and in four of the 244 normal samples. However, HSV-2 was not found in any of the cell specimens. In addition, HSV-2 was not detected in any of the 150 HPV-positive cervical cancer tissue samples that had been obtained from other laboratories. The researchers conclude that HSV-2 is absent from high-grade and cancerous lesions of the uterine cervix.

1. Tran-Tranh D et al., Herpes simplex virus type II is not a cofactor to human papillomavirus in cancer of the uterine cervix, American Journal of Obstetrics and Gynecology, 2003, 188(1): 129-134.


Women who use folic acid supplements during pregnancy are no more likely than those who do not to have multiple births, according to a population-based cohort study of women from three provinces in China who registered with a pregnancy monitoring system between October 1993 and September 1995 and who delivered at or after 20 weeks' gestation by December 31, 1996.1 Of the 242,015 women with pregnancies that were not affected by a birth defect, 53% had taken 400 mcg of folic acid daily during pregnancy. Overall, fewer than 1% of the women had multiple births (mostly same-sex twins)--0.59% of women who had taken folic acid and 0.65% of those who had not (rate ratio, 0.9). Results were unchanged after adjustment for maternal age, education and occupation, and after analysis of whether folic acid was used before ovulation, at the time of fertilization or after conception. According to the analysts, the findings suggest that "consumption of 400 mcg of folic acid alone per day, before and during early pregnancy, does not increase a woman's likelihood of having a multiple birth."

1. Li Z et al., Folic acid supplements during early pregnancy and likelihood of multiple births: a population-based cohort study, Lancet, 2003, 361(9355): 380-384.


Men's support of and involvement in family planning in Jordan increased considerably following a nationwide campaign aimed at gaining public acceptance of modern contraceptives and at encouraging joint contraceptive decision-making by spouses.1 Organized by the Jordanian National Population Committee, the Together for a Happy Family campaign ran from March 1998 to March 2000, using the mass media and holding community discussion groups to disseminate five key messages--that partners should discuss family planning, family planning is consistent with Islam, modern methods are safe and effective, sons and daughters are of equal value and use of modern methods enhances the quality of life for the whole family. Ninety-eight percent of the 1,122 men surveyed after the various campaign events reported having used a contraceptive method and having discussed family planning with their wife--a proportion significantly higher than that among 969 men interviewed in 1996 (93%). After the campaign, the level of contraceptive knowledge among men also increased: They were significantly more likely to indicate that condoms are safe (22% vs. 9%) and effective (21% vs. 11%), and that the IUD is safe (50% vs. 34%) and its use is permitted by the teachings of Islam (55% vs. 30%).

1. Johns Hopkins Bloomberg School of Public Health, Men in Jordan get involved in "Together for a Happy Family," Communication Impact! 2003, No. 14.


Nearly one-half of single young Chinese women seeking abortions have had sex against their will, according to a study conducted among abortion patients aged 21 or younger at 17 urban hospitals between January and November 2000.1 Forty-eight percent of the 2,383 respondents to a self-administered questionnaire reported that they had ever been coerced into having sexual intercourse (e.g., by use of violence, threats, verbal insistence or deception). Among these respondents, 80% indicated that the perpetrator was their boyfriend, whereas 21% said that it was a colleague, 18% a schoolmate and 9% their boss. Roughly two-thirds said that their first episode of intercourse had been forced. A significantly higher proportion of women who had been forced to have intercourse than of women who had not been coerced had been younger than 18 at sexual debut (31% vs. 19%). In a logistic regression analysis, unwanted sex was associated with having sex for material or financial gain (odds ratio, 7.3), consuming alcohol during intercourse (3.5), having been beaten by a partner (2.2), having multiple partners (1.8), having sex after watching pornographic videos (1.7) and having less than a high school education (1.2). The researchers suggest that interventions to prevent sexual coercion be included in adolescent reproductive health programs in China.

1. C Yimin et al., Sexual coercion among adolescent women seeking abortion in China, Journal of Adolescent Health, 2003, 31(6):482-486.


HIV is the leading cause of mortality among women in South Africa, according to an analysis of a random sample of death certificates from 1997 to 2001.1 Using international guidelines to classify diseases, Statistics South Africa found that overall, HIV infection accounted for the highest proportion of female deaths (9%). "Ill-defined" causes and cerebrovascular disease each caused 8% of deaths, and influenza and pneumonia, tuberculosis and nonischemic heart disease each accounted for 7%. Other conditions--for example, breast cancer, perinatal disorders and anemia--each accounted for 1-6% of female deaths. Women aged 15-39 and black women were the groups most likely to die of HIV infection (21-23% and 14%, respectively), whereas women aged 50 or older and white women were the least likely (1% for each). By comparison, men most commonly died of "unspecified unnatural" causes, such as suicide, drowning or road injuries (16%), and they were less likely than women to die because of HIV (7%).

1. Statistics South Africa (Stats SA), Causes of Death in South Africa 1997-2001: Advance Release of Recorded Causes of Death, Pretoria, South Africa: Stats SA, 2002.


• According to United Nations Population Fund (UNFPA) estimates, 150,000 pregnant women will be displaced or seriously affected by the war in Iraq, and more than 20,000 will require emergency medical care, such as cesarean delivery, for high-risk pregnancies. Noting that the maternal mortality rate in Iraq is already much higher than that in developed countries--370 vs. 21 per 100,000 live births--and that 130 infants die for every 1,000 born alive, UNFPA urged relief efforts to "ensure that the needs of Iraqi women are fully addressed." [McDermott A, Iraq's female health crisis, Mar. 29, 2003, <http://news.bbc. co.uk/1/hi/ health/2896945.stm>, accessed Apr. 14, 2003.]

• Access to cesarean sections is not improving in Sub-Saharan Africa, according to an analysis of Demographic and Health Surveys from countries where two such surveys were conducted in the 1990s. The proportion of live singletons delivered by cesarean section generally decreased during the decade and remained lower than 5% in all countries studied except Kenya; the proportion of single births occurring in health facilities also decreased in most countries. The analysts attribute these trends to "the lack of progress of Safe Motherhood programmes in a region where maternal mortality is extremely high." [Buekens P, Curtis S and Alayón S, Demographic and Health Surveys: caesarean section rates in Sub-Saharan Africa, British Medical Journal, 2003, 326(7381):136.]

• Childhood mortality is declining in Nepal: Between 1980 and 2000, the mortality rate among infants younger than one decreased by one-third--from 114 to 76 deaths per 1,000 births--and that among children younger than five decreased by nearly one-half--from 200 to 110 per 1,000. Contributing factors include a 900% increase in the proportion of 12-23-month-old children who were vaccinated against diphtheria, pertussis and tetanus (from 8% to 80%) and a 27% reduction in the total fertility rate (from 6.4 to 4.7). [U.S. Agency for International Development (USAID), USAID Country Health Statistical Report: Nepal, March 2003, Washington, DC: USAID, 2003.]