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The human papillomavirus (HPV) vaccine may be equally effective if given on dosage schedules other than the standard one (i.e., injections at zero, two and six months), according to a study of 903 female students aged 11–13 conducted in Hoa Binh province, Vietnam, between September and December 2007.1 Thirty days after receiving the third of three injections, young women who had been vaccinated on two alternative schedules (zero, three and nine months or zero, six and 12 months) had concentrations of antibodies against four HPV serotypes (16, 18, 6 and 11, all of which are associated with an elevated risk of cervical cancer) that were no different than those of women who were vaccinated on the standard schedule; women who received the vaccine on a third alternative schedule (zero, 12 and 24 months) had antibody concentrations against all HPV types except 11 that were lower than those achieved using the standard schedule. The vaccine was generally tolerated well by participants, regardless of schedule. The authors comment that "the World Health Organization acknowledges that programmatic constraints must be considered in the decision to commence national HPV immunization programs. The option of delivering HPV vaccine on flexible schedules will allow countries to minimize costs and maximize feasibility according to local vaccination practices."

1. Neuzil KM et al., Immunogenicity and reactogenicity of alternative schedules of HPV vaccine in Vietnam, JAMA, 2011, 305(14):1424–1431.


Maternal and perinatal mortality rates associated with delivery by cesarean section do not differ by whether the procedures are performed by clinical officers— nonphysician health care providers trained to perform clinical tasks—or by medical doctors, according to a metaanalysis of six controlled studies conducted between 1987 and 2009.1 In the combined sample of 16,018 women in five countries (Burkina Faso, Malawi, Mozambique, Tanzania and Zaire), cesareanrelated maternal and perinatal mortality rates were high (1% and 11%, respectively). The risk of maternal death or perinatal death associated with cesareans performed by clinical officers did not differ from the risk among those performed by doctors; however, cesareans performed by clinical officers were more likely to be complicated by infection or wound opening (odds ratios, 1.6 and 1.9, respectively). The authors conclude that "enhanced access to emergency obstetric surgery through greater deployment of clinical officers, in countries with poor coverage by doctors, can form part of the solution to meet Millennium Development Goals 4 (reducing child mortality) and 5 (improving maternal health)." However, the increased risk of complications with cesareans performed by clinical officers led the authors to suggest that there may be "a need for enhanced training."

1. Wilson A et al., A comparison of clinical officers with medical doctors on outcomes of caesarean section in the developing world: metaanalysis of controlled studies, BMJ, 2011, doi: 10.1136/mbmj.d2600.


Individual, family and community characteristics are associated with young people’s experience of premarital sex in India, according to a study conducted in six of the country’s states between 2006 and 2008.1 In the sample of 45,555 married and unmarried women and men aged 15–24, fewer than 1% reported having had premarital sex by age 15; 5% of women and 11% of men had had premarital sex by age 20, and 10% and 30%, respectively, had done so by age 25. Of those who had had premarital sex, 86% of women and 60% of men had first had sex with an oppositesex romantic partner. For 18% of women and 2% of men, their first sexual experience had been forced, mostly by a romantic partner (13% and 1%). Rural residence, substance use, having peers as confidants and having peers who had experienced premarital sex were positively associated with having had premarital sex among both men and women (hazard ratios, 1.2–5.1); education, mother’s education, having parents as confidants and economic status of the neighborhood were negatively associated (0.78–0.98). The authors comment that their findings "underscore the role that a supportive family environment plays in delaying the onset of premarital sex." They add that sexual and reproductive health programs "must target not only young people but also their peers and the influential adults in their life, including parents."

1. Santhya KG et al., Timing of first sex before marriage and its correlates: evidence from India, Culture, Health & Sexuality, 2011, 13(3):327–341.


Emergency contraceptive (EC) pills are substantially less effective at preventing pregnancy if taken on the fifth day rather than on one of the first four days after unprotected sex, according to a study of data from four controlled trials conducted between 1993 and 2010.1 In the combined sample of 6,794 women who received 1.5 mg of levonorgestrel within 120 hours of unprotected sex, those who took EC on any of the first four days had a similar pregnancy rate (1–2%); however, those who received it on day 5 had a higher rate (5%). In regression analysis, women who took EC on the second, third or fourth day after unprotected sex had no greater risk of pregnancy than those who did so during the first 24 hours; however, women who received EC on day 5 had nearly six times the odds of becoming pregnant (odds ratio, 5.8). The authors comment that they found "no evidence of an increase in pregnancy rates with the delay in administration of 1.5 mg of [levonorgestrel]… until the fourth day inclusive after an act of unprotected sex." They add that "it is uncertain whether [levonorgestrel] administration on the fifth day still offers some protection against unwanted pregnancy."

1. Piaggio G, Kapp N and von Hertzen H, Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials, Contraception, 2011, 84(1):35–39.


Implementation of routine HIV counseling and testing—in which patients must explicitly choose not to receive those services—is associated with substantially greater uptake of such services than voluntary testing and counseling, according to a study conducted in Zambia between July 2008 and December 2010.1 Of the 44,420 patients who came to primary clinics in Lusaka during the study period without knowing their HIV status and who received routine pretest counseling, 31,197 (75%) accepted testing—nearly twice the number who accepted when they had to opt in to testing and counseling. Twentyone percent of clients who were tested were HIVpositive; of those, 38% enrolled in treatment. The rate of acceptance of HIV testing increased from 52% to 83% over the study period. The authors comment that routine counseling and testing increases uptake of services, but caution that "since patients undergoing [providerinitiated HIV testing and counseling] are less likely to be prepared for a positive HIV test result than those undergoing [voluntary counseling and testing], it would also be helpful to determine whether more extensive counseling or a different form of counseling about enrollment in HIV care and treatment would be beneficial."

1. Topp SM et al., Optout providerinitiated HIV testing and counseling in primary care outpatient clinics in Zambia, Bulletin of the World Health Organization, 2011, 89(5):328–335.


A substantial proportion of emergency contraceptive (EC) users in Kenya use the method regularly for family planning, according to a study of female clients of pharmacies in five of the country’s provinces.1 Of the 147 women who purchased EC for their own use at a pharmacy during the fiveday study period in August 2007, 58% had purchased the method at least one other time during the previous month, 34% had purchased it at least one other time two or more months before and 8% were purchasing it for the first time. On average, women had used EC nearly four times in the prior six months (mean, 3.8). Eighteen percent reported using EC at every act of sexual intercourse in the past six months, and another 30% used it after most episodes of intercourse during that period. Greater proportions of those who had purchased EC at least twice in the last month than of others considered EC more convenient than other methods (70% vs. 48%) and thought that it could be used as a regular method (42% vs. 25%). The authors comment that their findings "suggest that EC effectively meets the needs of this subset of [family planning] users and… should be considered as an important element of the [family planning] method mix. This underscores the utility of positioning EC as both an ‘emergency’ and a ‘regular’ method of [family planning]."

1. Keesbury J, Morgan G and Owino B, Is repeat use of emergency contraception common among pharmacy clients? Evidence from Kenya, Contraception, 2011, 83(4):346–351.


Mobile vans that offer STI services are effective at reaching atrisk individuals in developing country settings who might not seek such services from traditional clinics, according to a study conducted in Escuintla province, Guatemala, between February 2006 and May 2009.1 Of the 2,874 men and women older than 15 who were tested for HIV and syphilis during the study period, 54% went to a community health care center–based STI clinic and 46% went to a mobile clinic at different sites (e.g., bars and brothels) within the study area. The majority of female sex workers and men who had sex with men were seen at mobile clinics (73% each). Forty percent of clients reported having previously been tested for HIV; among men who had sex with men, a greater proportion of those seen at STI clinics than of those seen at mobile clinics had been tested (42% vs. 21%). Overall, 19% of the HIV cases and 69% of the syphilis cases detected were diagnosed at mobile clinics; HIV prevalence was higher at STI clinics than at mobile clinics for men who had sex with men (8% vs. 1%) and for non–highrisk clients (7% vs. 1%). The authors comment that their findings "provide evidence of the success of STI clinics in identifying new cases of HIV among atrisk populations, as well as emphasizing the benefits of using innovative approaches such as the [mobile clinics] to increase access to hardtoreach groups."

1. Lahuerta M et al., Comparison of users of an HIV/syphilis screening communitybased mobile van and traditional voluntary counseling and testing sites in Guatemala, Sexually Transmitted Infections, 2011, 87(2):136–140.


•According to a report by the United Nation’s Population Fund, 38 of 58 developing countries examined might not meet the fifth Millennium Development Goal of having 95% of births delivered by skilled attendants by 2015. State of the World’s Midwifery 2011 shows that as many as 3.6 million deaths could be avoided each year through adequate midwifery services. The report is available at <http://www.unfpa.org/sowmy/resources/docs/main_report/en_ SOWMR_Full.pdf>.

•The World Health Organization has published a set of guidelines designed for use by national public health officials and managers of HIV and STI programs to address the STIrelated needs of men who have sex with men and of transgender people. Prevention and Treatment of HIV and Other Sexually Transmitted Infections Among Men Who Have Sex with Men and Transgender People can be found at <http://whqlibdoc. who.int/publications/2011/9789241501750_ eng.pdf>