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The IUD, an effective contraceptive known to reduce the risk of endometrial cancer, may also be protective against cervical cancer. A pooled analysis of 26 studies conducted in developed and developing countries on four continents between 1985 and 2007 found that the odds of cervical cancer were reduced by 45% among women who had ever used an IUD (odds ratio, 0.6).1 The results were similar for the two major types of cervical tumors (squamous-cell carcinoma, 0.6; and combined adenocarcinoma and adenosquamous carcinomas, 0.5), but the association did not hold for women who were infected with human papillomavirus (HPV), and it was not affected by women's duration of IUD use. There was no association between IUD use and HPV infection among women without cervical cancer. The researchers remark that "women, gynaecologists, and reproductive-health professionals can be reassured that IUDs do not seem to increase the risk of cervical HPV infection; and our study contributes solid evidence that IUD use might even reduce the risk of developing cervical cancer."

1. Castellsagué X et al., Intrauterine device use, cervical infection with human papillomavirus, and risk of cervical cancer: a pooled analysis of 26 epidemiological studies, Lancet Oncology, 2011, 12(11):1023–1031.


Offering a greater variety of condom brands through public family planning programs may not increase men's condom use, according to a study conducted in 2002–2004 in Ghana, Kenya and South Africa.1 In the pooled sample of 620 sexually active adult men who had access to 3–4 types of free condoms— including premium and local brands, as well as the standard brand provided by the U.S. Agency for International Development—the proportion of sexual acts with all partners reported as protected had increased by three percentage points (from 85% to 88%) by the end of the six-month study period. However, in the control sample of 611 similar men who had access to only the standard brand, the percentage of acts reported as protected increased by seven points over the same period (from 84% to 91%). The authors conclude that "the provision of one type of male condom in public sector programs appears justified," and that "programs should not focus on the number of brands available, but should encourage effective promotion of available brands together with emphasizing consistent and correct use."

1. Weaver MA et al., The effects of condom choice on self-reported condom use among men in Ghana, Kenya and South Africa: a randomized trial, Contraception, 2011, 84(3):291–298.


A national payment-for-performance scheme implemented in 2005 by the Rwandan government offering health facilities financial incentives for use and quality of specific maternal and child health services appears to be at least somewhat effective, according to an evaluation of the program conducted in 2006–2008.1 Over the two-year study period, facilities randomly selected to receive payments for 14 key maternal and child health services (ranging from $0.09 per first prenatal care visit to $4.59 per institutional delivery) reported increases in the numbers of child preventive care visits (56% among 0–23-month-olds and 132% among 24–59-month-olds) and institutional deliveries (23%), compared with control facilities that received a traditional budget that was increased every three months by the average amount paid to intervention facilities, to account for funding differences. There were no differences between the groups in the numbers of vaccinations or prenatal care visits, but payment-for-performance facilities did show a relative improvement in the quality of their prenatal care. The authors conclude that "higher payments provide stronger incentives" and "incentives have a larger effect on services in which providers have more control over delivery, such as prenatal care quality."

1. Basinga P et al., Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation, Lancet, 2011, 377(9775): 1421–1428.


One in five people in Soweto, South Africa, who tested positive for HIV declined free antiretroviral therapy, most commonly because they felt healthy at the time.1 Among the 7,287 adults who presented at a Soweto HIV testing facility between 2008 and 2009 for voluntary counseling and testing, 35% received a positive diagnosis for HIV. Of those who had a CD4+ cell count low enough (<200/ul) to be eligible for immediate, free, on-site antiretroviral therapy, 80% agreed to treatment, but 20% refused. The vast majority (92%) of those who initially declined treatment continued to do so two months later. Factors associated with increased odds of refusal included having active tuberculosis and being single, divorced or widowed (odds ratios, 3.2 and 1.8, respectively). More than 35% of those who refused treatment reported "feeling healthy" as their main reason for doing so. The authors conclude that South Africa's expanding efforts to reach those living with HIV and in need of treatment "will require marketing the concept of [antiretroviral therapy] as a life-saving intervention, even for people who report feeling healthy."

1. Katz IT et al., Antiretroviral therapy refusal among newly diagnosed HIV-infected adults, AIDS, 2011, 25(17):2177– 2181.


Written invitations given to men by their pregnant partner can increase their participation in voluntary HIV counseling and testing, according to an antenatal clinic–based study conducted between 2006 and 2007 in Cape Town, South Africa.1 One thousand pregnant clients of an antenatal clinic in Khayelitsha township were given a written letter for their male partner, inviting him to participate in a couple-oriented antenatal care visit the following week, as well as either voluntary HIV counseling and testing or a general pregnancy information session. Thirty-five percent of women in the counseling and testing group brought their male partner to the clinic the following week, compared with 26% of those in the pregnancy information group. In multivariate analyses, men invited to counseling and testing were more likely than men invited to a pregnancy information session to accompany their partner to the antenatal care clinic visit (odds ratio, 1.5). In addition, men invited for counseling and testing were more likely than men invited to the pregnancy information session to undergo counseling and testing at their clinic visit (relative risk, 2.8). The authors comment that their findings "suggest that in Khayelitsha—and perhaps in other similar settings in Sub-Saharan Africa—it is possible to increase the number of [male sex partners] attending HIV testing in [antenatal clinics] by inviting them."

1. Mohlala BKF, Boily MC and Gregson S, The forgotten half of the equation: randomized controlled trial of a male invitation to attend couple voluntary counseling and testing, AIDS, 2011, 25(12):1535–1541.


Women in sexual relationships with older men may underestimate the age difference between themselves and their partners, and in turn, their risk of HIV. According to an analysis of survey data from both male and female members of 519 couples in Likoma, Malawi, 89% of women with a partner of similar age (no more than five years older) correctly reported the age difference between themselves and their partner;1 however, only 24% of women with a partner six or more years older—and just 10% of those with a partner 10 or more years older—correctly reported that their partners were that much older. Among women in relationships with men at least six years older, a smaller proportion of those younger than 25 than of those 25 or older correctly reported the age difference between themselves and their partners (14% vs. 29%). Among the 43 couples in which the male partner was HIV+, only 16% of women reported having a partner six or more years older, when the actual proportion was 47%. The authors conclude that "women's survey reports of their partner's age significantly underestimate the extent of and the HIV risk associated with age mixing," and that "future studies of the effect of sexual mixing patterns on HIV risk in Sub-Saharan African countries should take reporting biases into account."

1. Helleringer S, Kohler HP and Mkandawire J, Women underestimate the age of their partners during survey interviews: implications for HIV risk associated with age mixing in northern Malawi, Sexually Transmitted Diseases, 2011, 38(11): 1030–1035.


Women who have greater autonomy in making important household decisions may also be better able to decide whether and when they have sex, according to an analysis of the most recent Demographic and Health Survey data from Ghana, Malawi, Mali, Rwanda, Uganda and Zimbabwe. Of nonpregnant women currently in a monogamous union, 61–88% had had sex in the last month; women's average time since last sex ranged from three days in Rwanda and Zimbabwe to 14 days in Ghana. In multivariate analyses controlling for household, relationship and demographic characteristics, women's autonomous decision making on issues such as family health care and large household purchases was negatively associated with time since last intercourse in all six countries. That is, the greater the number of important household decisions a woman reported being able to make on her own, rather than jointly with her partner, the greater the number of days since she had last had sex. The authors comment that their findings are important because understanding how women's position in the household is associated with their sexual activity "may be an essential piece in protecting the sexual rights of women and helping them to achieve a sexual life that is both safe and pleasurable."

1. Hindin MJ and Muntifering CJ, Women's autonomy and timing of most recent sexual intercourse in Sub-Saharan Africa: a multi-country analysis, Journal of Sex Research, 2011, 48(6): 511–519.


•On October 31, 2011, the world's population reached seven billion people. To examine what that milestone means now and for the future, the United Nations Population Fund has released a report entitled People and Possibilities in a World of 7 Billion, available at <http://foweb. unfpa.org/SWP2011/reports/EN-SWOP2011-FINAL.pdf>.

•In "Stop Making Excuses": Accountability for Maternal Health Care in South Africa, Human Rights Watch finds that South Africa’s maternal mortality ratio has more than quadrupled over the last decade. The report, which calls on South Africa to do more to identify barriers to quality health care and to use that information to strengthen the health system, is available at <http://www.hrw.org/sites/default/ files/reports/sawrd0811webwcover.pdf>.

•According to a Kaiser Family Foundation global policy report, official development assistance for health efforts including HIV/AIDS and family planning increased by nearly 300% between 2002 and 2009, and grew as a share of overall assistance, despite the economic crisis. The report entitled Donor Funding for Health in Low- & Middle- Income Countries, 2002–2009, is available at <http://www.kff.org/ globalhealth/upload/7679-05.pdf>.