WHO STATEMENT ON HORMONAL CONTRACEPTIVES AND HIV
According to a technical statement released by the World Health Organization (WHO), all hormonal contraceptive methods should continue to be available without restriction to women living with HIV or at high risk of HIV infection.1 On January 31 and February 1, 2012, WHO convened a meeting of 75 experts in international family planning and HIV to determine whether to change the safety guidelines for hormonal contraceptives in light of recent findings suggesting an increased risk of HIV acquisition among women who use the progesterone-only injectable. After careful review and extensive discussion of all the available evidence, the committee did not find sufficient cause to change the existing guidelines, which recommend no restrictions on the use of any hormonal contraceptive method for women living with or at high risk of HIV. However, because the research on an association between the risk of HIV acquisition and the use of the progesterone-only injectable was deemed inconclusive, the committee decided to add a clarification strongly advising that women at high risk of HIV who choose to use the method also always use condoms and other preventive measures.
World Health Organization, Department of Reproductive Health and Research, Hormonal Contraception and HIV: Technical Statement, 2012, <http://www.who.int/reproductivehealth/topics/family_planning/Hormonal_contraception_and_HIV.pdf>, accessed Feb. 22, 2012.
HPV VACCINE PROGRAMS IN THE DEVELOPING WORLD
High rates of human papillomavirus vaccine coverage among young adolescent females appear to be achievable in developing countries, according to an assessment of demonstration projects implemented by the nongovernmental organization PATH and country governments in India, Peru, Uganda and Vietnam between 2006 and 2010.1 Some 52,755 female 10–14-year-olds in 11 project areas were eligible to participate in the vaccination programs, which were based in schools or health centers, or combined with other existing health interventions. Researchers surveyed a random combined sample of 7,269 parents or guardians of eligible adolescents from all project areas, and estimated that the proportion of eligible adolescents who received the full three-dose course of vaccine ranged from 53% (a combined program in Uganda) to 99% (a health center–based program in Vietnam). All school-based programs achieved high coverage (83% in Peru, 91% in Uganda and 96% in Vietnam). In India, the two programs implemented were each based in both schools and health centers, and achieved coverage of 68–88%, depending on geographical area and delivery approach. More than two-thirds of parents or guardians reported having their daughter vaccinated to protect her against cervical cancer, to prevent her from getting a disease or infection, or because they believed vaccines were good for her health; for adolescents who were not vaccinated, school absenteeism was the reason most commonly cited. The authors conclude that “high vaccination coverage can be achieved through a variety of strategies,” and suggest that “reinforcing positive motivators…could enhance acceptability in communities and increase vaccination coverage.”
LaMontagne DS et al., Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries, Bulletin of the World Health Organization, 2011, 89(11):821–830B.
WHAT YOU DO KNOW CAN HURT YOU?
Knowledge of the protection male circumcision offers against HIV infection may influence circumcised men to engage in risky sexual behaviors, according to a study conducted in Cape Town, South Africa.1 Among 304 HIV-negative men attending an urban health clinic who reported having been circumcised for cultural or religious reasons, and not for HIV prevention, 25% had heard that male circumcision protects against HIV infection. On average, men scored in the middle on a risk compensation scale measuring the extent to which they believed that circumcised men can safely engage in risky sexual behaviors (2.0 on a scale of 0.0 to 4.0), and slightly below the middle on a scale measuring their perception of the HIV risk of a circumcised man engaging in various sexual acts with an HIV-positive woman relative to that of a uncircumcised man (–0.4 on a scale of –4.0 to 4.0). Men’s risk of having had vaginal sex without a condom in the previous three months was positively associated with their knowledge that circumcision protects against HIV, their belief that circumcision compensates for risky sexual behavior and their perception that the risk of infection during sex with an HIV-positive woman is lower for circumcised men (relative risks, 1.1 each). In addition, men’s greater perception that circumcision lowers the HIV risk of sex with an infected partner was associated with a greater number of sex partners in the previous three months (1.1). The authors conclude that overlooking “the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised” could “undermine current efforts to reduce HIV transmission through male circumcision.”
Eaton LA et al., The influence of male circumcision for HIV prevention on sexual behavior among traditionally circumcised men in Cape Town, South Africa, International Journal of STD & AIDS, 2011, 22(11):674–679.
MATERNAL LEAVE POLICY AND CHILDHOOD VACCINATIONS
The amount of paid maternal leave guaranteed to women by a country’s national labor policy is positively associated with the levels of vaccine uptake among its children, according to an analysis of policy data from 185 United Nations member countries worldwide.1 On average, women around the globe are guaranteed the equivalent of 17 weeks of paid full-time maternal leave. Duration of maternal leave varies substantially by region, ranging from nine weeks in East Asia and the Pacific to 34 weeks in Europe and Central Asia. Virtually all countries provide paid maternal leave of at least six weeks, which covers the period of administration of the Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis and the first dose of the diphtheria, pertussis and tetanus (DPT) vaccine; 40% provide at least 14 weeks, which covers the polio vaccine and all three doses of DPT; and only 18% provide at least 39 weeks, which covers the measles vaccine. In multivariate analyses, a 10% increase in the number of weeks of paid maternal leave was associated with an increase in coverage for vaccines delivered soon after birth (16 percentage points for BCG and 15 points for the first dose of DPT); the associated increase was even greater for those delivered later (22 points for polio and the third dose of DPT, and 25 points for measles). The authors comment that maternal leave has been positively associated with other maternal and child health outcomes, such as breast-feeding uptake and reduced child morbidity and mortality rates, and that their analysis “provides an additional reason to pursue stronger leave policies.”
Daku M, Raub A and Heymann J, Maternal leave policies and vaccination coverage: a global analysis, Social Science & Medicine, 2012, 74(2):120–124.
NEGOTIATING SEX AND CONDOM USE IN VIETNAM
Of a nationally representative sample of 4,632 Vietnamese women aged 15–49, only 57% of those who were married and sexually active in the 12 months before interview reported having self-efficacy in negotiating sexual activity—that is, they believed that they could refuse to have sex with their husband and could ask him to use a condom if they wanted to.1 Greater proportions of women who claimed self-efficacy than of those who did not reported using condoms at last sex (11% vs. 6%) and using condoms consistently (8% vs. 5%). In multivariate analyses, women with self-efficacy were more likely than others to have used condoms at last sex and to use condoms consistently (odds ratios, 1.6 each). In addition, self-efficacy and the two condom use measures were positively associated with several other independent variables, such as women’s daily viewing of television, knowledge that condoms can prevent HIV and knowledge of where to obtain condoms (1.4–3.5). The authors suggest that “the availability of condoms for disease prevention should continue to be widely promoted, and that efforts should be made to assist women in asserting their need for protection from HIV infection.”
1. Do M and Fu H, Is women’s self-efficacy in negotiating sexual decisionmaking associated with condom use in marital relationships in Vietnam? Studies in Family Planning, 2011, 42(4):273–282.
A MORE AFFORDABLE METHOD OF MEDICATION ABORTION?
Treatment with mifepristone before administration of misoprostol is a highly effective medical protocol to induce abortion, although mifepristone is expensive and is not available in some countries. To determine whether the drug letrozole—which in a pilot study acted synergistically with misoprostol to terminate pregnancies in the first trimester—could be an inexpensive alternative to mifepristone for second-trimester abortions, researchers in Hong Kong conducted a placebo-controlled trial of 130 women seeking termination of pregnancies at 12–20 weeks of gestation from the Department of Obstetrics and Gynecology at the University of Hong Kong.1 Among the women randomized to pretreatment with 7.5 mg of letrozole orally for three days before receiving 400 mcg misoprostol vaginally every three hours until abortion occurred, the abortion rates were 69% by 12 hours, 95% by 24 hours and 99% by 48 hours. The same protocol was used for the control group, except that women were pretreated with a placebo instead of letrozole; in this group, abortion rates were 65%, 92% and 97%, respectively—not significantly different from those of the letrozole group. Neither the median interval between induction and abortion (10 hours for the letrozole group vs. 11 hours for the control group) nor the most commonly reported side effects (fever above 38 degrees Celsius, and chills and rigors) differed between groups. The authors conclude that the letrozole regimen “does not improve the abortion rate in the second trimester when compared with that of the misoprostol-only regimen.”
1. Lee VCY et al., A prospective double-blinded, randomized, placebo-controlled trial on use of letrozole pretreatment with misoprostol for second-trimester medical abortion, Contraception, 2011, 84(6):628–633.
HIV PREVENTION PROGRAM IS LINKED TO LOWER PREVALENCE
Significant reductions in HIV prevalence have been found in three of the six high-prevalence states in India in which Avahan—a large-scale HIV prevention initiative that focuses on high-risk groups such as injection drug users and female sex workers—was launched in 2003. According to an analysis of antenatal clinic sentinel surveillance data, HIV prevalence decreased in all six states between 2003 and 2008, ranging from 17% in Andhra Pradesh to 51% in Tamil Nadu.1 Researchers attributed most of the decline in prevalence in each state to the natural course of the epidemic, but estimated that the proportion associated with Avahan ranged from 2% in Maharashtra to 13% in Karnataka. The reduction in HIV prevalence associated with Avahan was significant in three of the six states: Andhra Pradesh, Karnataka and Maharashtra. Overall, researchers estimated that 100,178 HIV infections were prevented as a result of Avahan, mostly in Karnataka (41,682) and Andhra Pradesh (34,217); 61% of the infections averted were among men. The authors comment that the benefits of the program varied across states, likely because “Avahan’s business model encouraged local adaption and innovation in implementation,” and suggest further research to determine which types of interventions and which modes of delivery contributed to the decline in HIV and should be adopted during the program’s next phase.
Ng M et al., Assessment of population-level effect of Avahan, an HIV-prevention initiative in India, Lancet, 2011, 378(9803):1643–1652.