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The risk of death among participants in antiretroviral therapy (ART) programs in Africa is higher among men than among women, according to a meta-analysis of 23 cohort studies published within the past five years.1 Of the pooled sample of 216,000 study participants in 14 African countries who had initiated ART between 2001 and 2010, the pooled proportion of males was 35%; an estimated 40% of the HIV cases in the included countries were among men. Compared with women in ART programs, men in such programs had a 37% greater risk of mortality (hazard ratio, 1.37). Among the six cohort studies that reported baseline CD4 counts by gender, male participants initiated ART at a lower cell count, on average, than did female participants (96 vs. 112 cells/uL). The authors conclude that their findings add "to the body of evidence that men are disadvantaged in terms of treatment access and outcomes of care in Africa," and suggest that the results be used to "promote equal access to treatment and care."

1. Druyts E et al., Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis, AIDS, 2013, 27(3):417–425.


Female genital cutting remained common in Egypt five years after the country’s law was changed to completely ban the practice. According to a study conducted in Upper Egypt among educated women attending outpatient clinics with daughters aged 8–14, 76% of those interviewed in 2006—before the ban was implemented—reported that at least one of their daughters had had genital cutting.1 Among a comparison group of similar women who completed an almost identical survey in 2011, a significantly lower but still substantial proportion reported that at least one of their daughters had had genital cutting (72%). The most common single reasons for having a daughter undergo genital cutting were the same in 2011 and 2006: family pressure (43% and 45%, respectively) and religious obligation (38% and 40%). A significantly lower proportion of women in 2011 than in 2006 reported that a physician performed the genital cutting procedure on their daughter (35% vs. 39%). The authors conclude that "in addition to the law, a change in attitude is needed to eradicate [female genital cutting.]"

1. Hassanin IMA and Shaaban OM, Impact of the complete ban on female genital cutting on the attitude of educated women from Upper Egypt toward the practice, International Journal of Gynecology and Obstetrics, 2013, 120(3):275–278.


Health facilities in Africa run by nongovernmental organizations (NGOs) or faith-based organizations (FBOs) offer obstetric services that are at least comparable to those offered by government-run facilities, according to a descriptive analysis of WHO Global Survey on Maternal and Perinatal data from Kenya, Uganda and the Democratic Republic of Congo.1 In the three African countries, 22 NGO/FBO institutions and 20 government institutions offered obstetric care services; 11,594 women had delivered in NGO/FBO institutions over the study period, compared with 25,825 in government institutions. There were no differences between NGO/FBO facilities and government facilities in terms of level (primary, secondary or tertiary) or urban-rural location. The types of obstetric services available and equipment used were also the same across facilities, with a few exceptions. Greater proportions of NGO/FBO institutions than of government institutions were equipped with a biochemical laboratory (95% vs. 70%), were able to administer magnesium sulfate for preterm labor (86% vs. 55%) and used electronic fetal monitoring (32% vs. 5%). In addition, compared with government facilities, NGO/FBO facilities had a greater proportion of deliveries attended by an obstetrician (12% vs. 2%), and lower rates of eclampsia, stillbirth and high-risk "near miss" neonates. The authors conclude that "greater recognition and integration of FBO/NGOs into strategies to improve maternal and neonatal health is essential, given both the volume and quality of care they already contribute."

1. Vogel JP et al., Role of faith-based and nongovernmental organizations in the provision of obstetric services in 3 African countries, American Journal of Obstetrics & Gynecology, 2012, 207(6):495–497.


Women’s perceived risk of HIV is positively associated with their preference to either speed up or stop their childbearing, according to a study conducted in July 2009 among rural ever-married women of reproductive age in Southern Mozambique.1 Among the 1,260 women surveyed, 37% reported wanting a child soon (within two years), 20% wanted a child later (not within two years), and 44% wanted to stop childbearing. Thirty-five percent of women thought it likely that they were HIV-positive, 22% thought it impossible, and 43% did not know. In multinomial analyses, two associations were found: Women who perceived themselves as at risk of HIV were more likely than those who perceived themselves as not at risk to want to stop childbearing rather than have a child later (odds ratio, 1.5) and to want to have a child soon rather than have one later (1.9). The authors comment that their results point to the "heterogeneity of reproductive goals among women who are, or fear they might be, HIV-positive." They suggest that "reproductive health interventions cannot be one-size-fits-all; they must adapt to shifts in and complexities of fertility desires."

1. Hayford SR, Agadjanian V and Luz L, Now or never: perceived HIV status and fertility intentions in rural Mozambique, Studies in Family Planning, 2012, 43(3):191–199.


The population-level benefit of hormonal contraceptives in preventing unintended pregnancies—and indirectly mother-to-child transmission of HIV—greatly outweighs the detriment of increased HIV risk associated with their use, according to analysis of data from 3,704 female participants of two biomedical trials conducted between 2004 and 2009 in Durban, South Africa.1 At enrollment, 78% of women reported using at least one contraceptive method; 36% were using a hormonal method (i.e., pill or injectable), 27% condoms and 15% other methods (i.e., IUD, spermicide or traditional methods). During the study period, 272 women became infected with HIV; compared with women who were using other contraceptive methods during the study, those using hormonal contraceptives had a greater risk of seroconversion and a lower risk of pregnancy (hazard ratios, 1.3 and 0.4, respectively). In population- level analyses, if no one used hormonal contraceptives, there would be an estimated 12% decrease in HIV infections; however, if everyone used them, there would be an estimated 72% decrease in pregnancies. The authors conclude that "the use of hormonal contraceptives is a speculative risk factor for HIV-1 seroconversion. However, its population-level impact in terms of the risk of HIV-1 infection is lower than its population-level benefit in preventing unintended pregnancies and, indirectly, HIV-1 infections among neonates."

1. Ramjee G and Wand H, Population-level impact of hormonal contraception on incidence infection and pregnancy in women in Durban, South Africa, Bulletin of the World Health Organization, 2012, 90(10):748–755.


Most male clients of female sex workers in Bangladesh who experience STI symptoms seek care for those symptoms, according to a cross-sectional study conducted in Dhaka and Chittagong between November 2005 and July 2006.1 Of the 1,414 males recruited from three typical sex trade settings (in a brothel, in a hotel and on the street) who reported having had sex with a female sex worker in the previous month, one-third (32%) reported having experienced STI symptoms (e.g., urethral discharge, genital ulcer and pain during urination) in the previous 12 months; of those, a greater proportion were clients of sex workers on the street than of those in brothels or hotels (47% vs. 28% and 25%, respectively). Seventy-three percent of men who had had symptoms had done so once in the last month, 17% twice and 10% more than twice. Some 82% of men who had had STI symptoms had sought treatment for them; of those, 45% had gone to a pharmacist, 37% to a qualified public or private medical professional, 9% to a nongovernmental organization clinic and 8% to a herbal provider. The authors conclude that their findings "suggest the need to strengthen interventions for improving the skills of informal providers such as pharmacists and traditional practitioners for better management of STIs."

1. Ahmed A, Reichenbach LJ and Alam N, Symptoms of sexually transmitted infections and care-seeking behaviors of male clients of female sex workers in Bangladesh, Sexually Transmitted Diseases, 2012, 39(12):979–984.


Before visiting a clinic to obtain a medical abortion, many women in India unsuccessfully attempt to self-induce an abortion. According to a study conducted in Bihar and Jharkhand between December 2008 and May 2010, 3,394 women sought and were eligible for a medical abortion at five selected clinics during the survey period;1 of those, 31% reported having attempted to terminate a pregnancy on their own by taking medications or oral preparations. Forty-three percent of women who had attempted to self-induce an abortion had done so by taking some type of over-the-counter allopathic medication—14% had taken misoprostol only, 4% mifepristone only, 11% both of these, and 14% another drug, including emergency contraceptive or standard oral contraceptive pills. An additional 22% had taken a traditional preparation, and another 13% had taken a homeopathic preparation. None of the women who had taken both mifepristone and misoprostol had used the correct regimens or dosages, and most of the traditional and homeopathic preparations taken lacked any agent that could result in an abortion. The authors conclude that "there is clearly interest among women in non-surgical methods of abortion" and in a method that "avoids contact with certified providers." They suggest that chemists need to be informed about the correct regimens and dosages of mifepristone and misoprostol, and must be encouraged to convey this information to their clients.

1. Kumar R et al., Unsuccessful prior attempts to terminate pregnancy among women seeking first trimester abortion at registered facilities in Bihar and Jharkhand, India, Journal of Biosocial Sciences, 2013, 45(2): 205–215.


Achieving a Demographic Dividend explains the demographic and economic phenomena that occur when a country’s population moves from high to low birth and death rates. It explores the experiences of Asian and Latin American countries and considers the prospects for African nations. The bulletin can be found at <http://www.prb.org/pdf12/achieving-demographic-dividend.pdf>.

•The Henry J. Kaiser Family Foundation has released a policy report that tracks the most recently available data on funding from governments and other donor organizations for health—including family planning and HIV—in low- and middle-income countries. The report—which finds that investment increased overall between 2002 and 2010, but was essentially flat for the last several years—is available at <http://www.kff.org/globalhealth/upload/7679-06.pdf>.

Update is compiled and written by Jared Rosenberg, senior editor of International Perspectives on ­Sexual and Reproductive Health.