HIV/AIDS and Sexual and Reproductive Health Integration: Quarterly Highlights Newsletter (July 2008)
Contents
Asia-Pacific operational framework for linking HIV / STI services with reproductive, adolescent, maternal, newborn and child health services.
Corporate Author: World Health Organization [WHO]
Source: Geneva, Switzerland, WHO, 2008. [40] p.
URL: http://tinyurl.com/6zeoz2
Distinct interventions are needed to improve reproductive health (RH), adolescent reproductive health (ARH), maternal, neonatal and child health (MNCH), and prevention and management of HIV and other sexually transmitted infections (STI). Yet common underlying causes and shared solutions provide the basis for linkages that can strengthen all services and increase the reach of HIV prevention and testing. This Operational Framework provides information about how to create these linkages and what factors to take into account in doing so. The emphasis is not on creating all possible linkages, but on doing what is possible and advisable given local factors such as epidemiology, current skill sets, the current organization of the health system, resources available, and health system usage patterns. In settings with low HIV prevalence, for example, outreach to specific populations may be more important than forming linkages between two broad-based services. Especially when resources are limited, linkagesthat add information (such as prevention messages or a simple screening) will be easier to implement than linkages that require extensive clinical judgment for referral or clinical treatment. Central policies are needed to support the introduction of linkages, but they should incorporate community input and allow for local-level modification and ownership. If these factors are taken into account, linkages between RH, ARH, MNCH and HIV/STI services have great potential to achieve efficiency gains and increased targeting of client populations.
Is male circumcision as good as the HIV vaccine we've been waiting for? [editorial]
Author: Klausner JD | Wamai RG | Bowa K | Agot K | Kagimba J
Source: Future HIV Therapy. 2008;2(1):1-7.
URL: http://tinyurl.com/6f9q9h
What would the reaction of the international public health community have been if a year ago scientists had announced the discovery of a vaccine or chemical gel that, in three separate clinical trials, had reduced the risk of heterosexual HIV infection in men by at least 60%? Considering that even with increasing access to antiretroviral therapy AIDS continues to be a huge killer - ever day over 2000 men become infected with HIV in sub-Saharan Africa alone, which eventually also results in millions of new cases in their partners and children - would not such an announcement have surely sparked a massive surge of excitement and renewed investment in HIV prevention? In fact, in December 2006 officials form the US NIH did announce the discovery of an intervention at least as effective, for heterosexual transmission, as the long hoped for AIDS vaccine. However, unlike many previous breakthroughs in medicine, this time the intervention was not discovered by a team of scientists toiling in academic or government laboratories. Rather, some two decades ago anthropologists, demographers and epidemiologists initially noticed, and then eventually proved beyond a reasonable doubt, that male circumcision (MC) very significantly reduces the risk of heterosexual HIV infection in men.
Young males' gendered sexuality in the era of HIV and AIDS in Limpopo Province, South Africa
Author: Ragnarsson A, Onya HE, Thorson A, Ekstrom AM, Aaro LE
Source: Qualitative Health Research. 2008;18(6):739-746.
URL: http://tinyurl.com/6zbz7m
This article is focused on young males' sexual identity and behaviors in rural South Africa. The study comprised 19 focus group discussions with adolescents aged 12 to 14 years. The informants depict male sexuality as biologically predetermined, where physical needs and practices such as circumcision legitimize early sexual debut. Furthermore, the construction of male sexual identity and power imbalances in relationships are already evident at an early age, and age and economics are pertinent factors affecting social relations. Violent behavior and sexual abuse are supported by constructed gender inequalities forming an often negative and nonsupportive environment for young people. We stress the importance of planned HIV and sexuality education for young adolescents with support structures that can help endorse individual actions and informed choices. This is especially important in resource-poor settings where young people are likely to be less empowered than is the case in more affluent settings.
Assessing microbicide acceptability: A comprehensive and integrated approach.
Author: Morrow KM, Ruiz MS
Source: AIDS and Behavior. 2008 Mar;12(2):272-283.
URL: http://tinyurl.com/6eo3el
A safe, effective, and acceptable microbicide is needed in order to decisively impact the global AIDS pandemic. As such, microbicide acceptability research is of paramount importance. In order to best utilize limited financial resources and save precious development time, acceptability studies should be fully integrated into preclinical and clinical trial contexts where candidate products are being developed and tested. An integrated approach for examining theoretically valid and relevant variables is needed so that data across studies and products can more effectively advance the field. We propose an approach for measuring factors related to microbicide acceptability in each phase of product development, and dependent on what product-specific knowledge is already established in the field. We discuss the roles that behavioral and social science methodologies should play in all phases of microbicide development, as well as the challenges faced when conducting acceptability research in the context of preclinical and clinical trial settings.
Fertility choices and management for HIV-positive women
Author: Coll O, Lopez M, Hernandez S
Source: Current Opinion in HIV and AIDS. 2008 Mar;3(2):186-192.
URL: http://tinyurl.com/6boknu
It is becoming increasingly important to address the issue of reproductive counseling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review. Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method. Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.
Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming. Guidance for decision-makers on human rights, ethical and legal considerations. Pre-publication.
Corporate Author: Joint United Nations Programme on HIV / AIDS [UNAIDS] | AIDS Law Project, South Africa
Source: Geneva, Switzerland, UNAIDS, 2008 Mar. 28 p.
URL: http://tinyurl.com/5bwybm
Throughout the world, HIV prevalence is generally lower in populations that practise male circumcision than in populations where most men are uncircumcised. This has been observed over the years of the HIV epidemic and has now been confirmed through three randomized controlled trials concluded in 2005-2006. The trials showed that male circumcision reduces by 60% the transmission of HIV from women to circumcised men. The results have led to the conclusion that male circumcision is an effective risk-reduction measure for men, and should be used in addition to other known strategies for the prevention of heterosexually acquired HIV infection in men.
Sexual behavior and reproductive health among HIV-infected patients in urban and rural South Africa.
Author: Lurie M, Pronyk P, de Moor E, Heyer A, de Bruyn G
Source: JAIDS. Journal of Acquired Immune Deficiency Syndromes. 2008 Apr;47(4):484-493.
URL: http://tinyurl.com/6a2f98
With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission. We surveyed 3819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic. Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; x/2 odds ratio [OR] = 3.531; P less than 0.001), to have any current sexual partners (75.3% vs. 51.2%; x/2 OR = 2.908; P less than 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; x/2 OR = 3.886; P less than 0.001) and with casual partners (68.6% vs. 48.3%; x/2 OR = 2.337; P less than 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm3 as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner. HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.
Sexual responses to living with HIV/AIDS in Lome, Togo
Author: Moore AR, Amey F
Source: Culture, Health and Sexuality. 2008 Apr;10(3):287-296.
URL: http://tinyurl.com/5rpca3
A qualitative study of sexual behaviour among 88 people living with HIV was conducted in Lome, Togo. Data were collected by means of open-ended interviews. Three separate sexual-behaviour patterns were identified: people who reported not having sex at all; people who reported using condoms consistently; and people who reported not using condoms at all or using them inconsistently. Reasons given to explain these behaviours were analysed. Findings reveal the need for different programmes and policy approaches to dealing with problems of HIV and AIDS in Lome, Togo.
Africa: At the cutting edge--male circumcision and HIV
Source: IRIN News, Apr. 18, 2008
URL: http://tinyurl.com/5c4w9k
This article discusses the available evidence to support male circumcision's role in HIV prevention. While some researchers cite that studies in South Africa and Kenya have shown that male circumcision can reduce HIV risk, other researchers argue that there is not yet enough evidence available suggesting that male circumcision should be scaled up. The article also discusses cultural implications of male circumcision in sub-Saharan Africa.
India: Move over, moods: The female condom is becoming a surprisingly popular birth control tool
Author: Naithani S
Source: Tehelka Magazine. 26 Apr 2008
URL: http://tinyurl.com/6z5frb
This news article discusses attempts in India by the National AIDS Control Organization and the Hindustan Latex Family Planning Promotion and Trust to introduce the female condom outside of its initial target of sex workers Reasons for the relative high uptake of the female condom in certain areas of India are cited in the article.
Reasons for multiple sexual partnerships: Perspectives of young people in Zambia
Author: Nshindano C, Maharaj P
Source: African Journal of AIDS Research. 2008 May;7(1):37-44
URL: http://tinyurl.com/6rgsv6
Epidemiological evidence so far suggests that multiple sexual partnerships are an important factor driving the HIV epidemic. Recently, there has been renewed emphasis on fidelity and partner-reduction in preventing HIV infections. Like many countries in sub-Saharan Africa, Zambia is facing a severe HIV epidemic and young people are heavily affected. This study explores youths' perspectives on multiple sexual partnerships in the context of HIV and AIDS. The study draws on four focus group discussions and 10 in-depth interviews with university students in Lusaka, Zambia, in 2006. While the young people were generally aware of the HIV-related risk associated with multiple sexual partnerships, they felt several obstacles prevented them from changing their sexual behaviour. Of special interest are their perceptions related to socio-economic disadvantages and cultural factors.
Costing adult male circumcision in high HIV prevalence, low circumcision rate countries
Author: Fieno JV
Source: AIDS Care. 2008 May;20(5):515-520.
URL: http://tinyurl.com/6zgkk2
The dramatic evidence that male circumcision has a substantial effect in preventing HIV infection might be the most important medical finding in the course of the AIDS epidemic since the introduction of highly active antiretroviral therapy (HAART). The transition from clinical trails to implementation of a general adult male circumcision (AMC) program is beginning, and this paper uses an AMC cost model (in Microsoft Excel) to estimate the cost of a rapid scale-up of an AMC program in Mozambique, a country with a generalized epidemic and low rate of male circumcision. There are three major findings: (1) Even the most modest of AMC programs would place great stress on human resources, and task-shifting might lead to more accidents or adverse events that would increase the cost per AMC. (2) The fiscal burden of AMC is surprisingly low, but a rapid scale-up of AMC poses additional fiscal stress for Mozambique's already under-funded public health system. (3) AMC as an HIV prevention tool is very robust in terms of its cost-effectiveness in Mozambique, even at a high AMC accident or complication rate. Any AMC roll-out in Mozambique would face severe constraints in the health system (namely human resources) that would likely limit the scale of an AMC program and perhaps its effectiveness against its generalized epidemic.
Hormonal contraception and HIV prevalence in four African countries.
Author: Leclerc PM | Dubois-Colas N | Garenne M
Source: Contraception. 2008 May;77(5):371-376
URL: http://tinyurl.com/5cewul
The HIV seroprevalence among women aged 15-24 years was compared according to their pattern of contraceptive use in four African countries: Kenya, Lesotho, Malawi and Zimbabwe. Data were derived from Demographic and Health Surveys (DHS) conducted between 2003 and 2006 on representative samples, totaling 4549 women. It is indicated that users of depo-medroxyprogesterone acetate (DMPA) have a significantly higher seroprevalence than nonusers [odds ratio (OR)=1.82, 95% CI=1.63-2.03] and higher than users of oral contraceptives and users of traditional methods. The results were confirmed in a multivariate analysis including as controls, age, duration since first intercourse, urban residence, education, number of sexual partners in the last 12 months and marital status. A somewhat smaller net effect (OR=1.34, 95% CI=1.10-1.63) was found. In contrast, oral contraceptives and traditional methods did not show any risk for HIV (OR=0.96 and 0.92, respectively). The increased risk of DMPA was present in three of the four countries investigated, and significant in Zimbabwe and Lesotho, the countries with the highest HIV seroprevalence. The HIV risk attributable to DMPA remained small altogether and was estimated as 6% in the four countries combined.
Human papillomavirus infection and cervical disease in human immunodeficiency virus-1-infected women
Author: Denny L, Boa R, Williamson AL, Allan B, Hardie D
Source: : Obstetrics and Gynecology. 2008 Jun;111(6):1380-1387.
URL: http://tinyurl.com/6hdrjx
The objective was to report on the natural history of high-risk human papillomavirus (HPV) infection and cervical disease in human immunodeficiency virus (HIV)-1-infected women living in Cape Town, South Africa. This was a prospective study of 400 untreated, HIV-1-infected women who underwent high-risk HPV DNA testing, cytology, colposcopy, histology, and CD4 count testing every 6 months for 36 months. Human immunodeficiency virus viral loads and HPV type distribution were determined at entry and after 18 months. Sixty-eight percent of the women were highrisk HPV DNA positive at entry, 35% had a cytologic diagnosis of low-grade squamous intraepithelial lesion (LSIL), and 13% had high-grade squamous intraepithelial lesion (HSIL). There were no cancers. Abnormal cytology and high-risk HPV positivity were strongly correlated with low CD4 counts and high HIV viral loads. The most prevalent types of HPV were HPV-16, -52, -53, -35, and -18. Incident high-risk HPV infection occurred in 22%, and of those infected with high-risk HPV, 94% of infections persisted over an 18-month period, and 6% cleared their infections. Cytologic progression to SIL from normal/ atypical squamous cells of undetermined significance cytology occurred in 17% of cases, but only 4% of cases of LSIL progressed to HSIL. There is a high level of high-risk HPV infection in HIV-1 infected women, but progression to HSIL over 36 months occurred in the minority of cases. We recommend an initial colposcopy for an abnormal test, and if no high-grade lesion is identified, triennial screening would be appropriate. Human papillomavirus type 16 was the commonest, and HPV-18 was the fifth commonest, suggesting that vaccination against these two types would have a significant effect.
The safety of adult male circumcision in HIV-infected and uninfected men in Rakai, Uganda.
Author: Kigozi G, Gray RH, Wawer MJ, Serwadda D, Makumbi F
Source: PLoS Medicine. 2008 Jun;5(6):e116.
URL: http://tinyurl.com/5uqcqf
The objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men. A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts greater than 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1-2 d and 5-9 d, and at 4-6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47-1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05-2.33). Overall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.
HIV and sexual risk behaviors among recognized high-risk groups in Bangladesh: Need for a comprehensive prevention program.
Author: Islam MM, Conigrave KM
Source: International Journal of Infectious Diseases. 2008 Jul;12(4):363-370.
URL: http://tinyurl.com/5tt9rf
The objective of this study was to examine trends in HIV and related risk behaviors among recognized high-risk groups in Bangladesh, the types and extent of prevention initiatives that have been undertaken, and highlight the immediate needs. Journal publications and conference abstracts and proceedings were reviewed. Experts involved in the development and evaluation of current programs or policy were contacted for official reports and policy documents. The trends in sexual risk behaviors over five rounds of national surveillance were tabulated. Gaps in the ongoing prevention interventions have been assessed in the light of the Anderson-May equation. Periodic surveillance on recognized high-risk groups shows that HIV prevalence has been increasing steadily. In the capital city, HIV prevalence in one subset of a high-risk group is close to the level of a concentrated epidemic (4.9%). The high prevalence of sexual risk behaviors among drug users and sex workers and their clients is alarming. Although a small increase in condom use and a reduction of syphilis have been noted among subsets of high-risk groups in recent years, this is clearly not enough to curb the threat of a possible HIV epidemic. There is an urgent need for a comprehensive prevention program that should include more efforts on education and condom promotion, effective management of all sexually transmitted infections, a screening program for migrant workers, the continuation of both behavioral and serological components of HIV surveillance, and the expansion of surveillance to cover the remaining high-risk groups, with due consideration to the consistency of surveillance indicators.
Events
This section lists upcoming public health conferences, meetings, or other events that include activities and information concerning HIV/AIDS and Sexual and Reproductive Health Integration. If you know of an upcoming event that may be of interest to HIV/SRH Integration professionals, please e-mail info@hivandsrh.org.
XVII Annual International AIDS Conference - Mexico City, Aug. 3-8, 2008
URL: http://www.aids2008.org/
Integration of Sexual and Reproductive Health and HIV/AIDS into Global Fund Proposals, Satellite session, XVII International AIDS Conference, Mexico City, Aug. 3, 2008
URL: http://www.hivandsrh.org/satellite.php
Linking sexual and reproductive health: increasing the evidence base of innovative approaches to achieve Universal Access to HIV prevention, treatment, care and support and to reproductive health service, Satellite session, XVII International AIDS Conference, Mexico City, Aug. 3, 2008
URL: http://www.hivandsrh.org/Events/satellite1.php
First Conference on Strengthening Links Between Reproductive Health and HIV/AIDS: Sexual Violence as a Nexus, Safari Park Hotel, Nairobi, Kenya, Sep.29-Oct. 1, 2008
URL: http://www.svconference2008.org/
Partner Profiles: Voices from the Field
From Brazil to Madagascar, healthcare professionals learn lessons and achieve successes implementing HIV/SRH Integration programs using a variety of innovative strategies. Read the following "Voices from the Field" interviews to hear about Integration programs in a variety of countries.
Mantshi Menziwa, MPH and Saiqa Mullick - FP and HIV Integration Program, Population Council, South Africa
Mantshi Menziwa is a senior program officer with the Population Council's Reproductive Health (RH) program. Saiqa Mullick is a senior associate with the Population Council's Reproductive Health program coordinates operations research on reproductive tract infections (RTIs) and the integration of HIV and AIDS into reproductive health services in east and southern Africa.
URL: http://www.hivandsrh.org/Voices/Menziwa-Mullick.php
Francesca Stuer, Medhanit Wube, Tamrat Aseefa - Home and Community Based Care, Family Health International, Ethiopia
Medhanit Wube, MPH, RN, is currently working as Home-Based Care Team Leader for FHI in Ethiopia. Tamrat Assefa, MPH, RN, is currently working as FP/HIV Integration Coordinator for FHI in Ethiopia. Francesca Stuer, MSc, RN, currently serves as Country Director for FHI in Ethiopia.
URL: http://www.hivandsrh.org/Voices/Stuer-Wube-Aseefa.php/
Zubaida Abubakar, Usman Gwarzo, Christoph Hamelmann, Mohammed Dada Ibrahim, Hadiza Khamofu - GHAIN Project, Family Health International, Nigeria
Zubaida is currently the reproductive health/PMTCT officer for FHI/Nigeria. Usman is FHI/Nigeria's senior advisor on reproductive health and PMTCT. Christoph became FHI/Nigeria country director in May 2007. Mohammed joined FHI/Nigeria in 2004 as director of medical services. Hadiza became FHI/Nigeria's associate director of medical services in December 2007.
URL: http://www.hivandsrh.org/Voices/FHINigera.php/
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