Search

Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.

Background: Sexual and reproductive health (SRH) services for HIV-positive women and men often neglect their fertility desires. We examined factors associated with pregnancy intent among recently diagnosed HIV-positive women (N = 106) and men (N = 91) who reported inconsistent condom use and were enrolled in an SRH intervention conducted in public sector HIV care clinics in Cape Town. Methods: Participants were recruited when receiving their first CD4+ results at the clinic. All reported unprotected sex in the previous 3 months. Logistic regression identified predictors of pregnancy intent for the total sample and by gender. Results: About three fifths of men and one fifth of women reported intent to conceive in the next 6 months. In the full-sample multiple regression analysis, men [adjusted odds ratio (AOR = 6.62)] and those whose main partner shared intent to conceive (AOR = 3.80) had significantly higher odds of pregnancy intent; those with more years of education (AOR = 0.81) and more biological children (AOR = 0.62) had lower odds of intending pregnancy. In gender-specific analyses, partner sharing pregnancy intent was positively associated with intent among both men (AOR = 3.53) and women (AOR = 13.24). Among men, odds were lower among those having more biological children (AOR = 0.71) and those unemployed (AOR = 0.30). Among women, relying on hormonal contraception was negatively associated with intent (AOR = 0.08), and main partner knowing her HIV status (AOR = 5.80) was positively associated with intent to conceive. Conclusions: Findings underscore the importance of providing integrated SRH services, and we discuss implications for clinical practice and care.

A letter to the editor is presented in response to the article "Opening the Market for Lower Cost Hearing Aids: Regulatory Change Can Improve the Health of Older Americans" by J. Blustein and B.E. Weinstein which appears in a 2016 issue of the journal.

OBJECTIVES: To assess the uptake of HIV testing among preschool children with HIV-positive mothers in a peri-urban population-based study in KwaZulu-Natal South Africa an area of high HIV prevalence. METHODS: All children 4-6 years old and their primary caregivers from the area were invited to participate. All participants were asked about prior HIV testing and were offered counselling and voluntary HIV testing irrespective of previous testing. Twenty-seven HIV-infected mothers were interviewed to identify barriers to testing their children. RESULTS: One thousand five hundred and eighty-three children (88% of eligible children) and their caregivers participated. Of the biological mothers 86% were previously tested for HIV (27% tested positive). Among the surviving 244 children born to an infected mother only 41% had been tested for HIV (23% tested positive). Subsequently 90% of previously untested children of infected mothers underwent HIV testing (9.3% were positive). Overall seroprevalence among study children was 4.9%. All infected mothers interviewed endorsed the belief that children of HIV-infected women should be tested for HIV. Women who missed opportunities for antenatal HIV testing reported no systematic testing of their children at later ages. CONCLUSIONS: In this community with high HIV prevalence HIV testing of children is infrequent despite high testing coverage among caregivers. The low proportion of children tested for HIV particularly those of infected mothers is of great concern as they are at high risk for morbidity and mortality associated with untreated childhood HIV infection. HIV testing programs should strengthen protocols to include children especially for those who missed PMTCT opportunities in infancy. (c) 2011 Blackwell Publishing Ltd.

In recent years, neonatal mortality rates for low-birthweight infants have declined both in neonatal intensive care units and in several populations in the industrialized world. With regard to impairment among surviving low-birthweight infants, studies from newborn intensive care units show considerable variation in the reported rates of handicaps. Much of this variation arises from a lack of uniform criteria for diagnosis, sample selection and follow-up, factors further compounded by small sample size. At the present time it is premature to conclude that changes in newborn care have either lowered or raised rates of impairment among surviving low-birthweight infants.

SUMMARY To maintain a stable over-all prevalence of handicap, the rate of handicap among survivors must decline in parallel to the decline in mortality among live births. The 24 per cent decline in mortality among low-birthweight infants in New York City between 1962 and 1976 requires a 35 to 39 per cent decline in the rate of neurological impairment among lowbirthweight survivors simply to avoid the production of an increased number of handicapped children in the population as a whole. Such evidence as we have suggests that the declining morbidity may not be keeping pace with the recent declines in mortality: thus, although more healthy survivors will result from newborn intensive care, a modest increase in the prevalence of handicap may also ensue.

SUMMARY Reports of cerebral palsy prevalence rates per live births in recent decades in western nations show a mixed pattern. Declining rates were noted in Bristol, England, and in Denmark; but more recently a rising rate was noted in Ireland. In Western Sweden a decline has been followed by a recent rise, and in Western Australia a rise has been followed by a decline. Rates with not statistically significant changes have ben found in Iceland and Birmingham, England, and over the seven-year span of the US Collaborative Perinatal Project, although their over-all direction was downward. No single factor is likely to explain the trends observed.

SUMMARY The distribution of enuresis was found to vary with social class and family setting. A model of enuretic survivors illustrates that general factors connected with social class seem most relevant to children of an age to enter school, family deviance to pre-pubertal schoolchildren, and discontinuous family relationships to pubescent children. Trends in these data have been examined for congruence with hypotheses formulated from these findings, before seeking a larger body of material in which probability tests can be made. Structural and cultural factors differentiated between the families of five-year-old enuretic children and their controls. Enuretic families had made fewer extraneous marriages than the families of controls, they had less often established residential independence at marriage, and the mother had gone out to work in the child's early years somewhat more often. The elements common to deviant families differentiated between the families of ten-year-old enuretic children and their controls. The families of ten-year-old enuretic children were more often in poverty, and their mothers more often handicapped or burdened. Continence was somewhat delayed in children exposed at an early age to a wide range of social interaction and less exclusive relations with their mothers; was furthur delayed in children whose mothers were personally or socially handicapped in the maternal role; and was apparently most delayed in those who suffered total disruption of maternal relations. RESUME Les families des enfants enuretiques On a trouve que la distribution de l'enuresie variait avec la classe sociale et les conditions familliales. Un modele de survivants enuretiques demontre que les facteurs generaux en connection avec la classe sociale semblent plus applicables aux enfants en âge d'entrer a l'ecole, les deviations familliales aux ecoliers avant la puberte, et l'interruption de rapports familliaux aux enfants puberes. On a examine si les tendances revelees dans ces donnees sont conformes aux theories formulees d'apres trois resultats avant de rechercher une plus grande masse de materiel ou Ton pourra pratiquer des calculs de probabilite. Des facteurs de structure et de culture differenciaient les families des enfants enuretiques de cinq ans de celles de leurs controles. Les families d'enuretiques avaient contracte moins de seconde mariages que les families des controles, elles avaient moins souvent etabli des residences independantes au moment du mariage, et la mere etait partie travailler pendant les premieres annees de l'enfant un peu plus souvent. Les elements communs aux families desunies differenciaient les families des enfants enuretiques de 10 ans de celles de leurs controles. Les families des enfants enuretiques de 10 ans etaient plus souvent pauvres, et leurs meres etaient plus souvent handicappees ou surmenees. La continence etait en quelque sorte retardee chez les enfants exposes pendant leur jeune âge â une large serie d'intereactions sociales et a des relations moins exclusives avec leur mere; elle etait encore plus retardee chez les enfants dont les meres etaient handicapees personnellement ou socialement dans leur role maternel; et les delais les plus importants apparemment survenaient chez ceux qui souffraient d'une interruption totale des relations maternelles. ZUSAMMENFASSUNG Familienverhaltnisse enuretischer Kinder Es wurde festgestellt dass das Auftreten von Enuresis aufgrund sozialer Klasse und Familienumgebung variiert. Eine Aufstellung von Enuretikern zeigt dass allgemeine, mit der sozialen Stellung verbundene Faktoren den starksten Einfluss auf Kinder im Vorschulalter, Familien-Abweichungen auf Kinder im prepubertaren Schulalter und unter-brochene Familienverhaltnisse auf pubertare Kinder haben. Die aus disen Daten ersichtlichen Tendenzen sind auf Kongruenz mit aus drei Befunden formulierten Hypothesen untersucht worden, bevor man darangeht, einen grossen Korpus von Material zusammenzutragen, in dem Wahrscheinlichkeits-Tests ausgefuhrt werden konnen. Struktur- und Kulturfaktoren differenzierten sich zwischen den Familien mit funfjahrigen enuretischen Kindern und ihren Vergleichsfamilien. Enuretische Familien hatten weniger ‘auswartige’ Ehen geschlossen, hatten bei der Eheschliessung nicht so oft eigene Wohnungen bezogen, und wahrend der fruhen Jahre des Kindes war die Mutter etwas haufiger zu auswartiger Verdienstarbeit gegangen. Die den abweichenden Familien gemeinsamen Elemente unterschieden sich zwischen den Familien zehnjahriger enuretischer Kinder und ihren Vergleicheobjekten. Die Familien zehnjahriger enuretischer Kinder litten ofter an Armut, und ihre Mutter waren ofter behindert oder uberbelastet. Diese Befunden werden erortert im Hinblick darauf, wie sie auf die Beziehungen enuretischer Kinder mit ihren Familien und im besonderen mit ihren Muttern einwirken. RESUMEN Familias de ninos enureticos Se hallo que la distribucion de la enuresis varia segun la clase social y la situacion familiar. Un estudio de ninos no curados muestra que factores generates asociados con la clase social son los mas pertinentes para los ninos que comienzan la escuela, que la desviacion familiar es mas pertinente en la prepubertad, y que relaciones familiares interrumpidas son muy importantes para los ninos que han llegado a la pubertad. Se han examinado tendencias en estos datos para hallar si acuerdan con unas hipotetis deducidas de tres experiencias, antes de buscar una materia mas grande para hacer pruebas de probabilidad. Las familias de los ninos enureticos de 5 anos, y las familias de ninos no enureticos de la misma edad, se diferenciaban por su estructura y cultura. Los padres de los ninos enureticos se habian casado menos veces afuera, el matrimonio al casarse tenia menos veces una morada suya, y la madre habia trabajado mas veces durante los primeros anos de vida del nino. Las familias de los ninos enureticos de 10 anos y las de los ninos de control se diferenciaban en todo lo que contribuye a la desviacion familiar. Las familias de los ninos enureticos eran mas veces pobres, y sus madres tenian mas veces incapacidades o un exceso de trabajo. Continencia estaba algo retardada en ninos expuestos muy jovenes a relaciones sociales extensas, y a relaciones menos exclusivas con sus madres; estaba mas retardada en ninos cuyas madres tenian inhabilidades personales o sociales para el papel de madre, y muy retardada en ninos que sufrieron un rompimiento total de relaciones con sus madres.

SUMMARY Nocturnal enuresis was shown to be more common among children who have been placed in the care of others because of the inability of their own families to care for them than among children living in their own homes. This high frequency appeared to be partly a result of factors preceding their being placed in care, as was suggested by the investigation of enuresis in residential institutions. But the prevalence of enuresis was also shown to be influenced by the conditions of the placement itself, as could be inferred from a comparison of children in children's homes and in foster homes. This supported the hypothesis that the character of authority relations between adults in their care influenced the acquisition of nocturnal control of the bladder. Factors in selection, such as early separation from the mother (which was shown to favour enuresis) did not appear to bias this result. RESUME Enuresie nocturne en tant que phenomene ties institutions On a montre que Ľenuresie nocturne etait plus commune chez les enfants soignes par d'autres a cause de Ľincapacite de leur propre famille a s'occuper d'eux que chez les enfants vivant chez eux. Cette haute frequence parait etre en partie le resultat de facteurs precedent leur placement, comme Ľa suggere une etude de Ľenuresie dans un nombre d'institutions residentielles. Mais la prevalence de Ľenuresie etait aussi influencee par les conditions du placement lui-meme, comme on a put conclure en comparant les enfants residant dans des maisons d'enfants et chez des parents nourriciers. Ce fait vient aĽappui de la theorie selon laquelle le caractere de Ľautorite entre les adultes et les enfants a leur charge influence Ľacquisition du controle nocturne de la vessie. Des facteurs pris separement, tels que la separation precoce de la mere (qui s'est montree etre un facteur favorisant Ľeenuresie) n'ont pas semble influencer ces resultats. ZUSAMMENFASSUNG Nachtliches Bettnassen als Erscheimmg in Anstalten Es wurde festgestellt dass das nachtliche Bettnassen haufiger auftritt bei Kindern, die wegen der Pflegeunfahigkeit ihrer eigenen Familien in Fremdenpflege gegeben worden sind, als bei Kindern, die in ihren eigenen Heimen leben. Dieses haufige Auftreten schien zum Teil ein Ergebnis von Faktoren zu sein, die zeitlich schon vor der Abgabe dieser Kinder in auswartige Pflege erschienen; dieses zeigte sich bei der Untersuchung von Enuresis in einer Anzahl von Wohnanstalten. Doch wirkten auf die Haufigkeit des Bettnassens auch die Bedingungen des Pflegeortes ein, welches sich beim Vergleich von Kindern in Kinderheimen mit solchen, die bei Pflegeeltern wohnten, herausstellte. Dieses verleiht Nachdruck der Hypothese dass der Charakter der autoritaren Beziehungen zwischen den Erwachsenen und den ihnen anvertrauten Kindern die Erwerbung der nachtlichen Blasenkontrolle beeinflusst. Auswahlfaktoren, so wie fruhe Trennung von der Mutter (es erwies sich dass diese Enuresis herbeifuhrt), schienen dieses Ergebnis nicht einseitig zu beeinflussen. RESUMEN Enuresis nocturna como fenomeno de las instituciones La enuresis nocturna se veia menos en ninos que vivian en sus propias casas que en ninos al cuidado de otros, porque sus familias no eran capaces de cuidar de ellos. Parecia que esta alta frecuencia resultaba en parte de factores anteriores a la residencia de los ninos en una institucion, como sugirio la investigation de la enuresis en un numero de instituciones residenciales. Pero se revelo tambien que la frecuencia de la enuresis tenia que ver con las condiciones de colocacion, como se podia inferir de una comparacion entre unos ninos en instituciones y otros al cuidado de familias particulares. Esto dio apoyo a la hipotesis que el caracter de las relaciones entre los ninos y los adultos en autoridad importa mucho en la adquisicion de control nocturno de la vejiga. No parecia que este resultado fuese modificado por factores de selection, por ejemplo separation muy joven de la madre.

In an interesting and innovative approach to the study of poverty, health and policy, William Pick, Laetitia Rispel and Shan Naidoo have summarized three important commissioned government reports generated during the racially segregated apartheid years in South Africa. They seek thereby to evaluate both the background factors and the social context under which these reports were generated, and to evaluate effects of both on policy. In doing so, the authors usefully review material perhaps too infrequently examined in subsequent decades. However, the degree to which these three commission reports truly serve as landmarks in their effects remains an open question. Having lived through the period under review, we cannot but doubt whether in themselves these commission reports promoted or even reveal the central historical developments and links between poverty, health and policy over the past century in South Africa, as the writers suggest they do. First, consider the two figures accompanying the text. Figure i shows the decline in infant mortality over the period 1929-198 3 among whites only. No comparable national data were available for blacks (indigenous South Africans, by far the majority; South Africans of mixed descent, so-called coloured people; and South Africans of Indian origin). This figure, thereby necessarily limited to

This pilot study evaluated a 15 session classroom intervention for HIV and pregnancy prevention among grade 8–10 boys and girls (ages 14–17) in rural South Africa, guided by gender-empowerment theory and implemented by teachers, nurses, and youth peer educators. Pre- and post-intervention surveys included 933 male and female students in two intervention and two comparison schools. Main outcome: condom use at last sex; secondary outcomes: partner communication; gender beliefs and values; perceived peer behaviors; self-efficacy for safer sex. At five months post-intervention, change in condom use did not differ between intervention and comparison schools. Intervention school youth had greater increases in self-efficacy for unsafe sex refusal [OR=1.61; 95% CI=1.01, 2.57] and condom use [OR=1.76; 95% CI=1.07, 2.89], partner communication [OR=2.42; 95% CI=1.27, 4.23], and knowledge of HIV testing opportunities [OR=1.76; 95% CI=1.08, 2.87]. This gender-focused pilot intervention increased adolescents’ self-efficacy and partner communication, and has potential to improve preventive behaviors.

Sputum smears for acid-fast bacilli (AFB) are the primary methods for diagnosis of tuberculosis (TB) in many countries. The tuberculin skin test (TST) is the primary method for diagnosis of latent TB infection (LTBI) worldwide. The poor sensitivity of the former and the poor specificity of the latter warrant the development of new tests and strategies to enhance diagnostic capabilities. We evaluated the sensitivity of an “in-tube” gamma interferon release assay (IGRA) using TB-specific antigens in comparison to the TST and the sputum smear for AFB in TB cases in South Africa. The sensitivity of the IGRA for TB was considered a surrogate of sensitivity in LTBI. Among 154 patients with a positive culture for Mycobacterium tuberculosis , the sensitivity of the IGRA for the diagnosis of TB varied by clinical subgroup from 64% to 82%, that of the TST varied from 85% to 94%, and that of two sputum smears for AFB varied from 35% to 53%. The sensitivity of the IGRA in human immunodeficiency virus (HIV)-infected TB cases was 81%. HIV-infected TB patients were significantly more likely to have indeterminate IGRA results and produced quantitatively less gamma interferon in response to TB-specific antigens than HIV-negative TB patients. The overall sensitivity of the TST in all TB cases was higher than that of the IGRA (90% versus 76%, respectively). The combined sensitivities of the TST plus IGRA and TST plus a single sputum smear were 96% and 93%, respectively. The TST combined with IGRA or with a single sputum smear may have a role in excluding the diagnosis of TB in some settings.

With growing recognition of the potential value of microbicides for HIV/STI prevention, the importance of the acceptability of this brand-new technology has been widely acknowledged. We review the current body of microbicide acceptability research, characterize the limitations in assessment approaches, and suggest strategies for improvement. Electronic databases and abstracts of recent meetings were searched for acceptability data regarding vaginal and rectal products that may be used for HIV prevention. Of the 61 studies reviewed, more than half assessed acceptability based primarily on the description of a hypothetical microbicide, or with the demonstration of a spermicide or lubricant. Physical characteristics of microbicidal products, their effects after insertion, and their effects on sensation during intercourse (for both partners) were the dimensions most frequently assessed (measured in 77%, 49% and 49% of studies, respectively). Attention to the social context of use was inadequate. As acceptability is likely to be a key determinant in the use-effectiveness of microbicides, in-depth understanding of the social processes that shape microbicide acceptability across diverse populations will become increasingly valuable. This includes exploring the effects that sexual partners, health care providers, and key opinion leaders have on the acceptability of microbicides among women and men, including youth and people living with HIV. Future research will benefit from studies of the acceptability of other contraceptive-barrier methods (especially the female condom), use of an agreed-upon operationalization of acceptability, use of acceptability assessments within clinical trials, expansion of measurement domains, and assessment of changes in perceptions of acceptability and use over time. Failure to understand the key factors associated with microbicide acceptability is likely to hinder the adoption and continued use of products that are effective in preventing HIV infection.

More than 10 years have elapsed since the female condom became widely available, and it remains the only femaleinitiated means of preventing both pregnancy and sexually transmitted infections (STIs), including HIV. The female condom was developed as an alternative to the male condom, and it was hailed as a method that would enable women to have greater control over their own protection from disease. With the support of the Joint United Nations Programme on HIV/AIDS (UNAIDS), public and private funders, and the manufacturer, more than 90 developing countries have introduced the method through public distribution, social marketing campaigns or commercial outlets. In several countries that have actively promoted its use, such as South Africa, Brazil, Ghana and Zimbabwe, steadily increasing female condom sales to the government suggest that effective programs can generate demand. At the same time, there have been disappointments. Uptake in the West and in some developing countries has been lower than was initially anticipated, demonstrating that successful introduction will not be as straightforward as was hoped. 1 A study by Kulczycki and colleagues published earlier this year shows that the method is not popular among some women. 2 Indeed, there are still gaps in knowledge about how acceptable the female condom is for long-term use and whether promoting it can help reduce STI rates. Despite both successes and disappointments, promotion of the female condom remains important, especially in the face of heterosexually acquired HIV infection rates that are soaring globally. It is unfortunate, therefore, that a discourse has emerged recently that marginalizes the female condom as a viable prevention option, out of concerns about its high cost and the need for women to obtain their partner’s cooperation in order to use it. 3 Such a conclusion is premature, as the picture is far more complex. In this viewpoint, we review what has been learned about the female condom over the past decade, and argue for a renewed commitment to behavioral intervention research and the implementation and evaluation of large-scale female condom programs.

The authors argue that men should be involved in the reproductive health discourse. They express concern over the lack of inclusion of men in the discussion about the long-acting reversible contraceptives (LARC) technology and discuss topics including enhancing the role of partners in reproduction, the potential benefits of men's participation in reproductive health education, and male investment in childbearing and rearing.

Objectives. We evaluated female-condom use among women participating in an HIV/STD intervention designed to reduce unprotected sex and expand prevention strategies. Methods. Women (n = 360) were recruited from a family-planning clinic and were randomized into an 8- or 4-session intervention group or a control group. We conducted follow-up interviews at 1, 6, and 12 months. Results. At 1 month, the odds ratios of first-time female-condom use were 9.49 (95% confidence interval [CI] = 4.01, 22.20) in the 8-session group and 4.39 (95% CI = 1.84, 10.49) in the 4-session group relative to controls. Repeated use (n = 21) was predicted by perceived ability to use, by self and partner satisfaction, by dislike of male condoms, and by previous diaphragm use. Conclusions. Gender sensitive cognitive-behavioral interventions can influence women to try the female condom. To increase long-term use, interventions may need to include self-insertion practice and involvement of male partners.

Background: Data are limited on the female condom’s effectiveness against STDs. Goal: The goal was to compare STD rates between women given small-group education on and free supplies of either female or male condoms. Study Design: Female patients at an STD clinic (n = 1442) were randomly assigned to condom type and followed via medical records for STDs (gonorrhea chlamydia early syphilis or trichomoniasis). Results: In an intention-to-treat analysis the odds ratio for a comparison of STD occurrence between the female and male condom groups was 0.75 (95% confidence interval [CI] 0.56–1.01) and it did not change with adjustment. In a second analysis among women returning for subsequent screening incidence rates for the first new postintervention STD per 100 woman-months of observation were 6.8 in the female condom group and 8.5 in the male condom group (rate ratio = 0.79 [CI 0.59–1.06]). Conclusion: Compared with those provided with male condoms alone women counseled on and provided with female condoms fared no worse and experienced a nonsignificant reduction in STDs. (authors)

CONTEXT: Family planning providers can play an important role in helping women to identify their risk of HIV and other sexually transmitted diseases (STDs) and to adopt preventive measures. In-depth investigation of providers’ attitudes about approaches to STD risk assessment, contraceptive counseling and dual protection—concurrent protection from STDs and unintended pregnancy—has been limited. METHODS: In semistructured interviews conducted in 1998, 22 health care providers from a large New York City agency offering contraceptive and STD services described how they balanced STD and pregnancy concerns, viewed risk assessment and assessed various contraceptive methods. RESULTS: STD prevention was seen as an integral part of family planning counseling, and most providers believed that risk assessment should be conducted universally. Providers viewed dual protection as use of condoms along with an effective contraceptive; few advocated use of the male or female condom alone. The female condom was believed to be a disease prevention method of last resort and was considered appropriate only for specific groups of women. Although providers lacked understanding about the effectiveness of the female condom and how to counsel clients concerning its use, they expressed interest in learning more. CONCLUSIONS: Training is needed to reduce providers’ negative perceptions of the female condom and to reinforce the importance of individualized counseling tailored to women’s specific circumstances. Studies are needed on how to encourage family planning providers to promote male and female condoms as effective contraceptive methods. Perspectives on Sexual and Reproductive Health, 2003, 35(2):71‐78

This article focuses on the continual placebo-controlled trials in women to assess the efficacy and safety of antiretroviral drugs despite the results that have shown that the antiretroviral drugs prevent sexual transmission of HIV. The authors state their belief that to undertake more placebo-controlled trials would be short-sighted and unethical and to delay implementation would cost the lives of the women whom the drugs are intended to benefit. They conclude that a broader perspective of study design and of the assessment of scientific evidence than presently exists would provide a constructive way forward to learn how best to implement new interventions to improve public health.

The current Ebola outbreak is unique in its magnitude and its dispersion in dense, mobile populations. Physician and nurse responders face high mortality, and foreign aid in the form of medical supplies and staff continues to be unequal to the scope of the problem. Fear and loss have overwhelmed affected communities, already among the poorest in the world and still recovering from brutal civil wars. While the number of Ebola cases in Liberia appears to be on the decline, Ebola infections in Sierra Leone and Guinea continue to increase.1 That the response to the epidemic be swift and massive is a matter of life and an unknown number of deaths. Survivors of Ebola infection are valuable resources still largely overlooked in the struggle to contain the epidemic. With a case recovery rate of around 30% at the present time for the current West African epidemic,2 survivors already number thousands. There are several reasons why Ebola survivors may be critical to controlling the epidemic. First, and most importantly, the recovered have developed immunity to the current strain of Ebola and therefore are able to care for the sick with little to no risk of re-infection. In a sense, survivors are the only people in the world who are ‘vaccinated’ against further Ebola infection with the strain in circulation. This uniquely positions them to mediate between the infected and uninfected and between local people and foreign responders. Second, survivors can donate their blood, as their antibodies might be protective and help those infected to survive the deadly virus. Although it has not yet been proven to be effective, passive immunotherapy with survivors’ blood (convalescent plasma) could be an effective treatment for the tens of thousands of people projected to battle Ebola. Indeed, research into the biological and clinical progress in survivors is critical to a further understanding of Ebola.3 Third, unlike most foreign response staff, survivors speak local languages, understand cultural dynamics and may be viewed more favourably than outsiders during this time of intense fear and community mistrust. Hence, they could care for the sick in both medical and home-based settings. Employing trained Ebola survivors as caregivers would also give them a source of income in a context of increased poverty and stigmatization. Finally, Ebola survivors may play a role in generating an effective, community-based response in exposed localities. Community-initiated actions in epidemics are recognized as important to public health, and have already been proven successful in an African context. For instance, over the past 15 years the Treatment Action Campaign (TAC) in South Africa has generated an effective, nationwide social movement among those HIV-positive, stigmatized, and deprived of treatment.4 A comparable movement among Ebola survivors could establish their effectiveness as advocates and educators, countering stigma and building community trust. Therefore, for all these reasons, we advocate creating and expanding initiatives to identify, recruit and train the recovered for roles they might desire. Adults known to having been infected and recovered should be identified through medical records and community leaders, as well as recruited through public messages. Their immunity can be established through blood tests. Interested survivors could be trained in essential caregiving roles, allowing non-immune staff to move to positions that minimize their exposure to Ebola. In this way, infections and mortality among healthcare workers would be greatly reduced. Survivors trained as community advocates and educators could teach others how Ebola is transmitted and could mitigate misinformation.5,6 They could also help families and communities to understand the necessity of isolating those who are symptomatic and of avoiding contact with their bodily fluids. To counter stigmatization of survivors as carriers of disease, public health campaigns will be needed to inform affected communities that the recovered pose no threat to the uninfected and, rather, have an important role in controlling the epidemic and caring for the sick. Training, remuneration and perhaps assignment of an honorific title should raise the status of survivors and counter stigma. Survivors can give hope and emotional support to both the uninfected and infected by demonstrating that life can go on after Ebola infection. Slowing and then stopping the spread of Ebola in West Africa is not only crucial to the region, but also to public health around the world, as demonstrated by the recent spread of the virus to Spain and the USA. But overcoming the crisis wrought by Ebola will require sustained action, cultural insight, and cooperation among affected communities and international responders. Training survivors has the potential to save untold thousands of lives and decrease the likelihood of infections spreading to unaffected populations. The United Nations International Children's Emergency Fund (UNICEF), Medecins Sans Frontieres and Partners in Health have recently initiated interventions that incorporate Ebola survivors, thereby supporting the feasibility of our proposal.7,8 Survivors of the epidemic have a vital role to play in the recovery of their own communities and nations beyond the current outbreak. Even after Ebola transmission is controlled in West Africa, survivors who are trained as caregivers, community health educators and advocates can continue these supportive roles, helping to strengthen their countries’ poorly resourced and understaffed healthcare systems.

This article seeks to fill the gap in female condom acceptability research by examining family planning (FP) providers' attitudes and experiences regarding the female condom in three countries (South Africa, the US, and Nigeria) to highlight providers' potential integral role in the introduction of the female condom. The case studies used data drawn from three independent projects, each of which was designed to study or to change FP providers' attitudes and practices in relation to the female condom. The case study for New York City used data from semistructured interviews with providers in one FP consortium in which no special female condom training had been undertaken. The data from South Africa were drawn from transcripts and observations of a female condom training program and from interviews conducted in preparation for the training. The Nigerian study used observations of client visits before and after providers were trained concerning the female condom. In New York City, providers were skeptical about the contraceptive efficacy of the female condom, with only 8 of 22 providers (36%) reporting they would recommend it as a primary contraceptive. In South Africa, providers who had practiced insertion of the female condom as part of their training expressed concern about its physical appearance and effects on sexual pleasure. However, they also saw the female condom as a tool to empower clients to increase their capacity for self-protection. Structured observations of providers' counseling interactions with clients following training indicated that Nigerian providers discussed the female condom with clients in 80% of the visits observed. Despite the lack of a uniform methodology, the three case studies illuminate various dimensions of FP providers' perceptions of the acceptability of the female condom. FP providers must be viewed as a critical factor in female condom acceptability, uptake, and continued use. Designing training programs and other interventions that address sources of provider resistance and enhance providers' skills in teaching female condom negotiation strategies may help to increase clients' use of the female condom.

A flexible, risk-reduction approach, as compared with a single method approach, may increase sexually transmitted disease (STD)/HIV protection for women attending STD clinics. A brief intervention was tested in an observational study of 292 STD clinic patients in three distinct cohorts. These included subjects counseled on (1) the "women's safer sex hierarchy of prevention methods" (hierarchy cohort, n = 118), including the female condom (FC), male condom (MC), diaphragm, cervical cap, and spermicides, (2) MC only (n = 62), or (3) FC (n = 112) only. We evaluate method use and level of protection achieved at 6-month follow-up among the women in the hierarchy cohort and compare the level of unprotected sex across the three cohorts, using ordinal logistic regression analyses and an imputation procedure to account for attrition. In the hierarchy cohort, the MC, FC, spermicidal film, foam, suppository, and diaphragm were used with main partners by 80%,46%, 37%, 28%, 17%, and 5% of women, respectively. Spermicides were used frequently, mainly in conjunction with condoms. As compared with hierarchy subjects, both MC cohort subjects (OR = 2.3, p = 0.01) and FC cohort subjects (OR = 1.6, p = 0.11) were more likely to report 100% unprotected sex. The tendency for subjects to move toward higher levels of protection was observed most strongly in the hierarchy group. Hierarchical-type counseling, compared with single method counseling, leads to increased protection during sex among women at high risk of STD/HIV infection and should be implemented in STD clinics.

A concern with hierarchy messages which promote male condoms and female-controlled barrier methods along a prevention continuum is that they may discourage condom use. This studys aim was to measure male-condom and female-condom use among women who received hierarchy counseling and compare this with women counseled about condoms only. Three observational cohorts that correspond to prevention message received were assembled and consisted of female sexually transmitted disease (STD) clinic patients who were counseled about male condoms female condoms or a hierarchy message. The hierarchy message promoted male and female condoms the diaphragm and cervical cap spermicides and withdrawal in descending order of effectiveness against STDs. After counseling women were interviewed and returned for follow-up visits at 2 weeks 4 months and 6 months. The outcome was the mean proportion of male condom- or female condom-protected coital acts at each follow-up visit in the hierarchy cohort. The outcome was dichotomized as high (70% or more of coital acts protected) or low (fewer than 70%) and generalized estimating equations were used to compare observed follow-up condom use with baseline within the hierarchy cohort and observed follow-up condom use between cohorts. It was assumed that condom use in persons not present at 6 months was equal to baseline levels and condom use estimates were calculated for each full cohort that was initially enrolled. The mean proportion of condom-protected coital acts in the hierarchy cohort was significantly increased from baseline at each follow-up visit. There were no differences in observed condom use during follow up between the hierarchy cohort and either the male-condom or the female-condom cohort. However when the full cohort initially enrolled was considered 6-month condom use was significantly higher in the hierarchy cohort than in the male-condom cohort. Hierarchy counseling was associated with a significant increase in condom use. The authors findings suggest that offering a choice of male and female condoms results in increased protection over counseling in male condoms alone. (authors)

Using an ethnographic approach, the authors explored the awareness among women in southern Africa of the HIV epidemic and the methods they might use to protect themselves from the virus. The research, conducted from 1992 through 1999, focused specifically on heterosexual transmission in 5 sites that were selected to reflect urban and rural experiences, various populations, and economic and political opportunities for women at different historical moments over the course of the HIV epidemic. The authors found that the female condom and other woman-controlled methods are regarded as culturally appropriate among many men and women in southern Africa and are crucial to the future of HIV/AIDS prevention. The data reported in this article demonstrate that cultural acceptability for such methods among women varies along different axes, both over time and among different populations. For this reason, local circumstances need to be taken into account. Given that women have been clearly asking for protective methods they can use, however, political and economic concerns, combined with historically powerful patterns of gender discrimination and neglect of women's sexuality, must be viewed as the main obstacles to the development and distribution of methods women can control.

Introduction: Effective public health interventions to reduce the incidence of sexually transmitted disease (STD), including HIV, among women are urgently needed. Methods: A randomized trial among STD clinic patients of two types of counseling regarding methods to reduce disease transmission: a 'hierarchical' message (HP), with counseling on male condoms, female condoms, diaphragms, cervical caps, and spermicides (three formulations) and a single method message (SM) covering male condoms only or female condoms only. For this analysis, 1591 subjects received one of three educational messages at the central public STD clinic in Philadelphia. Disease incidence data for up to 6 months following the index visit were extracted from the clinic's electronic database. The primary outcome was STD reinfection: laboratory-confirmed trichomonas infection and/or clinical diagnoses of at least one of four STD. Rates were based on the full sample of randomized women (full sample) and on the subset who spontaneously returned between 22 days and 183 days following their initial visit (returners). Results: Rates of trichomonas infection (SM 2.5% full sample and 12.9% returners versus HP 2.4% full sample and 11.5% returners) and clinical diagnoses (SM 6.3% full sample and 39.7% returners versus HP 6.9% full sample and 41.2% returners) did not differ across the two arms of the randomized trial, both as a straight percentage and in survival analysis (P =.81). Conclusion: At least in this single-session intervention trial, increasing choices in protection for women did not produce a change in disease risk compared with single-method approaches.

Objective: To determine whether low-cost treatment of HIV using vitamin A would be beneficial, we examined the effect of vitamin A supplementation on morbidity of HIV-1 infected women. Objective: Methods: We conducted a randomized, double blind placebo-controlled trial at King Edward VIII Hospital, in Durban, South Africa. In total, 312 HIV-seropositive pregnant women between 28 and 32 weeks' gestation were recruited into this trial. Patients were randomized to receive placebo or 5000 IU retinyl palmitate and 30 mg beta-carotene daily. At delivery of their children, patients received placebo or 200,000 IU retinyl palmitate. The main outcome measures were pre- and postnatal report of HIV-related symptoms. Objective: Results: Vitamin A did not confer any significant beneficial effect on the report of either HIV or pregnancy-related symptoms during the pre- or postnatal period. Objective: Conclusion: In this study of HIV-infected pregnant women, vitamin A supplementation given in doses designed to decrease mother-to-infant transmission did not result in significant beneficial effect on reported symptoms pre- or postnatally. Further investigation with larger number of participants, tailoring supplementation for specific clinical conditions, outside the context of pregnancy, is required to help clarify the possible clinical benefits of vitamin A.

Legal barriers to conducting public health research on methods of protection for anal intercourse were lifted in the United States in 2003 when the US Supreme Court invalidated all state antisodomy laws. Although research funding has been available for the development of rectal microbicides, the female condom, which has already been approved for vaginal use, has not been evaluated for anal use. Although there is no evidence that the female condom is safe for anal intercourse, it has already been taken up for off-label use by some men who have sex with men. This demonstrates the urgent need for more protection options for anal intercourse and, more immediately, the need to evaluate the safety and efficacy of the female condom for anal intercourse.

Relatively few interventions have tested the efficacy of female condom promotion either alone or in combination with other barrier methods. We evaluated the efficacy of a two-session (enhanced) cognitive-behavioral intervention (EI) (n = 147) against a one-session control (minimal) educational intervention (MI) (n = 149) to promote female condom (FC) use among female students aged 18–28 at a South African university. We assessed change from baseline to 2.5 and 5 months in number of vaginal intercourse occasions unprotected by male or female condoms in EI versus MI using generalized linear models with a log link function and GEE. Both groups reported significant reductions in number of unprotected vaginal intercourse occasions from baseline to each follow-up, with no significant difference between the two-session and single-session intervention. Introduction of a brief group-based MI FC promotion intervention with FC access holds promise for delivery in clinics and other community venues.

We evaluated potential gender differences in the development of HIV related neurologic impairment, by matching 38 pairs of HIV positive male and female injecting drug users on their baseline age, education, disease stage and CD4 counts, and following them for 3.5 years. Adjusting for age, education, drug use, history of head injury and baseline CD4 count, more women had sensory abnormalities and symptoms than men at baseline, but the odds of having neurological impairment, particularly extrapyramidal signs and sensory abnormalities were increased over time in men but not in women. Men with ARC or AIDS had more neurological impairment than women in similar stages of illness. This study suggests further investigations of gender differences in HIV disease progression.

Data from a prospective study undertaken at an urban hospital in Durban, South Africa, were used to investigate associations between maternal-infant HIV transmission, mode of delivery, and specific circumstances of cesarean deliveries. A total of 141 children of HIV-infected women were followed until the children were 15 months of age to determine their HIV status. supplementary data were collected from obstetric records, masked to the HIV status of the children. In this African and predominantly breast-fed population, infants delivered vaginally were more likely to be infected (39.8% infected) than were infants delivered by cesarean section [22.9% infected; odds ratio (OR), 0.45; 95% confidence interval (CI), 0.20-0.99]. There were no significant differences between cesarean deliveries undertaken following prior rupture of membranes and those undertaken with membranes intact, but numbers for this comparison were small. Singleton cesarean deliveries without concurrent obstetric complications had lower rates of transmission than did vaginal deliveries (OR, 0.20; 95% CI, 0.04-0.94). These results suggest that certain intrapartum events may modify the risk of HIV transmission and highlight the importance of collecting more detailed intrapartum information in order to clarify the route by which mode of delivery may be associated with maternal-infant HIV transmission.In South Africa, researchers tried to follow 229 mother-child pairs attending the prenatal care clinic of and delivering at King Edward VIII Hospital in Durban until the index child was at least 15 months old. They examined the associations between mode of delivery and maternal-infant HIV transmission. Outcomes were known for 136 women and their 141 children. There were no significant differences between these mother-child pairs and those lost to follow-up in terms of maternal age, parity, weight at first prenatal visit, number of prenatal visits, or the detection of other sexually transmitted diseases, nor in the child's gender, birth weight, gestation, circumstances of delivery, or feeding practices. Children delivered by cesarean section were less likely to develop HIV infection than those delivered vaginally (22.9% vs. 39.8%; odds ratio [OR] = 0.45 for univariate analysis and 0.41 for multivariate analysis). Singleton cesarean deliveries without concurrent obstetric complications were significantly less likely to develop HIV infection than vaginal deliveries (11.7% vs. 39.8%; OR = 0.20; p 0.5). The HIV transmission rates in the other cesarean section subgroups were not significantly different than those in the vaginal delivery group. They were still lower, however. Survival to 18 months was not significantly different between the nine HIV infected infants delivered by cesarean section and their vaginally delivered counterparts (67% vs. 74%; p = 0.7). These findings indicate that some intrapartum events may influence the risk of HIV transmission. They highlight the need to collect more detailed intrapartum information to identify the route by which mode of delivery may be associated with maternal-infant HIV transmission. The intrapartum events that may have influenced HIV transmission in this study include ruptured membranes, twin delivery, and intrapartum hemorrhage.

Spontaneous abortion is the most common adverse reproductive outcome. Despite evidence that negative life events increase risk for a number of medical disorders, their role in pregnancy disruption has not been investigated. The present study tested an a priori hypothesis that recent negative life events increase the odds of spontaneous abortion of a chromosomally normal conceptus. Between 1984 and 1986, 192 women aged 18-42 years who visited a medical center after spontaneous abortion were interviewed about positive and negative events that had occurred in the 4-5 months preceding the loss. Subsequently, women with chromosomally normal (n = 111) and chromosomally abnormal (n = 81) losses were identified on the basis of tissue culture after interview. The women with chromosomally abnormal loss provided an estimate of the expected frequency of life events against which to compare the event frequencies of women with chromosomally normal loss. Analyses were adjusted for duration of the recall period, payment status, maternal age, education, and ethnicity. Seventy percent of the women with chromosomally normal losses reported having had one or more negative life events in the months preceding loss, compared with 52% of the women with chromosomally abnormal losses (adjusted odds ratio = 2.6, 95% confidence interval (CI) 1.3-5.2). For private patients (n = 69), the adjusted odds ratio was 4.2 (95% CI 1.3-13.4); for public patients (n = 123), it was 1.9 (95% CI 0.8-4.8). The associations held for postconception events alone and were absent for positive events. Results were unaltered by adjustment for smoking, caffeine intake, and alcohol consumption. With recall bias precluded by the study design, the strength, timing, and specificity of these associations suggest that recent negative life events play a role in chromosomally normal spontaneous abortion. Efforts to replicate these results and to elucidate underlying biologic mechanisms are required.

Background: Although the proportion of cases of acquired immunodeficiency syndrome related to intravenous drug use has increased dramatically over the past decade, there has been no longitudinal examination of primary neurologic disease in this group. Objective: To study the development of neurologic disease in human immunodeficiency virus (HIV)—negative and HIV-positive men and women who were intravenous drug users over a 3.5-year period. Design: Prospective observational cohort study. Setting: Subjects were recruited from an infectious disease clinic at a New York City Hospital or from a methadone maintenance program. Participants: Ninety-nine HIV-negative (62 men and 37 women) and 124 HIV-positive (85 men and 39 women) intravenous drug users volunteered. Main Outcome Measure: The development of clinically significant manifestations in six neurologic domains. Results: With multivariate adjustment for current and past substance abuse, age, education, and head injury, we examined the odds of developing HIV-related neurologic disease. Extrapyramidal signs and reduced motor ability became increasingly apparent over time in HIV-infected men as their CD4 cell count declined and as the subjects developed the acquired immunodeficiency syndrome. Fewer neurologic signs were seen in the women. Conclusions: The impact of HIV infection among intravenous drug users parallels that in homosexual men and is independent of alcohol and other drug use.

Objective: To study the role of host genotype in pediatric infection with human immunodeficiency virus type 1 (HIV-1) and progression to acquired immunodeficiency syndrome (AIDS). Methods: Human leukocyte antigen (HLA) class II and complement C4 genotypes were determined by means of molecular genetic techniques for 243 black children born to HIV-1-infected mothers in New York City and San Francisco. Survival, cumulative incidences of opportunistic infections and encephalopathy, and rates of CD4 + T cell decline were compared in children of different genotypes. Results: Among HIV-1-infected children, the HLA-DR3 haplotype (DRB1*0301-DQA1*0501-DQB1*0201) was associated with increased incidence of encephalopathy, faster rate of CD4 + cell decline, and death before 2 years of age. Deletion of the C4A gene was independently associated with increased incidences of encephalopathy and early death. DPB1*0101 was associated with survival to at least 2 years of age. The presence of DQB1*0604 was associated with increased risk of HIV infection. Conclusions: These results are consistent with previously reported associations between HLA genotypes and faster progression to AIDS among HIV-infected adults. The DR3 haplotype and C4A deletion may reflect the same underlying mechanism of susceptibility in that the DR3 haplotype is in linkage disequilibrium with other C4A null alleles. In addition, the class II locus DPB1 may have an independent effect on survival. (J PEDIATR 1995;127:544-9)

While the relationship between CD4 counts and clinical symptoms is well established among homosexual men, the same is not true for injection drug using men and women (IDUM and IDUW). In this paper we investigate whether CD4 counts have the same clinical implications for IDUM and IDUW as for homosexual men. We estimated the CD4 counts at which 50 per cent of the HIV-infected but AIDS-free population has AIDS related complex (ARC) based on three biannually measured CD4 counts. The analyses involve interval, right and left censored threshold data. We took the parametric approach, assuming that the threshold values for ARC arise from a family of distributions that includes symmetric, left or right skewed distributions, in which the logistic and extreme value distributions are embedded as special cases. The resulting estimates of median thresholds of CD4 counts for ARC were 249, 424 and 755 for homosexual men, IDUM, and IDUW, respectively. The results were robust with respect to the assumptions on the underlying distribution.

We determined whether survival of children following AIDS diagnosis is improving over time through 1991. AIDS surveillance data from New York City Department of Health on 914 pediatric AIDS patients, diagnosed between 1979 and 1991 and presumed due to maternal-infant HIV transmission, were analyzed. Survival following AIDS diagnosis, established from hospital records and death certificates, was compared by calendar year of initial diagnosis using Kaplan-Meier lifetable analysis. Cox Proportional Hazards regression models were used to compare survival for patients diagnosed earlier or later in the decade, controlling for age at diagnosis, presenting opportunistic illness, and gender of the child. Patients diagnosed with AIDS from October 1987 to September 1989 survived longer, median survival 17 months after diagnosis, than patients diagnosed before September 1987, median survival 10 months (relative risk [RR] = 0.76; 95% confidence intervals [Cl] = 0.62, 0.93). Patients diagnosed from October 1989 to December 1991 also survived a median of 17 months. Secular improvements in survival after AIDS diagnosis remained after controlling for age at diagnosis, presenting diagnosis, and gender, even if deaths within three months of diagnosis were excluded. These data suggest that for recent years, survival following AIDS diagnosis in those contracting the infection through maternal-infant transmission has been prolonged. Possible explanations for these findings include both methodological issues (changes in diagnostic criteria, incomplete ascertainment of deaths) and substantive issues (developments in therapeutic interventions and management of pediatric AIDS).

Summary. Identifying when - during pregnancy, delivery or the postnatal period - transmission of human immunodeficiency virus (HIV) from mother to infant usually takes place is critical to the development of methods to prevent maternal-infant transmission. Evidence is reviewed in this paper as to whether transmission occurs prepartum (early or late in gestation), intrapartum, or postpartum with breast feeding. Evidence in support of the notion of prepartum transmission has come from isolation of HIV from aborted fetal organs, comparison of maternal-child viral genotypes and study of neonatal cell-mediated immune responses. Evidence against prepartum transmission is that fewer than half of the children later known to be HIV-infected can be identified by virological tests carried out close to birth. A reduced rate of transmission in infants delivered by Caesarean section, and a reduced risk of transmission to second-born twins delivered vaginally, offers support to the view that intrapartum factors influence the risk of HIV transmission. Transmission through breast feeding can occur if a mother is infected postpartum and seems to pose some additional risk if she is already infected at parturition. The risk of infection increases with the stage of maternal HIV disease, but specific immunological, clinical and viral characteristics need to be investigated further. A clinical trial of zidovudine, used during late pregnancy and delivery and given to the infant at birth, has reported a significant reduction in transmission. Primary prevention of HIV infection in women remains a principal priority.