THE HUMAN COST OF GOVERNMENT FAILURE

Hundreds of thousands of people died and tens of thousands of babies were born with HIV between 2000 and 2005 because the South African government in 1999 ignored scientific consensus and decided not to implement an antiretroviral (ARV) treatment program, according to an analysis of data from UNAIDS, WHO and South Africa's Health Department, as well as data from published clinical trials, meta-analyses and observational studies.¹ The estimated number of lives lost per year because of a lack of ARV treatment ranged from 5,400 in 2000 to 96,000 in 2004, totaling 334,000 deaths or 2.2 million life-years lost over the entire period. And as a consequence of not implementing a program to prevent mother-to-child transmission (PMTCT), some 35,000 infants were born with HIV, resulting in an additional 1.6 million life-years lost. The authors comment that "the cost of ARVs and the availability of resources were not the absolute barrier explaining why South Africa did not implement a feasible PMTCT and treatment plan." They add that "The South African government…has continued to the present day to divert attention from ARV drugs to nontested alternative remedies."

1. Chigwedere P et al., Estimating the lost benefits of antiretroviral drug use in South Africa, Journal of Acquired Immune Deficiency Syndrome, 2008, 49(4):410– 415.

10 KEY FACTORS FOR PROGRAMS

A high-performing staff and client-centered care are among the 10 most important elements for a successful family planning program, according to a report by the Johns Hopkins Bloomberg School of Public Health based on a poll of and an online discussion with health care professionals from around the world.¹ The other most essential factors for success highlighted in Elements of Success in Family Planning Programming include supportive policies, evidence-based programming, strong leadership and good management, effective communication strategies, contraceptive security, easy access to services, affordable services and appropriate integration of services. An interactive companion Web site, www.fpsuccess. org, has been created to allow family planning programmers to engage in discussions and network with other professionals.

1. The INFO Project, Elements of success in family planning programming, 2008, <http://www.infoforhealth.org/pr/J57/J57.pdf&gt;, accessed Nov. 21, 2008.

PREGNANT ZAMBIAN WOMEN NOW LESS LIKELY TO HAVE HIV

HIV prevalence among pregnant women in Lusaka, Zambia, declined between 2002 and 2006, especially among those 17 or younger, according to a study of data from a public clinic–based program to prevent mother-to-child HIV transmission and from two rounds of cord-blood surveillance.¹ The proportion of women receiving antenatal care at 24 public facilities who were tested for HIV increased from 71% in 2002 to 94% in 2006, whereas the proportion who tested positive declined from 25% to 21%. Over the study period, significant declines in seroprevalence among clients occurred at 11 sites; the average decrease in prevalence was 1% per year. In the first round of cord-blood surveillance, between June and August 2003, 26% of women who received antenatal care and gave birth at public facilities were seropositive; that proportion was 22% in the second surveillance, between October 2005 and January 2006. Women aged 17 or younger had the largest decrease in seropositivity over the 28 months between the two periods, from 12% to 8%, a decline of 36%. HIV prevalence dropped by 21% among those aged 20–24 (from 26% to 20%) and by 13% among those aged 25–29 (from 32% to 28%). Because data came from pregnant or parturient women who attended public clinics in Lusaka, the authors caution that these trends may not be generalizable to all female adolescents or all women in Lusaka, or to the broader Zambian population. However, because they anticipate that seroprevalence among pregnant youth would be higher than that among adolescents in general, they believe that "these results from the youngest age groups in urban Zambia are encouraging," and support continued HIV prevention campaigns that promote condom use and safer-sex practices among youth.

1. Stringer EM et al., Declining HIV prevalence among young pregnant women in Lusaka, Zambia, Bulletin of the World Health Organization, 2008, 86(9):697–702.

NEW HPV TEST FOR USE IN POOR AREAS

A new rapid test developed for use in resource-poor settings to detect 14 cancer-causing types of human papillomavirus (HPV) has sensitivity and specificity at least comparable to those of other commonly used HPV testing methods, according to a study conducted between May 10 and June 15, 2007, in two hospitals in rural Shanxi, China.¹ Among 2,388 nonpregnant women aged 30–54 with no history of abnormal cervical cell growth who provided vaginal and cervical specimens for analysis by the new careHPV rapid DNA test, visual inspection with acetic acid and the standard HPV HC2 DNA test, 70 were found to have moderate or severe cervical intraepithelial neoplasia. The sensitivity and specificity of the careHPV test were greater than those of visual inspection with acetic acid and not significantly different from those of the HC2 test. Given their findings and the fact that the careHPV test has an assay time of only two and a half hours (compared with six hours for HC2) and requires minimal space and no electricity or running water, the authors comment that the new test "seems to have performance characteristics that merit further study and…might be appropriate for use in resource-constrained screening programmes."

1. Qiao YL et al., A new HPV-DNA test for cervical-cancer screening in developing regions: a cross-sectional study of clinical accuracy in rural China, Lancet Oncology, 2008, 9(10):929–936.

BIRTH ATTENDANT USE LOW IN AFGHANISTAN

The proportion of births in Afghanistan delivered by skilled birth attendants is extremely low, according to a study conducted in the country's 33 provinces between June and September 2004.¹ Of a sample of 9,917 women aged 18–45 who lived within a 90-minute walk of one of 617 selected health facilities and who had given birth in the two years prior to the study, only 13% reported that their most recent birth had been assisted by a doctor, nurse or midwife. In multivariate analysis, literacy and wealth were positively associated with use of a skilled attendant at most recent birth (odds ratios, 1.6–6.3); women who lived more than a 60-minute walk from a clinic were less likely than those who lived 30 minutes or less away of using a skilled attendant (0.6– 0.7). In addition, availability of a female doctor or midwife at the closest health facility was associated with increased use of skilled attendants (1.4), whereas facility fees were associated with decreased use (0.8). The authors comment that programs in place to increase literacy and decrease poverty should contribute to improving women's use of skilled attendants, but will take time. They suggest that reducing or removing user fees and implementing "culturally acceptable options that increase demand or use health workers with lesser skill levels" may be shorter term options that deserve consideration.

1. Mayhew M et al., Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study, American Journal of Public Health, 2008, 98(10):1849–1856.

FAMILY INTERFERENCE WITH CONTRACEPTIVE USE

One-fifth of ever-married literate women at private reproductive health clinics in Jordan have had their husband or other family members interfere with their use of contraceptives to avoid pregnancy, according to a study conducted in 2005.¹ Among the 353 women surveyed, 20% reported at least one type of interference in their efforts to avoid pregnancy; 11% reported that their husband had ever refused to use a contraceptive or tried to stop them from doing so, and 13% reported that someone else (usually their mother or mother-in-law) had tried to stop them. Furthermore, 31% had experienced physical violence and 20% sexual violence perpetrated by their husbands during marriage; many also reported that their husbands exhibited controlling behaviors. Women who had experienced physical violence, sexual violence or controlling behavior from their husbands were more likely than others to report interference (odds ratios, 2.4, 3.1 and 1.4, respectively). In contrast, women who had attended an urban clinic rather than a rural one had a reduced likelihood of reporting interference (0.4 for each behavior). The authors believe that family planning services should promote husbands' support for contraceptive use, and that increasing awareness of "the relationships between women's reproductive health and intimate partner violence could be an effective first step toward improving women's access to and effective use of contraceptives."

1. Clark CJ et al., Intimate partner violence and interference with women's efforts to avoid pregnancy in Jordan, Studies in Family Planning, 2008, 39(2): 123–132.

ASYMPTOMATIC STIS IN SOUTH AFRICAN MEN

Asymptomatic STIs are common among men in informal settlements in South Africa's West Rand (part of the Johannesburg metropolitan area), and such infections would not be treated under the syndromic management approach generally used in such resource-poor settings.¹ Among 309 men who participated in a mobile STI screening program conducted around Carletonville in 2006, 90% showed no signs of infection. Of the 301 men screened for urethritis-causing pathogens, 6% had gonorrhea, 9% chlamydia, 14% trichomoniasis and 7% M genitalium infection. There were no significant differences between symptomatic and asymptomatic men in the prevalence of three of the four pathogens; however, gonorrhea was more prevalent in the symptomatic group (22% vs. 5%). Given the greater numbers of asymptomatic men, the STI burden was much heavier in the asymptomatic group, with 2–25 times the number of infections, depending on the pathogen. The authors comment, "As the prevalence of symptomatic STI falls within countries adopting the syndromic management approach, asymptomatic STI are becoming an increasingly important component of the overall STI burden." They suggest that increased efforts may be required to screen hard-to-reach, high-risk men.

1. Lewis DA et al., The burden of asymptomatic sexually transmitted infections among men in Carletonville, South Africa: implications for syndromic management, Sexually Transmitted Infections, 2008, 84(5):371–376.

IN BRIEF

•In September, the United Nation's Development Fund for Women (UNIFEM) released Progress of the World's Women: Who Answers to Women? Gender and Accountability, 2008/2009. The full biennial global report, which features new data and calls for stronger accountability systems to move from commitments on women's rights to results, is available at <http://www.unifem.org/progress/2008/ media/POWW08_Report_Full_Text.pdf>.

•Family Health International's Contraceptive and Reproductive Health Technologies and Research Utilization program has released a new checklist that health care providers can use to screen clients who would like to begin using a contraceptive implant. The checklist, based on the World Health Organization's Medical Eligibility Criteria for Contraceptive Use recommendations, helps identify medical conditions that would make use of the implant unsafe, and determines with reasonable certainty that a woman is not pregnant before initiating the method. It can be found at <http://www.fhi.org/RH/ Pubs/servdelivery/checklists/index.htm>.