IMPROVED INTERVENTION REDUCES PEDIATRIC HIV

KwaZulu-Natal, South Africa made progress toward eliminating pediatric HIV when, in April 2008, it strengthened its prevention of mother-to-child HIV transmission program of providing single-dose nevirapine antiretroviral therapy (ART) to HIV-infected women and their babies at delivery, by also providing zidovudine ART to pregnant women beginning at 28 weeks’ gestation, according to a cross- sectional assessment study.1 Of the nearly 19,500 mothers with infants aged 0–16 weeks who participated in the study conducted between May 2008 and April 2009, 90% had been tested for HIV during their recent pregnancy. Thirty-four percent who had been tested knew that they were HIV-positive or had learned it during their recent pregnancy; of these women, 96% had received ART—including 67% who had received both nevirapine and zidovudine, and 14% who were on lifelong ART. Of the nearly 8,000 infants aged 4–8 weeks tested for HIV, 7% were positive; the rate was reduced among those whose mothers were on lifetime ART or had received zidovudine alone or with nevirapine (3–6%). The authors conclude that low levels of mother-to-child transmission "indicate the rapid, successful implementation of interventions" and that the transmission rate "is likely to decrease further as delivery of these interventions continues to improve."

1. Horwood C et al., Elimination of paediatric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission, Bulletin of the World Health Organization, 2012, 90(3): 168–175.

MANY TEENAGERS REGRET HAVING SEX THEIR FIRST TIME

In a 2007–2009 survey of sexually experienced 14–18-year-olds in the Philippines, El Salvador and Peru, 25–32% of females and 13–21% of males reported regretting having already had intercourse.1 In El Salvador and Peru, larger proportions of females than of males expressed regret (30% vs. 13%, and 32% vs. 19%, respectively), whereas in the Philippines, similar proportions of females and males regretted having had sex (25% vs. 21%). Among females in all three countries, the most common reason for initiating first sex was "I was in love" (46–56%); other common reasons among females were "I wanted to know what it was like," "I felt like it" and "uncontrolled situation," which were also the three most common reasons among males. Overall, more than a third of respondents gave a reason that was related to external pressure to have sex, and half said they had first had sex because of an uncontrolled situation or because they had viewed sexual films or magazines. In multivariate analyses, several reasons for having first sex were associated with subsequent regret: an uncontrolled situation, not knowing how to say "no" to a person who insisted on having sex and viewing sexual images (odds ratios, 1.7–2.1). Respondents who were female, who expressed high religiosity or who had ever had coerced sex were at elevated risk of regret (1.5–2.2). The authors conclude that "sex education seeking the empowerment of adolescents should include discussions about...uncontrolled sexual drive and sexual encounters that more frequently end up being regretted," and recommend that such issues should be addressed in "public advertisements directed to adolescents to empower them to make better informed decisions by avoiding situations of pressure."

1. Osorio A et al., First sexual inter-course and subsequent regret in three developing countries, Journal of Adolescent Health, 2012, 50(3): 271–278.

SYSTEMS APPROACH IMPROVES MATERNAL HEALTH

Maternal health indicators improved greatly in one province in the Philippines where a World Bank–funded program fast-tracked system-wide health reforms, while those indicators improved less, stagnated or worsened in provinces where reforms were introduced later and less systematically. In Sorsogon province, where interventions to improve health sector governance, human resources, financing and service delivery were implemented simultaneously beginning in 2006, the facility-based delivery rate increased by 44 percentage points over the following three years (from 28% to 72%);1 by contrast, the rate increased by no more than 24 percentage points in the other provinces of the Bicol region during that time. Similarly, the number of maternal deaths in Sorsogon dropped from 42 in 2006 to 18 in 2009, whereas the number in the other provinces decreased slightly (by 1–3 deaths), stayed the same or even increased over the period. In addition, Sorsogon spent a greater proportion of its total provincial budget between 2007 and 2010 on health than did the other provinces that reported such information (29% vs. 13–26%). The authors conclude that their findings "give a strong indication of how maternal health programmes can coordinate a package of multifunctional interventions to achieve a rapid impact."

1. Huntington D, Banzon E and Recidoro ZD, A systems approach to improving maternal health in the Philippines, Bulletin of the World Health Organization, 2012, 90(2):104–110.

INEQUITY IN INTERVENTIONS FOR MOTHERS AND CHILDREN

Maternal, newborn and child health intervention coverage varies considerably across countries and by income within countries, according to an analysis of national survey data from 54 developing countries whose progress toward Millennium Development Goals 4 (a reduction in child mortality) and 5 (a reduction in maternal mortality) is monitored by Countdown to 2015.1 Of the 12 interventions included in the study, having a skilled birth attendant present at delivery was the least equitable by income (with a 52 percentage-point difference in mean national coverage between the richest and poorest quintiles), followed by receiving at least four antenatal care visits for a pregnancy (a difference of 35 points). By contrast, early initiation of breast-feeding and provision of insecticide-treated bed nets for children were the most income-equitable interventions (differences in mean coverage of three and seven points, respectively). In analyses that compared a country’s skilled birth attendant coverage and its measles immunization coverage as a measure of overall equity, six countries (Chad, Nigeria, Somalia, Ethiopia, Laos and Niger) stood out as the least equitable overall, whereas two countries (Uzbekistan and Kyrgystan) were the most equitable. The authors conclude that "the most inequitable interventions should receive attention to ensure that all social groups are reached" and "the most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent."

1. Barros AJD et al., Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries, Lancet, 2012, 379(9822): 1225–1233.

CONDOM BREAKAGE AMONG FEMALE SEX WORKERS IN INDIA

Condom breakage is a common occurrence among sex workers in India that puts them and their clients at risk of STIs. According to a 2011 survey among nearly 300 female sex workers in Bangalore, 97% had used a condom at last sex with a client.1 Sixty-one percent had ever experienced condom breakage, 34% had had a condom break in the last month, and 12% had had a condom break the last time they used one. Condom breakage was associated with rough sex, use with a paying client and the condom being too large (odds ratios, 4.3–6.4). During a condom application test, 6% of sex workers broke the condom when applying it on a model penis; on a 10-point scale that assessed five aspects of condom application, half of the sex workers scored 1–5. The authors note that there is a need "to ensure that sex workers understand the risks of breakage, learn skills that can slow men down and have condoms that can fit."

1. Bradley J et al., Why do condoms break? A study of female sex workers in Bangalore, south India, Sexually Transmitted Infections, 2012, 88(3): 163–170.

ANOTHER BENEFIT LINKED TO MALE CIRCUMCISION

Kenyan men who are circumcised are half as likely as those who are uncircumcised to be infected with mycoplasma genitalium (MG)—a bacteria that causes urethritis, cervicitis and pelvic inflammatory disease, and is associated with HIV.1 According to a 2010 study of 526 men in Kisumu, 10% tested positive for MG; 57% received a positive diagnosis for herpes simplex 2 (HSV-2) and 1% each for chlamydia and gonorrhea. Smaller proportions of men with MG than of those without were circumcised (45% vs. 69%), and greater proportions were coinfected with HSV-2 (71% vs. 55%) and chlamydia (6% vs. 1%). Circumcised men’s odds of MG were half those of uncircumcised men (odds ratio, 0.5); HSV-2 and chlamydia were positively associated with MG coinfection (2.1 and 2.6, respectively). The authors comment that their findings add to "the benefits of male circumcision in preventing several sexually transmitted infections." They conclude that "because of its association with urethritis, cervicitis, and pelvic inflammatory disease, a reduction in MG through male circumcision is of public health importance to men and their female sex partners."

1. Mehta SD et al., The effect of medical male circumcision on urogenital Mycoplasma genitalium among men in Kisumu, Kenya, Sexually Transmitted Diseases, 2012, 39(4):276–280.

WOMEN’S DESIRE TO STOP CHILDBEARING IN GHANA

Women’s characteristics—such as their age, marital transitions and perceptions of health—are associated with whether they desire to stop childbearing, according to an analysis of data from eight rounds of a longitudinal survey conducted in southern Ghana between 1998 and 2003.1 Together, there were 2,038 woman-rounds of data; in 47%, women reported not wanting any more children. In regression analyses, every one-year increase in a woman’s age raised her odds of wanting no more children by 10%, while each of her additional living children raised her odds by 50%; getting married between rounds was associated with decreased odds of wanting no more children (odds ratio, 0.5). Women who reported that their health had gotten worse since the last round, believed that their household’s economic situation would get worse or perceived higher than average costs associated with an additional child were more likely than others to want to stop childbearing (1.5–1.9). Women who had discussed the costs and benefits of another child with their partner between rounds were less likely to want no more children (0.6). In additional analyses, the importance of economic and health considerations in regard to the desire to stop childbearing was greater among low-parity women than among high-parity women.

1. Kodzi IA, Johnson DR and Casterline JB, To have or not to have another child: life cycle, health and cost considerations of Ghanaian women, Social Science & Medicine, 2012, 74(7): 966–972.

IN BRIEF

•In its report, Trends in Maternal Mortality: 1990 to 2010, the World Health Organization (WHO) estimates that global maternal mortality has declined by 47% over the last 20 years, from more than 540,000 deaths in 1990 to fewer than 290,000 in 2010. The remaining burden of maternal mortality falls heavily on the developing world, where the risk of childbirth-related death is 15 times that of developed regions. The full report is available at <http://whqlibdoc.who.int/publications/ 2012/9789241503631_eng.pdf>.

•New WHO guidelines on HIV testing and counseling recommend that couples should undergo voluntary testing together and receive support to mutually disclose their serostatus. The guidelines, which also recommend that people with HIV living as part of a serodiscordant couple should be offered antiretroviral therapy to protect their own and their partner’s health, are available at <http://whqlibdoc.who.int/publications/ 2012/9789241501972_eng.pdf>.