CLIENTS WHO DARE NOT SPEAK THEIR NAME

At a public sexual health clinic in Sydney that gives clients the option not to provide a surname, 5% of first-time clients in 1998–2004 took advantage of that offer.1 These clients were less likely than others to have had contact with an infected partner, to have STD symptoms or to receive a diagnosis of an STD other than HIV (unadjusted odds ratios, 0.6–0.8); they were more likely to be seeking HIV testing or STD screening (1.4–1.6). Multivariate analysis showed that heterosexual men were more likely than women not to give a surname (1.3); currently and formerly married clients and, especially, those who did not report their marital status were more likely than never-married clients to opt for anonymity (1.6–5.5). Other characteristics associated with not giving a surname were having had a same-sex partner in the past 12 months, having had no partner in the past three months and receiving an HIV test at the initial clinic visit (1.2–1.5); sex workers were particularly likely to choose this option (5.7). The researchers observe that clients who chose anonymity "were not conspicuously at higher or lower risk" than others. They add, however, that "in settings where sex workers have higher [STD] rates, offering an anonymous option could have a marked public health benefit."

1. Spillane HC et al., Who declines to give a name at a sexual health service? Sexually Transmitted Infections, 2007, 83(2):160–162.

WHY NOT USE PROTECTION?

Why would women who do not wish to conceive have unprotected sex? According to an analysis of data collected in 2000–2002 by the Pregnancy Risk Assessment Monitoring System (PRAMS), many of them believe that they cannot become pregnant.1 The PRAMS survey, conducted in 26 states and New York City, asked women who reported an unintended pregnancy whether they had been "doing anything to keep from getting pregnant" and if not, which of six reasons explained why not. Of the 7,856 women included in the analysis, 33% had thought they could not conceive, and another 10% had thought that their partner was sterile. Despite having said that their pregnancy was mistimed or unwanted, 30% said that at the time they conceived, they had not minded the thought of a pregnancy. Partner’s reluctance to use contraceptives was reported by 22% of women, access difficulties by 10% and contraceptive side effects by 16%. The findings, the analysts conclude, "show a need to raise awareness of pregnancy risk and to explore the concept of intendedness."

1. Nettleman MD et al., Reasons for unprotected intercourse: analysis of the PRAMS survey, Contraception, 2007, 75(5):361–366.

POLICY HELPS PREVENT HIV

Federal guidelines and a state law aimed at expanding perinatal HIV services appear to have had an effect in California.1 The federal guidelines, issued in 1994 and 1995, recommend that HIV-infected women and their newborns receive zidovudine treatment to prevent perinatal transmission of the virus, and that all pregnant women be offered voluntary HIV testing. The California law, which grew out of these recommendations and took effect in 1996, requires that all women be offered an HIV test during prenatal care and that HIV-infected women be offered treatment for themselves and their infants. According to an analysis of data from two population-based studies, the proportion of HIV-infected women who had been offered an HIV test during pregnancy rose from 53% in 1987–1995, before the guidelines and policy were issued, to 84% in 1996–2002, the initial years of their implementation. Similarly, the proportion offered zidovudine treatment increased from 52% to 87%. In the later period, among women who were known to have HIV infection during pregnancy and were offered treatment, 94% were offered the full course of therapy. In the analysts’ view, although service gaps still exist, devoting resources to strengthen HIV testing and treatment policy is an effective strategy for preventing perinatal HIV infections and reaching infected women with appropriate care.

1. Sarnquist CC et al., The effectiveness of state and national policy on the implementation of perinatal HIV prevention interventions, American Journal of Public Health, 2007, 97(6):1041–1046.

SHAME ON ME?

When asked how they thought they would feel and how they thought other people would react to them if they tested positive for human papillomavirus (HPV), female university students who knew that the virus is sexually transmitted reported higher expected levels of shame and stigma than those who did not know how it is spread.1 Among the 811 respondents to a Web-based survey, who were 18–30 years of age, those who knew that the infection is quite common would not expect to feel as much shame, stigma and anxiety because of an HPV diagnosis as would those who were unaware of the infection’s prevalence. Women who knew that the virus is sexually acquired but not that it is very common had the highest expected levels of shame and stigma. Noting that respondents were addressing only a hypothetical situation, the researchers comment that if these findings apply to women actually undergoing HPV testing, they suggest that public health messages need to emphasize the prevalence of the disease and that widespread awareness of how common it is "could mitigate most of the negative psychosocial consequences of publicising the fact that HPV is sexually transmitted."

1. Waller J, Marlow LAV and Wardle J, The association between knowledge of HPV and feelings of stigma, shame and anxiety, Sexually Transmitted Infections, 2007, 83(2):155–159.

ABORTION NOT A FACTOR IN BREAST CANCER RISK

A large prospective study of U.S. women has found no association between induced or spontaneous abortion and the incidence of breast cancer.1 The Nurses’ Health Study II has been following a cohort of 25–42-year-old nurses enrolled in 1989 through questionnaires mailed every two years; to assess the relationship between abortion and breast cancer, researchers analyzed data from questionnaires completed between 1993, when information on induced and spontaneous abortion was first collected, and 2003. During the study period, 1,458 cases of breast cancer were identified among the 105,716 participants; hazard analyses adjusting for a wide range of risk factors revealed that women who had had an induced abortion or miscarriage were at no greater risk than others. Breast cancer incidence also showed no association with number of induced abortions, women’s age at induced abortion, parity or timing of abortion. The investigators caution that the results may not be applicable to postmenopausal women. However, they note that the prospective cohort study design avoids some of the pitfalls of earlier work on this issue, which has generally been based on case-control or retrospective studies, and therefore bolsters the importance of the findings.

1. Michels KB et al., Induced and spontaneous abortion and incidence of breast cancer among young women, Archives of Internal Medicine, 2007, 167(4):814–820.

HIV TESTING OPTIONS: THE DOLLARS AND SENSE

The Centers for Disease Control and Prevention’s recommended strategy of routine opt-out HIV testing, in which all 13–64-year-olds receiving services in any health care setting would be offered testing but could decline the offer, may not be the best approach.1 According to one analysis, more than 65 million Americans a year would be tested under this approach, 56,940 individuals with undiagnosed HIV infection would be reached and 3,644 transmissions and infections would be averted; the cost per transmission or infection averted would come to about $237,000. By contrast, if health care providers offered targeted counseling and testing to individuals at high risk of infection, close to 30 million men and women would be reached, including 188,170 who were unaware that they were HIV-positive, and 14,553 transmissions and infections would be averted; the cost per averted transmission or infection would be an estimated $59,000. (Total costs for both programs would be the same—about $865 million annually.) The targeted approach maintained its edge in analyses using varying assumptions about HIV prevalence and the effectiveness of counseling. Although the analyst describes multiple limitations of his work, he believes that if funding were available for one of these options, "the better investment would be a highly targeted program."

1. Holtgrave DR, Costs and consequences of the US Centers for Disease Control and Prevention’s recommendations for opt-out HIV testing, PLoS Medicine, 2007, 4(6):e194, <http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10…;, accessed June 27, 2007.

DOES LOCATION MATTER?

Living close to a family planning facility is not associated with a reduced risk of unintended pregnancy but may be related to an elevated risk of teenage pregnancy.1 In analyses of data from four states on women reporting unintended pregnancies in the 1999 and 2000 Pregnancy Risk Assessment Monitoring System and on all teenagers who gave birth in 2000, researchers found that virtually all women lived within a half hour (most within 15 minutes) of a family planning facility. Logistic regression analysis revealed no significant association between the risk of unintended pregnancy and travel time to a facility, the presence of a facility within a woman’s zip code or the availability of private physicians who provide family planning services. The risk of teenage pregnancy, by contrast, declined significantly as travel time to a facility increased and was elevated if the zip code area had a facility; the analysts speculate that these findings reflect confounding by facilities’ location in areas with a high level of family planning needs. Overall, they suggest that their results mean not "that family planning facilities are ineffective or that geographic access is not important," but "that geographic access is not a barrier…in these four states."

1. Goodman DC et al., Geographic access to family planning facilities and the risk of unintended and teenage pregnancy, Maternal and Child Health Journal, 2007, 11(2):145–152.

IN BRIEF

• The Joint United Nations Programme on AIDS has issued an interim set of guidelines aimed at ensuring the protection of the confidentiality and security of information about people with HIV infection. The guidelines, which were developed at a three-day workshop in May 2006, emphasize the need for countries and "organizations at all levels of the healthcare system" to adopt policies and practices that balance the goal of safeguarding the health of communities with individuals’ rights to privacy and confidentiality. Before the guidelines are finalized, they will be field-tested and evaluated; the final product is expected to include sample policies and procedures, as well as a self-assessment program. The draft guidelines are available at <http://data.unaids.org/pub/manual/2007/confidentiality_security_interim…;.

• In A Portrait of Sexuality Education and Abstinence-Only-Until-Marriage Programs in the States, the Sexuality Information and Education Council of the United States (SIECUS) presents a detailed look at abstinence-only education in 2006. For each state and the District of Columbia, SIECUS has compiled information on federal funding received for abstinence-only education; a description of sex education law and policy, and of recent legislative proposals and other events related to sex education; and data on youth. The state profiles are available at <http://www.siecus.org/policy/states/index.html&gt;.