Women In Resource-poor Settings Research Articles

Awareness of Cervical Cancer, Risk Perception, and Practice of Pap Smear Test among Young Adult Women of Dhulikhel Municipality, Nepal.

Despite being one of the most preventable forms of cancer, cervical cancer remains an important public health problem, especially in developing countries. However, there is limited evidence regarding awareness and practice of screening for cervical cancer among women in resource-poor settings like Nepal. This study is aimed at assessing the awareness of cervical cancer, risk perception, and practice of Pap smear tests among adult women of Dhulikhel municipality of Kavreplanchowk district in Nepal. Methodology. A community-based cross-sectional study was conducted among 422 women (aged 18-45 years) residing across the Dhulikhel municipality of Nepal. Systematic random sampling method with face-to-face interviews was conducted to collect data. A descriptive analysis was performed to assess the sociodemographic characteristics of the participants. The chi-square test was used to determine the factors associated with risk perception and participants' demographic characteristics. The mean age (±SD) of the participants was 30.7 ± 7.9 years. This study found that around 55% and 38% of women had heard about cervical cancer and Pap smear test, respectively. Of those who had heard of the Pap test, only 37.6% had ever practiced the test. Similarly, 33.2% and 12.1% knew about the correct age group and time interval to perform the Pap test, respectively. Among those who had heard about cervical cancer, nearly 57% had positive perceptions toward cervical cancer. In addition, risk perception of cervical cancer was found to be associated with participant age, family type, and marital status. The women had inadequate knowledge and practice of cervical cancer and Pap smear test. This study concluded the need for a context-specific and effective health awareness program to promote preventive measures for cervical cancer and enhance the practice of Pap smear test in the community.

High Fidelity: Delivery and use of an LPG stove intervention during pregnancy in the HAPIN trial

BACKGROUND AND AIM: Most previous cookstove trials have reported low intervention adoption and/or high continued traditional stove use, limiting interpretation of results. The Household Air Pollution Intervention Network (HAPIN) trial randomized 3195 pregnant women in resource-poor settings of four countries to a liquefied petroleum gas (LPG) stove and fuel intervention or to control. We assessed implementation fidelity (the extent to which the intervention was delivered as intended) and adherence (the extent to which it was adopted by participants) at the first trial endpoint: the end of the gestational period. METHODS: We tracked intervention fidelity through questionnaires at baseline ( 20 weeks gestation) and at two post-intervention visits (at 24-28 and 32-36 weeks of pregnancy), data collected by study staff (e.g. visual observations at fuel deliveries), and temperature-logging stove use monitors (SUMs) downloaded twice monthly. RESULTS:Over a median [Q1, Q3] follow-up period of 150 [131, 168] days per household, median time to repair for stoves requiring maintenance was 0 [0, 0] days (same day repair), and 87.2% of LPG refills were delivered within one week of request. 96.1% of intervention households reported LPG stove use at both follow-up visits. In the 70.0% of intervention households that retained traditional stoves after receiving their LPG stove, the median rate of traditional stove use was 0.0 [0.0, 1.6] days per 100 days of observation (using SUMs). In 70.6% of these households, traditional stoves were used on fewer than one in every 100 days of observation (Guatemala: 83.3%; India: 85.4%; Peru: 59.6%; Rwanda: 70.2%). CONCLUSIONS:The HAPIN intervention was largely delivered as intended, and participant adherence to the LPG stove intervention during pregnancy was high. Any observed differences in pollutant exposures or health outcomes between control and intervention groups are unlikely to be due to implementation failures during the gestational period. KEYWORDS: Air Pollution, Birth Outcomes, Community-engaged research, International Collaboration, Methodological study design, Particulate Matter

Understanding maternal dietary behaviour and perceived attributes of foods in the context of food insecurity in rural Bangladesh: a qualitative study

Background Evidence shows inadequate dietary diversity among women in resource poor settings in developing countries. We explored women’s perceived attributes related to food choices to understand their eating habits during pregnancy and lactation, in rural Bangladesh. Methods We conducted a qualitative study in two villages in Jamalpur District in northern Bangladesh. These villages experience high levels of poverty according to the 2010 Bangladesh Poverty Map. We undertook in-depth interviews (n=36) with pregnant and lactating women and conducted focus group discussions (n=2) with their husbands. We used the ProPAN (Process for the Promotion of Child Feeding - a tool to improve infant and young child feeding) methodology to develop a key food list to conduct the food attribute exercise. Data was audio-recorded, transcribed in Bangla, and translated into English. The transcripts were manually coded and analyzed using the inductive thematic approach. Results We found that: (i) animal-source foods and fruits were the least consumed in the women’s diet resulting in low dietary diversity; (ii) Consumption of diversified foods was influenced by access to food at home, while accessibility depended on affordability and availability in the local market or homestead gardens; and (iii) even though food was available and accessible at the household level, individual food choice and consumption were subject to personal preference, cultural norms and lack of knowledge about nutritious foods and subsequent health benefits during pregnancy and lactation. Conclusions The findings will assist in planning appropriate interventions to improve dietary diversity of pregnant and lactating women. Insights from this study will be useful for designing appropriate nutrition behaviour change communication in Bangladesh and other low-resource settings.

Community mobilization and maternal Care of Women Living with HIV in poor settings: the case of Mfuwe, Zambia

BackgroundResearch has shown that community mobilization is a useful strategy in promoting maternal care of HIV negative women in resource poor settings; however, similar evidence for women living with HIV is missing. Therefore, in this study we provide this evidence by exploring the relevance of community mobilization in the promotion of maternal health care among women living with HIV in resource-poor settings by using Mfuwe, a rural district in Zambia as a case study.MethodsBy relying on Focus Group Discussions (FGDs), qualitative data were collected from Mfuwe, Zambia. The data were digitally recorded, transcribed and later translated from CheChewa (local language) to English. We relied on Thematic analysis to analyze the data.ResultsBy focusing on community mobilization, our results showed that within their social fabrics, resource-poor communities often contain unrecognized and sometimes ignored strategies which are contextually-feasible and have been used for generations to promote maternal care for HIV positive women. Further, it was evident that although the three forms of community mobilization were largely and uniquely useful in promoting maternal health care of women living with HIV, they also presented unique and various shortcomings.ConclusionWe demonstrated that community mobilization was largely and often characterized as a force for good (e.g. providing support, improving access to maternal care etc.) and sometimes for bad (e.g. reinforced harmful misconceptions, superstition and stigma). Thus we recommend that community mobilization needs to be factored into maternal health care policies for HIV positive women in resource poor settings either to optimize their potential benefits or to minimize their potential harm.

Migrant perinatal depression study: a prospective cohort study of perinatal depression on the Thai-Myanmar border

PurposePerinatal depression is a significant contributor to maternal morbidity. Migrant women in resource-poor settings may be at increased risk, yet little research has been conducted in low-income and middle-income settings....

HIV-positive men's experiences with integrated family planning and HIV services in western Kenya: integration fosters male involvement.

A growing body of evidence indicates that integrating family planning (FP) services into HIV care is effective at improving contraceptive uptake among HIV-positive women in resource-poor settings, yet little research has examined HIV-positive men's experiences with such integration. We conducted in-depth interviews with 21 HIV-positive men seeking care at HIV clinics in Nyanza, Kenya. All clinics were intervention sites for a FP/HIV service integration cluster-randomized trial. Grounded theory was used to code and analyze the data. Our findings highlight men's motivations for FP, reasons why men prefer obtaining their FP services, which include education, counseling, and commodities, at HIV care clinics, and specific ways in which integrated FP/HIV services fostered male inclusion in FP decision-making. In conclusion, men appear invested in FP and their inclusion in FP decision-making may bolster both female and male agency. Men's positive attitudes towards FP being provided at HIV care clinics supports the programmatic push towards integrated delivery models for FP and HIV services.

Antibody Boosting and Longevity Following Tetanus Immunization During Pregnancy

To the Editor—Maternal and neonatal tetanus is a significant cause of mortality, estimated to cause 180 000 deaths annually [1]. Since the mid-1970s, tetanus vaccination of pregnant women has been included in the World Health Organization's (WHO) Expanded Programme on Immunisation (EPI) [2]. Two doses of tetanus toxoid are sufficient to generate an antibody response (immunoglobulin G [IgG] class) capable of protecting neonates from tetanus, 3 doses are recommended for pregnancy, and 5 are recommended for life [3]. Despite these recommendations, WHO has identified a lack of longitudinal data quantifying antitetanus antibody boosting and duration during pregnancy following immunization in the EPI schedule [4]. To address this gap, we determined levels of antitetanus IgG at multiple time points from enrollment to delivery (median, 30 weeks of follow-up) in 376 pregnant women participating in malarial antibody studies at the antenatal clinics of the Shoklo Malaria Research Unit in northwest Thailand (previously published with ethics statement in Fowkes et al [5]). The tetanus vaccination regimen (tetanus toxoid) followed EPI guidelines [3]: dose 1, as early as possible during pregnancy; dose 2, one month after dose 1; dose 3, 6 months after dose 2; dose 4, 1 year after dose 3; and dose 5, one year after dose 4. During the study, 48.9% of women received their first dose, 86.2% received doses 2–4, and 8.2% received the final dose (dose 5). The boosting and decay of tetanus antibody levels after vaccination was vaccine dose-dependent (Figure ​(Figure1).1). In the first 8 days after vaccination, antitetanus IgG increased rapidly at comparable rates in all vaccination groups (P > .85 relative to T1). Interestingly, at 8 days after vaccination, IgG responses peaked and then plateaued in those receiving ≥2 doses. In contrast, IgG responses in those receiving their first vaccination peaked later at 50 days after vaccination (Figure ​(Figure1,1, P < .001). After 50 days postvaccination, antitetanus IgG responses declined and calculated IgG half-life was dependent on vaccination dose: 7.12 years (95% confidence interval [CI], 3.02–∞) for dose 1; 10.97 years (6.71–∞) for doses 2–4; and 12.28 years (6.15–∞) for dose 5. These estimates are in concordance with published nondose-specific half-life estimates in nonpregnant American women (10 years, 95% CI, 8–14) [6]. Figure 1. Antitetanus immunoglobulin G (IgG) after vaccination in 376 pregnant women according to vaccination dose. Tetanus IgG levels (optical density) were determined by enzyme-linked immunosorbent assay as previously described [5] with tetanus toxoid coated ... The close consecutive sampling of antitetanus antibody levels has allowed us to define, in the greatest detail to date, antitetanus IgG kinetics postvaccination, and we provide the first estimates of tetanus IgG half-lives in pregnancy according to vaccination dose in the EPI schedule. These data are important for predicting protection in neonates and are invaluable for understanding the sustainability of protective humoral immunity in high-risk populations such as pregnant women in resource-poor settings.

Identifying with a process of change: A qualitative assessment of the components included in a smoking cessation intervention at antenatal clinics in South Africa

Introductionprevious research has suggested that pregnant women prefer a person-centred approach for smoking cessation interventions. However few studies have illustrated the mechanism through which such an approach has an influence on quitting or reduction rates among pregnant women in resource poor settings. Purposeto explore the role of different components included in a smoking cessation intervention delivered to disadvantaged pregnant women with high smoking rates attending public health antenatal clinics in South Africa. Methodsa qualitative design consisting of focus-group discussion with women exposed to the intervention was used. Women were purposively selected from four antenatal clinics and one tertiary hospital to represent different experiences of the intervention. Focus group discussions with four groups of smokers and four groups of quitters were conducted and a total of 41 women were interviewed. Data were analysed using content analysis. Main findingsthe main theme describing the intervention effect that emerged from the interviews was, ‘Making identification with change possible’. The categories ‘An impulse for change’, ‘An achievable recipe’, ‘A physical reminder’ and ‘A compassionate companion’ further described how each intervention component was perceived by women and how it contributed to behaviour change. Conclusionsbehaviour change interventions that are directly informed by the target population with regards to its design, content and delivery offer great opportunities for positive behaviour change. Women positively evaluated all the components employed in this intervention but rated the social support they received from peer-counsellors as the overriding aspect of the intervention.

Relating the construction and maintenance of maternal ill-health in rural Indonesia

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

Diabetes Buddies

The purpose of this study is to test the feasibility and acceptability of a mobile phone-based peer support intervention among women in resource-poor settings to self-manage their diabetes. Secondary goals were to evaluate the intervention's effectiveness to motivate diabetes-related health choices. Women with diabetes (n = 22) in Cape Town, South Africa, participated in a 12-week program focused on providing and applying knowledge of health routines to manage diabetes. Women were linked with a buddy via a mobile phone for support and were questioned daily about a health behavior via text message. Women were assessed at recruitment and then 3 and 6 months later by a trained interviewer using a mobile phone for data collection. The women were evaluated on technology uptake, reduction of body mass index, blood glucose levels, and increases in positive coping and general health-seeking behaviors. Women exchanged 16 739 text messages to buddies and received 3144 texts from the project. Women responded to 29% of texted questions (n = 1321/14 582). Women attended at least 9 of 12 possible intervention sessions; a third attended all 12 sessions (n = 8/22). Between baseline and 3 months, women increased their sleep and reported a higher level of positive action and social support coping, yet blood glucose increased by 3.3 points. From 3 to 6 months, spiritual hope decreased and diastolic blood pressure increased. One year later, the 22 women continue to attend meetings. Mobile phones are an easy and reliable way to provide peer support and disseminate health messages. Both positive and negative changes were observed in this pilot study.

Estimation of gestational age from fundal height: a solution for resource-poor settings

Many women in resource-poor settings lack access to reliable gestational age assessment because they do not know their last menstrual period; there is no ultrasound (US) and methods of newborn gestational age dating are not practised by birth attendants. A bespoke multiple-measures model was developed to predict the expected date of delivery determined by US. The results are compared with both a linear and a nonlinear model. Prospectively collected early US and serial symphysis-pubis fundal height (SFH) data were used in the models. The data were collected from Karen and Burmese women attending antenatal care on the Thai–Burmese border. The multiple-measures model performed best, resulting in a range of accuracy depending on the number of SFH measures recorded per mother (for example six SFH measurements resulted in a prediction accuracy of ±2 weeks). SFH remains the proxy for gestational age in much of the resource-poor world. While more accurate measures should be encouraged, we demonstrate that a formula that incorporates at least three SFH measures from an individual mother and the slopes between them provide a significant increase in the accuracy of prediction compared with the linear and nonlinear formulae also using multiple SFH measures.

Monitoring Severe Pre-Eclampsia and Eclampsia Treatment in Resource Poor Countries: Skilled Birth Attendant Perception of a New Treatment and Monitoring Chart (LIVKAN Chart)

The lack of easy to use protocols and monitoring charts in the management of pre-eclampsia/eclampsia contribute to substandard care of women in resource poor settings. A treatment monitoring tool (LIVKAN chart) has been developed to improve the quality of care for these women. Based on feedback from skilled birth attendants (SBAs), a two page document which provides a visual record of the treatment and monitoring of women with severe pre-eclampsia/eclampsia over a 24 h period was developed. It also contains detailed treatment guidelines as well as a summary of the woman's treatment. A two page document on instructions for use of the chart was also developed. The chart design was evaluated by different level SBAs via a semi structured questionnaire. There was a 92% (109) response rate. About 30% (33) and 58% (63) of the respondents provided care to women in Primary Health Care and referral health care facilities respectively. Ninety eight percentage of respondents indicated that the chart would be of additional benefit in their care of women with pre-eclamptic/eclampsia. Seventy three percentage of respondents indicated that the chart would also be useful to lower health care facility SBAs. The design of the chart ensures that guidelines for managing/monitoring of patients are instantly available on a concise easy-to-use chart which confers added advantage over other chart designs. Having been evaluated by SBAs, acceptability and utilization in poor resource settings should be high. A study has been designed to evaluate the acceptability and effectiveness of this new monitoring chart in both BEOCs and CEOCs in two sub-Saharan African countries.

Women in Resource-Poor Settings Are at Risk of Inadequate Intakes of Multiple Micronutrients1–4

A systematic review was conducted to identify all studies that were published between 1988 and 2008 reporting micronutrient intakes of women in resource-poor settings. Inclusion criteria were study location (resource-poor), dietary assessment method (24-h recall, estimated/weighed record, or locally validated FFQ), energy and 1 or more micronutrient intakes reported (vitamin A, vitamin B-6, vitamin B-12, vitamin C, thiamin, riboflavin, niacin, folate, iron, or zinc), age range (15–50 y), sample size (≥30), and sex (female). Of the 1560 papers identified, 52 papers were included. Results showed that, except for vitamin A (29%), vitamin C (34%), and niacin (34%), the reported mean/median intakes in over 50% of studies were below the Estimated Average Requirement (EAR). Folate intake was most often below EAR (91% of studies). Regional differences were apparent for intakes of vitamins A, C, and B-6 and riboflavin; mean/median intakes in Latin America exceeded the EAR, whereas in Asia, reported mean/median intakes of vitamin C, vitamin A, and riboflavin were below the EAR in 47, 50, and 77% of the studies, respectively, as was the case for vitamin B-6 in 75% of the studies in Africa. These results suggest that inadequate intakes of multiple micronutrients are common among women living in resource-poor settings and emphasize the need for increased attention to the quality of women’s diets. There is a need for more high-quality studies of women’s micronutrient intakes.

Making it happen: prevention of mother to child transmission of HIV in rural Malawi

HIV and AIDS, in resource-limited settings, contribute to increased maternal and infant mortality where such vital indicators are already high. In these settings, babies born to HIV-positive women continue to have added risks of acquiring HIV infection and dying from it before their fifth birthdays if no interventions are employed. Prevention of mother-to-child transmission (PMTCT) is an international initiative whose implications within the local context need to be known. An operational research approach was adopted to study the demand and adherence of key components within the PMTCT Programme among women in rural Malawi. This study was carried out at Malamulo SDA Hospital in rural Malawi and employed the mixture of both quantitative and qualitative approaches. While the introduction of innovative policies in antenatal care (ANC) that has positive impact particularly on marginalised women's access to the services, negative effects are also inevitable. Marginalised women in resource-poor settings fail to deliver at the health facility due to lack of transportation, economic difficulties, gender inequalities, tradition and negative attitude of health workers. Integration of HIV testing and opt-out testing in ANC coupled with the introduction of free maternal care resulted in more women accessing maternal services and PMTCT services. It is as a result of this that institutional delivery facilitates increased adherence to antiretroviral prophylaxis and is supported by both women and the communities. The paper summarises the research conducted and elaborates on how it contributed to actions to improve staff attitude, increase male involvement in reproductive health care and discussions on how available resources can be maximised.This article has been commented on by Thorkild Tylleskär. Please follow this link – http://www.globalhealthaction.net/index.php/gha/article/view/5370 – to read his Commentary.

HAART during pregnancy and during breastfeeding among HIV-infected women in the developing world: has the time come?

This editorial comment focuses upon the idea of offering HAART to all HIV-infected pregnant women including those in developing countries and considers the barriers or problems associated with this concept as well as the positive outcomes. It states that more data is needed but that a strategy would be to ensure that women with CD4 cell count below 350 cells/ml in resource-limited settings receive HAART that would then be continued after breastfeeding cessation for maternal health.

HIV, infant feeding and implementation failure: advancing policies for women with HIV infection and attaining the Millennium Development Goals

Coutsoudis et al.1 offer a viewpoint on the WHO guidelines on HIV and infant feeding that suggests that the use of infant formula among HIV-positive women in the developing world is, to a large extent, currently untenable. The article has many valid arguments: it is well known that promotion of formula feeding among HIV-positive women within the context of inadequate community support, unreliable formula supply and contaminated drinking water can result in excess infant mortality.2 However, empirical data exist that counter some of the authors’ views. It has been demonstrated that formula feeding among HIV-positive women in a context with counselling support and education, access to clean water and uninterrupted availability of breast-milk substitutes can offset the risk of infant mortality. In Cote d’Ivoire, there were no differences in risks of diarrhoea, respiratory infection, malnutrition, hospitalization or death in breastfed versus formula-fed infants of HIV-positive women. The authors of this study suggest that offering safer conditions (clean water, free formula) and a more supportive environment (replacement feeding counselling and education) were elements that reduced the potential threat of mortality among formula-fed infants. These findings were sustained after a two-year follow-up period.3 With safe formula feeding, the vertical HIV transmission rate can be reduced to less than 2%; this is an attainable goal in a resource-limited setting as indicated by results from a preliminary study in Rwanda.4 In addition to a low transmission rate, the mortality rate reported was modest (21 per 1000 person-years) among those infants enrolled at birth in the Inshuti Mu Buzima prevention of mother-to-child transmission programme in rural Rwanda that were offered free formula, materials, education and support through community health workers. Evidence from South Africa offers a more complex picture of infant feeding outcomes in the context of HIV. There, formula feeding demonstrated a protective effect on HIV transmission per death among those living in households with piped water (hazard ratio, HR: 0.51; 95% confidence interval, CI: 0.31–0.84). Among those who had piped water and fuel and who disclosed their HIV status, the protective effect of formula was greater (HR: 0.32; 95% CI: 0.16–0.62). However, among women who did not have piped water or fuel and did not disclose their HIV status, formula feeding conferred an increased risk of HIV transmission per death by 3.5 fold (HR: 3.45; 95% CI: 1.89–6.32).5 These findings suggest that contextual factors are critical when considering the appropriate feeding option for HIV-positive women in resource-poor settings, indicating that in some settings the provision of formula would result in increased child mortality as Coutsoudis et al.1 argue. However, these findings also suggest that aggressive measures to improve water quality and access to other resources may reduce the risk of child mortality associated with provision of infant formula. In fact, improving access to potable water may be the most critical element in offering safe feeding alternatives to HIV-positive women with infants in developing countries and should not be considered an unattainable goal. One of the eight Millennium Development Goals (MDGs) is to “ensure environmental sustainability” (Goal 7) and one of the targets is to “reduce by half the proportion of people without sustainable access to safe drinking water”. Although addressing the global water crisis may not be immediate, as indicated by the MDGs, targets for improving access to potable water must be set and attained for the near future. One should not lose sight of the fact that progress has been made in the past 20 years: since 1990 approximately 1.6 billion people have gained access to safe drinking water. During this period, the child mortality rate for developing countries declined from 103 to 80 per 1000 live births, suggesting improvement with respect to MDG Goal 4 of reducing child mortality.6 Therefore, despite the suggestion that “poverty is not easily or quickly reversed”1, a positive, goal-directed outlook can offer results more quickly. If programmes reducing mother-to-child transmission of HIV through formula feeding are deemed not feasible in a large majority of settings throughout the developing world, thousands of infants will continue to die due to the presumed inability to offer access to clean drinking water and a safe environment for formula feeding. However, in settings where women are offered a safe and supportive environment, the potential for child mortality can be offset and the risk of HIV transmission can be dramatically reduced. The fight against HIV/AIDS can serve as an entry point to demonstrate to families in remote areas that access to clean water and reduction in HIV transmission as well as child mortality are attainable goals as we work collectively towards reaching the MDGs. ■

Advances and failures in preventing perinatal human immunodeficiency virus infection.

An estimated 2.5 million children are currently living with HIV, the vast majority as a result of mother-to-child transmission. Prevention of perinatal HIV infection has been immensely successful in developed countries. A comprehensive package of services, including maternal and infant antiretroviral therapy, elective cesarean section, and avoidance of breast-feeding, has resulted in transmission rates of less than 2%. However, in developing countries, access to such services is often not available, as demonstrated by the fact that the vast majority of children with HIV live in Africa. Over the past few years, many developing nations have made great strides in improving access to much-needed services. Notably, in eastern and southern Africa, the regions most affected by HIV, mother-to-child-transmission coverage rates for HIV-positive women increased from 11% in 2004 to 31% in 2006. These successes are deserving of recognition, while not losing sight of the fact that much remains to be done; currently, an estimated 75% of pregnant women worldwide have an unmet need for antiretroviral therapy. Further work is needed to determine the optimal strategy for reducing perinatal transmission among women in resource-poor settings, with a particular need for reduction of transmission via breast-feeding.

Comparability of Self-Collected Vaginal Swabs and Physician-Collected Cervical Swabs for Detection of Human Papillomavirus Infections in Rakai, Uganda

The objective of this study was to compare human papillomavirus (HPV) DNA testing between self-administered vaginal swabs and physician-administered cervical swabs in women from rural Rakai District, Uganda. Between 2002 and 2003, women from a population-based cohort participated in an HPV study. Women collected self-administered vaginal swabs and were also offered a pelvic examination, which included physician-collected cervical samples. Hybrid-capture 2 was used to determine carcinogenic HPV status. Polymerase chain reaction was used to determine HPV genotypes. Unweighted kappa statistics were used to determine agreement. Compliance with self-collected swabs was > or =86%; however, only 51% accepted a pelvic examination. Carcinogenic HPV prevalence was 19% in self-collected and 19% in physician-collected samples. Agreement among paired observations was 92% with a kappa of 0.75. Kappa between self- and physician-collected samples was similar in HIV strata (k = 0.71 and 0.75 for HIV-positive and HIV-negative, respectively). In this community-based setting, detection of carcinogenic HPV was comparable among self- and physician-administered samples. Self-collection is a feasible and accurate means of obtaining HPV samples from women in resource-poor settings or persons reluctant to undergo a pelvic examination.

Men's sexual health matters: promoting reproductive health in an international context.

Recent concern regarding the control of sexually transmitted infections (STIs) has resulted in an increased interest in the sexual health of men. This interest has primarily focused on strategies to 'encourage and enable men to take responsibility for their sexual and reproductive behaviour and their social and family roles' (United Nations 1994). Whilst men are deemed to have 'responsibilities', women are said to have 'rights' with regard to making choices about reproductive health and accessing appropriate and effective services. Here it is argued that, whilst provision of services and interventions against STIs in men should never be at the expense of those for women, it is often clinically easier and more effective to diagnose and treat men with STIs compared to women in resource-poor settings. Indeed, this may prove to be an effective strategy in controlling the spread of STIs, and hence reducing the disproportionate burden of their complications suffered by women. The paper reviews key issues in relation to improved service delivery for sexual and reproductive health in men, notably: the heterogeneity of male populations; current knowledge regarding men's sexual behaviour; the role of sexuality; methods of studying sexual behaviour in resource poor countries; men's own concerns in relation to sexual and reproductive health; and where and how they access treatment. It is argued that the time has now come to determine and address men's sexual health needs if we are to expect them to participate fully as responsible partners in improving and protecting their own and others' sexual and reproductive health.

Administration of Zidovudine During Late Pregnancy and Delivery to Prevent Perinatal HIV Transmission—Thailand, 1996-1998

The efficacy of a short-term regimen of zidovudine (ZDV) in preventing perinatal HIV transmission was investigated in a randomized case-placebo study conducted at two teaching hospitals in Bangkok Thailand in 1996-97. The 198 women in the intervention group were given 300 mg of ZDV orally twice a day from 38 weeks of gestation until the onset of labor and 300 mg every 3 hours thereafter until delivery. Another 199 women received a placebo. Infants in both groups were fed formula rather than breast milk. At 6 months of age 52 children (17 from the ZDV group and 35 in the placebo group) were HIV-positive; all HIV infections were evident at 2 months of age. The HIV transmission risk was 9.2% (95% CI 5.0-13.5%) in the ZDV group and 18.6% in the placebo group (95% CI 13.0-24.0%) signifying a 51% decrease in risk. The ZDV regimen used in this study is more feasible for implementation in developing country settings than the one currently used in the US (associated with a 66% reduction in HIV transmission): it costs US$50 starts later in pregnancy involves less frequent dosing and oral dosing during labor and does not involve infant treatment. On the basis of these findings ministries of health and donor agencies are urged to develop strategies to increase access to prenatal HIV testing and ZDV treatment for HIV-infected pregnant women in resource-poor settings. Further evaluation is needed of the effect of breast feeding on the efficacy of this regimen.