Contents
Welcome to the Premier Issue of HIV/AIDS and Sexual and Reproductive Health Integration: Quarterly Highlights
Professionals working to integrate HIV/AIDS and Sexual and Reproductive Health (SRH) services face the challenge of wading through a myriad of information resources to find ones relevant to their field. A group of Integration professionals—members of the USAID Family Planning and HIV/AIDS Integration Working Group—recognized the need to manage the emerging knowledge base for this new field. Over 30 organizations of the Working Group collaborated to compile an on-line knowledge repository of scientific articles, project literature, training materials, photographs, communication materials, and other resources relevant to Integration—Resources for HIV/AIDS and SRH Integration (http://www.hivandsrh.org).
This premier issue of the HIV/SRH Integration: Quarterly Highlights electronicnewsletter draws from that repository to highlight important research findings and emerging resources added to the database in the last calendar quarter. Quarterly Highlights also showcases selected Integration research, news, special reports, and events published in the weekly e-zine, The Pop Reporter. (For Pop Reporter subscription information, see the end of this newsletter.)
Highlights from the Quarter
Male Circumcision and HIV
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Health care workers participate in a counseling role play on male circumcision (MC) during a training session in Lusaka, Zambia. The recent strong evidence linking lack of male circumcision with a high prevalence of HIV makes MC a potential public health intervention for addressing the problem of HIV in sub-Saharan Africa. It may also serve as an entry point for increasing male involvement in reproductive health.
Source: 2004 Emmanuel 'Dipo Otolorin, Courtesy of Photoshare.
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Male circumcision and HIV transmission resurged as a hot HIV/SRH topic in December 2006 when the National Institutes of Health announced the premature ending of male circumcision clinical trials in Kenya and Uganda. NIH reported that it was ending the trials because an interim review of trial data revealed that medically performed circumcision significantly reduces a man's risk of acquiring HIV through heterosexual intercourse. The topic has remained hotly debated, with opponents fearing a surge in risky behavior based on a false sense of HIV-prevention security and questioning the feasibility of scaling up safe delivery of male circumcision services. To add to concern, in March 2007 at a WHO/UNAIDS technical consultation meeting, researchers reported preliminary evidence that circumcised men who fail to wait until their wounds heal may have a heightened risk of infecting their female partners. Other research investigating HIV risk to women with circumcised partners, published in August 2007 in the journal
AIDS, found no increased risk (though wound healing was not examined), but no added protection either (with a questionable exception for at-risk populations). The last quarter has seen continued news items emerging about the male circumcision and HIV debate, including a recent announcement that PEPFAR (President’s Emergency Program for AIDS Relief) will begin investing significant money in making male circumcision available to African men.
Hormonal Contraceptives and HIV Acquisition
Another Integration issue that repeatedly surfaces in research articles and news releases is whether there is a relationship between use of hormonal contraceptives and HIV acquisition by women. A large prospective study, published in the January 2, 2007 issue of the journal AIDS found no overall statistically significant association between the use of either combined oral contraceptive (COC) pills or depot medroxyprogesterone acetate (DMPA) and HIV acquisition. Based on review of the results, the World Health Organization and International Planned Parenthood Federation decided to refrain from changing recommendations for hormonal contraceptive use. But now a study published in the August 2007 issue of the American Journal of Obstetrics and Gynecology again raises the issue. Researchers in that study reported an unexpected observation that hormonal contraception was associated with more rapid HIV disease progression, though they called for additional research to verify the finding.
Female-Controlled Methods
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Microbicides offer the potential for a female-controlled method of HIV prevention. Some may also have a contraceptive effect.
Source: Jefferson Jackson Steele
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The search continues for female-controlled methods of HIV prevention, and methods that have been considered include those that may offer protection against both HIV and unplanned pregnancy. Unfortunately, not all results have been promising. A study published in the Lancet in July 2007 observed no added protective benefit against HIV infection when the diaphragm and lubricant gel were provided in addition to condoms and a comprehensive HIV prevention package (including counseling and testing). While hopes are high for microbicides, researchers have also experienced setbacks with those substances. In January 2007, researchers halted a trial of a candidate microbicide called cellulose sulphate (Ushercell) because of 35 seroconversions among trial subjects, all of which happened at the three African sites of the trial. However, work on microbicides has not stopped, and the July 2007 issue of the Lancet included an article about new safety and efficacy trials of a microbicide gel, formulated with the antiretroviral tenofovir, to take place in South Africa.
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Looking for more information? Try these searches (just paste the URLs in your Web browser to search the HIV/SRH Integration database):
Male Circumcision and HIV
Hormonal Contraceptives and HIV
Microbicides
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Featured Resources
Shadow Report: Review of country-coordinating mechanism proposals with SRH-HIV integration submitted to the Global Fund Round 7
Source: Interact Worldwide and the Global AIDS Alliance
Date: 24 August 2007
URL: http://tinyurl.com/3dvl4m
The report considers efforts to integrate Sexual and Reproductive Health within the HIV/AIDS components of proposals submitted in July 2007 by Country Coordinating Mechanisms for the 7th Round of funding by the Global Fund to Fight AIDS, Tuberculosis and Malaria. This document contains a useful synthesis of several proposed integration activities, organized by country, and commentary on the scope and significance of the proposals. The authors state that the document does not represent an exhaustive coverage of integration proposals, but rather a review of selected final proposals. Integration activities proposed include: Voluntary Counseling and Testing integrated with family planning and antenatal care; Sexually Transmitted Infection services for vulnerable populations; procurement, promotion, and provision of condoms; Preventing Mother-to-Child Transmission; HIV testing in family planning settings; youth-friendly services; sexual and reproductive health counseling; and family planning services for women with HIV. The proposed countries for activities include Burundi, Madagascar, Malawi, Pakistan, Rwanda, and Tanzania.
Men's circumcision status and women's risk of HIV acquisition in Zimbabwe and Uganda
Authors: Turner AN, Morrison CS, Padian NS, Kaufman JS, Salata RA
Source: AIDS. 2007 Aug 20;21(13):1779-1789.
The objective of the study was to assess whether male circumcision of the primary sex partner is associated with women's risk of HIV. Data were analyzed from 4417 Ugandan and Zimbabwean women participating in a prospective study of hormonal contraception and HIV acquisition. After adjustment, male circumcision was not significantly associated with women's HIV risk; that is, the study did not indicate increased protection or risk from male circumcision. The interesting aspect of the study for Integration professionals working with at-risk populations concerns results that suggest some measure of protection specifically for at-risk populations, though the researchers state that these findings warrant further investigation. Prioritizing male circumcision services by population or tailoring male circumcision counseling messages for at-risk populations are not mentioned but may emerge as topics of interest in service delivery.
A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus
Authors: Stringer EM, Kaseba C, Levy J, Sinkala M, Goldenberg RL
Source: American Journal of Obstetrics and Gynecology. 2007 Aug;197(2):144.e1-144.e8.
URL:
http://tinyurl.com/2ryj2r
The purpose of this study was to determine whether the intrauterine contraceptive device (IUD) is effective and safe among women who are infected with the human immunodeficiency virus (HIV). Researchers randomly assigned 599 postpartum, HIV-infected women in Zambia to receive either a copper IUD or hormonal contraception and followed them for at least 2 years. The study found that IUDs were safe and effective for HIV-infected women and that pregnancy rates were lower for HIV-infected women randomized to the IUD arm than those randomized to the hormonal (DMPA or pills). The unexpected observation that hormonal contraception was associated with more rapid HIV disease progression requires urgent further study.
Diaphragm and lubricant gel for prevention of HIV acquisition in southern African women: A randomized controlled trial
Authors : Padian NS, van der Straten A, Ramjee G, Chipato T, de Bruyn G
Source: Lancet. 2007 Jul 21-27;370(9583):251-261
The study assessed the effect of provision of latex diaphragm, lubricant gel, and condoms compared to condoms alone on HIV seroincidence in women in South Africa and Zimbabwe. Researchers observed no added protective benefit against HIV infection when the diaphragm and lubricant gel were provided in addition to condoms and a comprehensive HIV prevention package. While the study shows no HIV-prevention benefit to the use of the diaphragm or lubricant gel, a disappointing result, the discussion section of the research article includes other interesting information about motivations for condom use that came out of the study. The decrease in condom use when participants used diaphragms suggests implications for counseling strategies related to dual protection.
A second chance for microbicides
Author: Baleta A
Women in the KwaZulu-Natal province of South Africa are signing up for the safety and efficacy trials of a microbicide gel, formulated with the antiretroviral tenofovir, which researchers hope will protect them from contracting HIV. If the gel works, it will be a major step forward in the quest for a female-controlled product to prevent infection. There are currently about 60 candidate microbicides being developed. Ten have proven safe and effective in animals and are now being tested in people in the USA, Africa, and India. However, in the past year, three trials were stopped prematurely because the microbicide being tested was ineffective, and in some cases harmful. This commentary includes some details of the tenofovir microbicide trial in South Africa (about 1000 participants at two sites)--such as provision of condoms to participants, even though they are told not to use the gel with the condoms. Sex workers constitute an important part of the trial, as they may have partners who refuse to use condoms and for whom female-controlled methods of protection are important. Other parts of the commentary discuss the state of microbicide research, including the challenges of eventual use of microbicides--like condoms, protection requires using consistently and correctly.
Voluntary HIV Counseling and Testing Integrated with Contraceptive Services Study (VICS): Ethiopia: Baseline preliminary analysis
Authors: Gillespie D, Brahmbhatt H, Bradley H, Karklins S, Tsui A
Source: [Baltimore, Maryland], Johns Hopkins Bloomberg School of Public Health, Bill and Melinda Gates Institute for Population and Reproductive Health, 2007 Jun. 55 p.
The Voluntary HIV Counseling and Testing Integrated with Contraceptive Services three-part study aims to determine if VCT programs can respond to the family planning needs and desires of VCT clients in Ethiopia. This baseline analysis reports on the first of three parts of the study (i.e., surveys with 4,019 clients at 8 VCT facilities in Ethiopia). Details of the other two parts—an intervention involving adding FP services to the VCT centers and additional interviews with clients and providers—are the scope of other reports. This report has a useful background description with supporting citations of the arguments for and against integration of HIV and FP services. Also of interest is the demographics of the study clients—the report notes that design of the intervention will need to provide for a mixture of mostly young clients—married and unmarried, some not yet sexually active, HIV-positive and –negative, and with differing fertility desires. The report also acknowledges the need to ensure a reliable supply of contraceptive supplies for the VCT centers, as this is a known challenge in Ethiopia. According to the report, a steering committee in Ethiopia refers to the integration plan as a best practice, so details of the intervention should offer a potential model for other integration efforts.
Events
This section lists upcoming public health conferences, meetings, or other events that include activities and information concerning HIV/AIDS and Sexual and Reproductive Health Integration. If you know of an upcoming event that may be of interest to HIV/SRH Integration professionals, please e-mail
info@hivandsrh.org.
4th Asia Pacific Conference on Reproductive and Sexual Health. Hyderabad, India, Oct 29-31, 2007
URL: http://www.4apcrsh.org/
Partner Profile
Resources included in the HIV/AIDS and Sexual and Reproductive Health Integration Web site represent the work of many organizations and individuals—virtual partners striving to advance global health goals through integration and linkages among health care services. This section spotlights one of these organizations or individuals contributing to the field of Integration.
Family Health International
Family Health International (FHI), headquartered in Research Triangle Park, Durham, North Carolina, U.S.A., has worked for years in the areas of HIV/AIDS and SRH Integration research, advocacy, training, and evaluation. In 2007, FHI began leading a team working with USAID to conduct a field assessment of HIV/FP Integration models in five countries. FHI has also conducted research in Integration areas such as: use of contraception for PMTCT; hormonal contraceptive use and risk of HIV acquisition; integration of family planning and VCT, ART, and PMTCT services; and integrated services for youth. FHI has published numerous research articles, counseling guides, bulletins, CD-ROMs, and other resources concerning Integration, such as an issue of their quarterly bulletin, Network (see 2004, Volume 23, Issue 3 at: http://www.fhi.org/en/RH/Pubs/Network/v23_3/index.htm) and the CD-ROM and on-line modules, Contraception for Women and Couples with HIV (see http://www.fhi.org/en/RH/Training/trainmat/ARVmodule.htm).
Subscription Information
Quarterly Highlights is a free electronic newsletter, distributed by e-mail four times a year, and archived on
http://www.hivandsrh.org. To subscribe, visit
http://www.infoforhealth.org and register to set up a free account. Under “Subscriptions,” select “HIV and SRH Integration Web Site News.”
Interested in submitting resources to the HIV/SRH Integration Web site or sharing a story with us about your country or organization's experience with integrating programs? Please send e-mail to:
info@hivandsrh.org.
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How to Request Copies of Full-Text Documents
Developing country users can request full-text copies of many of the documents listed in Quarterly Highlights. To request a copy of a document, click on the document URL or copy and paste the URL into your Web browser. You will be redirected to the Integration database, where you can add a document to your shopping “basket” after you set up a free user account.
