- Email: [email protected]
ROUND-UP Research
Round-Up
Nonoxynol-9 fihn shows no protection against HIV or other STDs two-year, randomised, controlled trial in Cameroon, involving 1292 sex workers, studied the microbicidal effectiveness of nonoxynol-9 film used with condoms as compared to a placebo Iilm used with condoms. An incredibly high rate of use of film and condoms together, or film alone, or condoms alone, was achieved in both groups during the study. Preliminary analysis of the data showed the overall incidence of HIV transmission to have fallen to under 7 per cent, roughly half the baseline rate estimated in this population. However, although the intervention itself helped to reduce the women’s risk of HIV, there was no difference in the HIV infection rate among the women using N-9 film vs. the placebo film group. Nor was there any protection against gonorrhoea or chlamydia, even though the women were tested and treated monthly for STDs. (N-9 works in vitro against all three of these infections.) Further, the women using the N-9 film had a somewhat higher rate of genital lesions and sores on the vulva than those in the placebo group, though this did not increase their risk of infection.* The data lead to the conclusion that N-9 vaginal film is safe to use but does not prevent sexual transmission of HIV, chlamydia or gonorrhoea. This information was only presented publicly in April 1997 and press released, not yet published. The results could mean that the N-9 dose in the film may not be high enough, or the N-9 did not work fast enough, or did not protect the cervix or spread throughout the vagina well enough - or the women became infected on days of non-use. Or, the gel in the placebo could have worked as well as the N-9 did. Research on a higher dose of N-9 in gel form in a similar trial seems justified. Microbicide research using other compounds, a number of which are under development, is now more urgent than ever. The high rate of self-protection practised by the women was an important achievement of this study; however, case-control rates of 6.6-6.7 per cent HIV incidence, 31-33 per cent gonorrhoea transmission, 20-22 per cent chlamydia trans-
A
mission and 42-33 per cent genital lesions in spite of high rates of protection, indicate how effective any new barrier and/or microbicidal method will need to be and also how much a cure for these infections is needed too.2 1. NIAID evaluates N-9 film as microbicide.Press release, 3 April 1997. National Institute of Allergy and Infectious Diseases, Washington DC. 2. Presentation by Ron Roddy (Family Health International, main researcher on the study) and comments by Mahmoud Fathalla, Alan Stone and others at: Practical and Ethical Dilemmas in the Clinical Testing of Microbicides, 27-30 April 1997, Airlie Retreat Center (Virginia), USA.
Anal HPV infection and cytological abnormalities in HIV-positive women HIS was a cross-sectional
cohort study of
T 102 HIV-positive and 96 HIV-negative women
selected from an ongoing study of gynaecological manifestations in women with HIV in New York City. It found that the prevalence of both anal human papillomavirus (58 per cent vs. 8 per cent) and anal cytological abnormalities (26 per cent vs. 6 per cent) was increased in women with HIV infection as compared to HIV-negative women. The strength of the association was greater in women with low CD4+ counts (low immune status). No other risk factor was found to be associated with these conditions upon multiple logistic regression analysis, not even those associated with cervical HPV and cytological abnormalities. The fact that these conditions were not associated with anal intercourse has also been found in other studies in women. In contrast, increased prevalence of anal cytological abnormalities and cancer is associated in HIV-positive men with a history of receptive anal intercourse. The natural history of progression to anal carcinoma in women is not known. Hence, these authors do not support a recommendation that anal cytology screening is done routinely.* 1. Hillemanns P, Ellerbrock TV, McPhillips S et al, 1996. Prevalence of anal human papiUomavirus infection and anal cytologic abnormalities in HIVseropositive women. AIDS. 10(14):1641-47.
181
Research
Resistance to HIV infection shown among sex workers in Nairobi N observational cohort study of incidence of HIV
Aln ’ fection among 424 initially HIV-negative sex
workers in Nairobi was carried out between 1985 and 1994. The aim was to find out whether some individuals are resistant to HIV infection. The incidence of seroconversion was found to decrease with increasing duration of exposure, which indicated that there are either differences in susceptibility to HIV or that acquired immunity develops. Analysis of epidemiological and laboratory data showed that persistent seronegativity was not explained by seronegative HIV infection or by differences in risk factors for HIV infection such as safer sex behaviours or incidence of other sexually transmitted infections. The authors conclude that a small proportion of highly exposed individuals, who may have natural immunity to HIV, are resistant to HIV.l 1. FowkeKFt,NagelkerkeNJD, KimaniJ et al, 1996. Resistance to HIV-l infection among persistently seronegative prostitutes in Nairobi, Kenya. Lancet. 348(16 Nov):l347-51.
Expert US panel still recommends zidovudine during pregnancy study in which zidovudine was given to preg-
An ant mice found higher rates of lung, liver, skin and genital tract cancer than in controls. The effect on lung and liver was regarded as moderate. The female genital tract cancers were more unusual and similar to some of the tumours seen in daughters of mice given diethystilboestrol (DES) during pregnancy. In January 1997, an expert panel met at the US National Institutes of Health and recommended that women should be told about these findings before they are offered zidovudine to help to prevent perinatal transmission of HIV to their babies. However, this panel still recommended the use of zidovudine for this purpose, as the study results still need to be con6rmed and the risk of HIV transmission during pregnancy and birth was considered much higher than the risk of cancer in children whose mothers have been treated. Continued monitoring of children born to HIV-positive women who take zidovudlne at the end of pregnancy was also recommended.’ 1. RowePM, 1997. US expert panel reaffirms benefit of perinatal zidovudine.Lancet. 349(25 January):258.
182
HIV viral load in semen not related to clinical stage of infection HIS
study
aimed
to
quantify
HIV load
T (measured as copies of viral RNA/ml)in blood,
semen and saliva and look for relationships to clinical and immunological status among 26 HIVpositive men aged 26 to 38 with no symptoms of genital tract infections. HIV RNA was detected in all blood samples and 96 per cent of semen and 96 per cent of saliva samples. The only negative semen sample was in a man with low viral load in blood and saliva who was a long-term nonprogressor. The copy number varied greatly in blood, semen and saliva, with the viral load in semen and saliva significantly lower than in blood. There was a direct correlation between copy number in plasma and saliva, which may reflect contamination of saliva by blood even in healthy subjects with no visible oral lesions, as shown in previous work. In 11 of the 26 men, the viral load was higher in saliva than in semen. In men with low CD4+ counts the viral load in saliva was greater than in those with higher CD4+ counts. Although there is a substance in saliva that exerts antiretroviral activity, a recent finding in the macaque monkey that cell-free SIV is significantly more transmissable orally than intra-rectally, it is possible but not known if HIV could be transmitted by saliva in people. The fact that semen and blood plasma levels of HIV were not correlated confirms previous studies and taken together with other inforniation, supports the notion that local factors, including inflammation and other infections, may exert a profound effect on HIV concentration in semen - independent of clinical and immunological stage of infection. In one man, two of three semen specimens contained higher viral load than blood samples. Hence, semen must be considered potentially infectious at all stages of immunodeficiency and adequate precautions sexually are always needed.’ 1. LiuzziG, Chirianni A, Clemeti M et al, 1996. Analysis of HIV-l load in blood semen and saliva: evidence for different viral compartments in a cross-sectional and longitudinal study. AIDS. 10(14):F51-56.
Reproductive
Health Matters, No 9, May 1997
Likelihood of condom use in various commercial sex settings in northeast Thailand
Women with positive Pap smears in Buenos Aires often not having treatment
research among 744 men in Thai villages, an extra 219 men in 18 migrant labour camps and some additional men in 5 cattlemarkets examined whether condoms were used when buying sex in brothels, at cattlemarkets, festivals and migrant labour settings. Sexual services were typically purchased as part of friendship group partying and generally included heavy alcohol consumption. The comparative role played by men with different sexual experiences in the spread of HIV was shown by the differential rates of STD infection. Only one per cent of village men (and none in the migrant sample) who had had only non-commercial sex partners reported ever having an STD, compared to 40 per cent of village men (and 47 per cent in the migrant group) who had purchased sex. Almost half the men surveyed, married and single, had visited sex workers, and 13 per cent had visited a sex worker in the year before the study. Visits to brothels were infrequent (67 per cent four times or less in the past year) and 82 per cent involved five or fewer partners. Visits to brothels were the most common form of buying sex (87 per cent). In scenarios other than brothels, however, condoms were much less likely to be used. During festivals, which might occur up to once a month, and other celebrations (eg. the end of sugar cane cutting for the season), sex is hurried, often behind buildings or under lorries, on a mat somewhere, with men lining up and drinking heavily. Finally, many of the men considered local women and women not identified as sex workers, with whom they might also have casual sexual encounters, as not being a risk and therefore they believed that condoms were not needed with them. Whether or not the men used condoms with their wives was not mentioned in the paper.l
clinical histories and used survey, in-depth interviews and participant observation to explore why women with positive Pap smears were not attending for treatment for cervical cell abnormalities at four public hospitals in Buenos Aires from 1986-1988. Of the total 458 women who had a positive smear in that period of time, 68 per cent did not go back to the hospital where the abnormality was fn-st detected and 44 per cent took no course of action to get treatment. Factors which affected whether women sought treatment were:
UALITATIVE
8 32 northeast
1.
Maticka-TyndaleE, Elkins D, Haswell-Elkins M et al, 1997. Contexts and patterns of men’s commercial sexual partnerships ln northeastern Thailand: implications for AIDS prevention. Social Science andMedicine. 44(2):199-213.
HIS study examined
T a community-based
characteristics of the women, such as their age, the number of children they had and how much they knew and understood about the meaning of a positive Pap smear; doctor-patient communication, such as when and how the women were informed of the test result and told that they needed treatment, and other things the doctor said; and aspects of service delivery, such as the amount of time women had to wait for a consultation and how long it lasted. The following recommendations for improving this situation were: develop protocols for testing and treatment of cervical cancer, eg. criteria for assessing test results. keep records up to date of where women with positive smears live, so that they are contactable. define which conditions are more or less critical in order to reduce waiting times, maximise the use of professionals’ time, and give women the incentive to return to the clinic to be treated. assure privacy during consultations, both in terms of physical space and of people walking in and out. guarantee that every woman who has a Pap smear is informed what it is for and why it is important for her to find out the results when the smear is taken, not only when the results are available. 183
Research
urge professionals to revise their belief that if women are told they may have cancer or its precursor, it will upset them so much that they will not seek treatment. Instead, it is lack of information that makes women uncertain why they need to attend. make professionals aware of the biases in their behaviour towards the most vulnerable women, ie. the least educated women, older women and those who ask no questions, to whom they seem to provide the least care and attention. revise the risk profile for cervical cancer in Argentina to include women who have never sought a Pap smear at all, or who have not had a gynaecological examination since they had their last child, often for more than 15 years, because women beyond reproductive age are seen not to need care any 1onger.l Ramos S, Pantelides E, Mormandi J et al, 1996. La deserci6n de mujeres con Papanicolaou positivo en hospitales ptiblicos de1Area Metropolitana de Buenos Aires. Revista de la Sociedad de Obstetricia y Ginecologia de Buenos Aires. 75(919).
Obstetric morbidity in South India NTERVIEWS with 3600 women in rural Karstate in India who had at least one pre-school-age child, found that many had serious obstetric problems associated with their last confinement. About ten per cent reported one or more classic symptoms of pre-eclampsia. Many of these were life-threatening conditions which occured during delivery, notable prolonged labour over 18 hours. Ten per cent reported excessive bleeding, loss of consciousness or convulsions post-partum and an additional 17 per cent mentioned symptoms of infections1
1 nataka
1. Bhatia JC and Cleland J, 1996. Obstetric morbidity in South India: results from a community survey. Social Science andMedicine. 43(10):1507-16.
Research on childbearing: a transcultural review HIS paper summarises and reviews the key on childbearing in both western and non-western countries. In non-western societies, there is currently a dysfunctional dichotomy between modern and traditional practices that prevents the solution of problems in childbirth management: poverty, illiteracy, unemployment, malnutrition, prostitution, substance abuse, high infant and maternal mortality, family disruption, single parenthood and lack of child care. The author calls for more research on how traditional practices contribute to obstetric complications and poor outcomes, and more work on how to incorporate traditional practices that enrich the experience. An examination of government policies in this area is also called for, and the institutionalisation of modern management practices that reduce risk. In western countries, problems are quite different. The research marks the importance of the isolation of the nuclear family and the strain this places on having children. Again, in general it appears that men are not taking paternity leave. The author suggests that resources be reoriented towards women’s needs, eg. improved maternity benefits, improved career opportunities for women with children and employerlinked child care. Research also points to the redundancy of antenatal classes for many couples and the need to identify and support women at risk who do not seek out such classes. It also suggests that post-natal assistance to new mothers and overwhelmed ‘second-timers’ is needed and may be welcome. Overall, research attention has shifted in the past 35 years to populations at risk, using large and representative sample sizes, and focuses on current social and health problems. This review suggests that interdisciplinary research will be most useful in future, combining ethnographic, epidemiological and intervention approaches, to develop a culturally informed data base for policy development and imp1ementation.l
T research
1. Steinberg S, 1996. Childbearing research: a transcultural review. Social Science and Medicine. 43(12):1765-84.
184
Reproductive
Review of figures on maternal deaths in Colombia N Colombia,
a recent study in Valle de Aburra,
1 where the health system is better than in other parts of the country, found that 50 per cent of maternal deaths had not been registered. To make the figures more accurate, a group of national and international organisations decided to bring together data from a range of sources and correct for the effects of sub-registration, using figures from the recently published 1993 census. The results gave a maternal mortality ratio of 78.2 maternal deaths per 100,000 live births. Estimates of 100 to 200 deaths have come out of other recent reports in Colombia, and experts were concerned that this figure might still be too low. The three main causes of deaths were toxaemia, which was by far the most important, followed by complications of abortion and haemorrhage from various causes.l 1. Trias M, 1996. Mortalidad materna (editorial). Revista Profamilia. 14(28):4-7.
Increasing prevalence of traditional contraceptives in Honduras HE use of traditional contraceptive methods in Honduras between 1987 and 1991-92 from 19 per cent of all contraceptive use to 26 per cent. Analysis of data from two national probability sample surveys found a drop in the numbers using no method (59 to 53 per cent), increased use of traditional methods (7.6 to 12 per cent), especially the rhythm method (3.5 up to 6.7 per cent), a drop in use of oral contraception (13.4 down to 10.1 per cent), an increase in female sterilisation (12.6 up to 15.6 per cent) and little or no change with other methods. Promotion of the rhythm method was intense on the part of religious groups in Honduras in that period, spending power decreased, and there were attacks on modern methods by various groups as well. In 1989, the government voted down a bill to reduce high fertility and increase low contraceptive use, and a bill was then introduced that would have limited family planning services further. While this too was defeated, there was a lot of public debate on both sides and in the media. Access to modern methods was not reduced in this period, but it would appear that
T increased
Health Matters, No 9, May 1997
the efforts of the family planning programme were not successful in increasing overall reliance on and use of modern methods1 1. Hubacher D, Suazo M, Terrell S et al, 1996. Examining the increasing prevalence of traditional contraceptive methods in Honduras. International
Family PlanningPerspectives.
22(4):163-68.
Treating breast cancer before surgery N the continuing
attempts
to increase
sura new approach is being tried. It is based on various methods of measuring the effect of chemotherapy on the primary tumour, and the adjustment of treatment accordingly. Thus, chemotherapy has long been used to downstage advanced primary tumours before surgery. This practice might be extended prior to surgery to all operable tumours, and randomised trials along these lines are being carried out. It seems certain that immunophenotyping of cancer cells will lead to customisation of adjuvant treatment regimens. Thus, second-look surgery might be done more often so that any benefit from chemotherapy can be checked, or biopsy to check oestrogen receptor status before any decision to use tamoxifen. Use of chemotherapy before as well as after surgery seems well accepted by women who have had it, but the question of how long to wait before carrying out lumpectomy once drug treatment has been started will not be easy to answer, nor whether breast surgeons would accept the possibility of using drug treatment alone.’
1 vival rates for women with breast cancer,
1. Epstein R, 1996. Treating breast cancer before surgery (editorial). BMJ. 313(30 November):1345-46.
185
Nonoxynol-9 fihn shows no protection against HIV or other STDs two-year, randomised, controlled trial in Cameroon, involving 1292 sex workers, studied the microbicidal effectiveness of nonoxynol-9 film used with condoms as compared to a placebo Iilm used with condoms. An incredibly high rate of use of film and condoms together, or film alone, or condoms alone, was achieved in both groups during the study. Preliminary analysis of the data showed the overall incidence of HIV transmission to have fallen to under 7 per cent, roughly half the baseline rate estimated in this population. However, although the intervention itself helped to reduce the women’s risk of HIV, there was no difference in the HIV infection rate among the women using N-9 film vs. the placebo film group. Nor was there any protection against gonorrhoea or chlamydia, even though the women were tested and treated monthly for STDs. (N-9 works in vitro against all three of these infections.) Further, the women using the N-9 film had a somewhat higher rate of genital lesions and sores on the vulva than those in the placebo group, though this did not increase their risk of infection.* The data lead to the conclusion that N-9 vaginal film is safe to use but does not prevent sexual transmission of HIV, chlamydia or gonorrhoea. This information was only presented publicly in April 1997 and press released, not yet published. The results could mean that the N-9 dose in the film may not be high enough, or the N-9 did not work fast enough, or did not protect the cervix or spread throughout the vagina well enough - or the women became infected on days of non-use. Or, the gel in the placebo could have worked as well as the N-9 did. Research on a higher dose of N-9 in gel form in a similar trial seems justified. Microbicide research using other compounds, a number of which are under development, is now more urgent than ever. The high rate of self-protection practised by the women was an important achievement of this study; however, case-control rates of 6.6-6.7 per cent HIV incidence, 31-33 per cent gonorrhoea transmission, 20-22 per cent chlamydia trans-
A
mission and 42-33 per cent genital lesions in spite of high rates of protection, indicate how effective any new barrier and/or microbicidal method will need to be and also how much a cure for these infections is needed too.2 1. NIAID evaluates N-9 film as microbicide.Press release, 3 April 1997. National Institute of Allergy and Infectious Diseases, Washington DC. 2. Presentation by Ron Roddy (Family Health International, main researcher on the study) and comments by Mahmoud Fathalla, Alan Stone and others at: Practical and Ethical Dilemmas in the Clinical Testing of Microbicides, 27-30 April 1997, Airlie Retreat Center (Virginia), USA.
Anal HPV infection and cytological abnormalities in HIV-positive women HIS was a cross-sectional
cohort study of
T 102 HIV-positive and 96 HIV-negative women
selected from an ongoing study of gynaecological manifestations in women with HIV in New York City. It found that the prevalence of both anal human papillomavirus (58 per cent vs. 8 per cent) and anal cytological abnormalities (26 per cent vs. 6 per cent) was increased in women with HIV infection as compared to HIV-negative women. The strength of the association was greater in women with low CD4+ counts (low immune status). No other risk factor was found to be associated with these conditions upon multiple logistic regression analysis, not even those associated with cervical HPV and cytological abnormalities. The fact that these conditions were not associated with anal intercourse has also been found in other studies in women. In contrast, increased prevalence of anal cytological abnormalities and cancer is associated in HIV-positive men with a history of receptive anal intercourse. The natural history of progression to anal carcinoma in women is not known. Hence, these authors do not support a recommendation that anal cytology screening is done routinely.* 1. Hillemanns P, Ellerbrock TV, McPhillips S et al, 1996. Prevalence of anal human papiUomavirus infection and anal cytologic abnormalities in HIVseropositive women. AIDS. 10(14):1641-47.
181
Research
Resistance to HIV infection shown among sex workers in Nairobi N observational cohort study of incidence of HIV
Aln ’ fection among 424 initially HIV-negative sex
workers in Nairobi was carried out between 1985 and 1994. The aim was to find out whether some individuals are resistant to HIV infection. The incidence of seroconversion was found to decrease with increasing duration of exposure, which indicated that there are either differences in susceptibility to HIV or that acquired immunity develops. Analysis of epidemiological and laboratory data showed that persistent seronegativity was not explained by seronegative HIV infection or by differences in risk factors for HIV infection such as safer sex behaviours or incidence of other sexually transmitted infections. The authors conclude that a small proportion of highly exposed individuals, who may have natural immunity to HIV, are resistant to HIV.l 1. FowkeKFt,NagelkerkeNJD, KimaniJ et al, 1996. Resistance to HIV-l infection among persistently seronegative prostitutes in Nairobi, Kenya. Lancet. 348(16 Nov):l347-51.
Expert US panel still recommends zidovudine during pregnancy study in which zidovudine was given to preg-
An ant mice found higher rates of lung, liver, skin and genital tract cancer than in controls. The effect on lung and liver was regarded as moderate. The female genital tract cancers were more unusual and similar to some of the tumours seen in daughters of mice given diethystilboestrol (DES) during pregnancy. In January 1997, an expert panel met at the US National Institutes of Health and recommended that women should be told about these findings before they are offered zidovudine to help to prevent perinatal transmission of HIV to their babies. However, this panel still recommended the use of zidovudine for this purpose, as the study results still need to be con6rmed and the risk of HIV transmission during pregnancy and birth was considered much higher than the risk of cancer in children whose mothers have been treated. Continued monitoring of children born to HIV-positive women who take zidovudlne at the end of pregnancy was also recommended.’ 1. RowePM, 1997. US expert panel reaffirms benefit of perinatal zidovudine.Lancet. 349(25 January):258.
182
HIV viral load in semen not related to clinical stage of infection HIS
study
aimed
to
quantify
HIV load
T (measured as copies of viral RNA/ml)in blood,
semen and saliva and look for relationships to clinical and immunological status among 26 HIVpositive men aged 26 to 38 with no symptoms of genital tract infections. HIV RNA was detected in all blood samples and 96 per cent of semen and 96 per cent of saliva samples. The only negative semen sample was in a man with low viral load in blood and saliva who was a long-term nonprogressor. The copy number varied greatly in blood, semen and saliva, with the viral load in semen and saliva significantly lower than in blood. There was a direct correlation between copy number in plasma and saliva, which may reflect contamination of saliva by blood even in healthy subjects with no visible oral lesions, as shown in previous work. In 11 of the 26 men, the viral load was higher in saliva than in semen. In men with low CD4+ counts the viral load in saliva was greater than in those with higher CD4+ counts. Although there is a substance in saliva that exerts antiretroviral activity, a recent finding in the macaque monkey that cell-free SIV is significantly more transmissable orally than intra-rectally, it is possible but not known if HIV could be transmitted by saliva in people. The fact that semen and blood plasma levels of HIV were not correlated confirms previous studies and taken together with other inforniation, supports the notion that local factors, including inflammation and other infections, may exert a profound effect on HIV concentration in semen - independent of clinical and immunological stage of infection. In one man, two of three semen specimens contained higher viral load than blood samples. Hence, semen must be considered potentially infectious at all stages of immunodeficiency and adequate precautions sexually are always needed.’ 1. LiuzziG, Chirianni A, Clemeti M et al, 1996. Analysis of HIV-l load in blood semen and saliva: evidence for different viral compartments in a cross-sectional and longitudinal study. AIDS. 10(14):F51-56.
Reproductive
Health Matters, No 9, May 1997
Likelihood of condom use in various commercial sex settings in northeast Thailand
Women with positive Pap smears in Buenos Aires often not having treatment
research among 744 men in Thai villages, an extra 219 men in 18 migrant labour camps and some additional men in 5 cattlemarkets examined whether condoms were used when buying sex in brothels, at cattlemarkets, festivals and migrant labour settings. Sexual services were typically purchased as part of friendship group partying and generally included heavy alcohol consumption. The comparative role played by men with different sexual experiences in the spread of HIV was shown by the differential rates of STD infection. Only one per cent of village men (and none in the migrant sample) who had had only non-commercial sex partners reported ever having an STD, compared to 40 per cent of village men (and 47 per cent in the migrant group) who had purchased sex. Almost half the men surveyed, married and single, had visited sex workers, and 13 per cent had visited a sex worker in the year before the study. Visits to brothels were infrequent (67 per cent four times or less in the past year) and 82 per cent involved five or fewer partners. Visits to brothels were the most common form of buying sex (87 per cent). In scenarios other than brothels, however, condoms were much less likely to be used. During festivals, which might occur up to once a month, and other celebrations (eg. the end of sugar cane cutting for the season), sex is hurried, often behind buildings or under lorries, on a mat somewhere, with men lining up and drinking heavily. Finally, many of the men considered local women and women not identified as sex workers, with whom they might also have casual sexual encounters, as not being a risk and therefore they believed that condoms were not needed with them. Whether or not the men used condoms with their wives was not mentioned in the paper.l
clinical histories and used survey, in-depth interviews and participant observation to explore why women with positive Pap smears were not attending for treatment for cervical cell abnormalities at four public hospitals in Buenos Aires from 1986-1988. Of the total 458 women who had a positive smear in that period of time, 68 per cent did not go back to the hospital where the abnormality was fn-st detected and 44 per cent took no course of action to get treatment. Factors which affected whether women sought treatment were:
UALITATIVE
8 32 northeast
1.
Maticka-TyndaleE, Elkins D, Haswell-Elkins M et al, 1997. Contexts and patterns of men’s commercial sexual partnerships ln northeastern Thailand: implications for AIDS prevention. Social Science andMedicine. 44(2):199-213.
HIS study examined
T a community-based
characteristics of the women, such as their age, the number of children they had and how much they knew and understood about the meaning of a positive Pap smear; doctor-patient communication, such as when and how the women were informed of the test result and told that they needed treatment, and other things the doctor said; and aspects of service delivery, such as the amount of time women had to wait for a consultation and how long it lasted. The following recommendations for improving this situation were: develop protocols for testing and treatment of cervical cancer, eg. criteria for assessing test results. keep records up to date of where women with positive smears live, so that they are contactable. define which conditions are more or less critical in order to reduce waiting times, maximise the use of professionals’ time, and give women the incentive to return to the clinic to be treated. assure privacy during consultations, both in terms of physical space and of people walking in and out. guarantee that every woman who has a Pap smear is informed what it is for and why it is important for her to find out the results when the smear is taken, not only when the results are available. 183
Research
urge professionals to revise their belief that if women are told they may have cancer or its precursor, it will upset them so much that they will not seek treatment. Instead, it is lack of information that makes women uncertain why they need to attend. make professionals aware of the biases in their behaviour towards the most vulnerable women, ie. the least educated women, older women and those who ask no questions, to whom they seem to provide the least care and attention. revise the risk profile for cervical cancer in Argentina to include women who have never sought a Pap smear at all, or who have not had a gynaecological examination since they had their last child, often for more than 15 years, because women beyond reproductive age are seen not to need care any 1onger.l Ramos S, Pantelides E, Mormandi J et al, 1996. La deserci6n de mujeres con Papanicolaou positivo en hospitales ptiblicos de1Area Metropolitana de Buenos Aires. Revista de la Sociedad de Obstetricia y Ginecologia de Buenos Aires. 75(919).
Obstetric morbidity in South India NTERVIEWS with 3600 women in rural Karstate in India who had at least one pre-school-age child, found that many had serious obstetric problems associated with their last confinement. About ten per cent reported one or more classic symptoms of pre-eclampsia. Many of these were life-threatening conditions which occured during delivery, notable prolonged labour over 18 hours. Ten per cent reported excessive bleeding, loss of consciousness or convulsions post-partum and an additional 17 per cent mentioned symptoms of infections1
1 nataka
1. Bhatia JC and Cleland J, 1996. Obstetric morbidity in South India: results from a community survey. Social Science andMedicine. 43(10):1507-16.
Research on childbearing: a transcultural review HIS paper summarises and reviews the key on childbearing in both western and non-western countries. In non-western societies, there is currently a dysfunctional dichotomy between modern and traditional practices that prevents the solution of problems in childbirth management: poverty, illiteracy, unemployment, malnutrition, prostitution, substance abuse, high infant and maternal mortality, family disruption, single parenthood and lack of child care. The author calls for more research on how traditional practices contribute to obstetric complications and poor outcomes, and more work on how to incorporate traditional practices that enrich the experience. An examination of government policies in this area is also called for, and the institutionalisation of modern management practices that reduce risk. In western countries, problems are quite different. The research marks the importance of the isolation of the nuclear family and the strain this places on having children. Again, in general it appears that men are not taking paternity leave. The author suggests that resources be reoriented towards women’s needs, eg. improved maternity benefits, improved career opportunities for women with children and employerlinked child care. Research also points to the redundancy of antenatal classes for many couples and the need to identify and support women at risk who do not seek out such classes. It also suggests that post-natal assistance to new mothers and overwhelmed ‘second-timers’ is needed and may be welcome. Overall, research attention has shifted in the past 35 years to populations at risk, using large and representative sample sizes, and focuses on current social and health problems. This review suggests that interdisciplinary research will be most useful in future, combining ethnographic, epidemiological and intervention approaches, to develop a culturally informed data base for policy development and imp1ementation.l
T research
1. Steinberg S, 1996. Childbearing research: a transcultural review. Social Science and Medicine. 43(12):1765-84.
184
Reproductive
Review of figures on maternal deaths in Colombia N Colombia,
a recent study in Valle de Aburra,
1 where the health system is better than in other parts of the country, found that 50 per cent of maternal deaths had not been registered. To make the figures more accurate, a group of national and international organisations decided to bring together data from a range of sources and correct for the effects of sub-registration, using figures from the recently published 1993 census. The results gave a maternal mortality ratio of 78.2 maternal deaths per 100,000 live births. Estimates of 100 to 200 deaths have come out of other recent reports in Colombia, and experts were concerned that this figure might still be too low. The three main causes of deaths were toxaemia, which was by far the most important, followed by complications of abortion and haemorrhage from various causes.l 1. Trias M, 1996. Mortalidad materna (editorial). Revista Profamilia. 14(28):4-7.
Increasing prevalence of traditional contraceptives in Honduras HE use of traditional contraceptive methods in Honduras between 1987 and 1991-92 from 19 per cent of all contraceptive use to 26 per cent. Analysis of data from two national probability sample surveys found a drop in the numbers using no method (59 to 53 per cent), increased use of traditional methods (7.6 to 12 per cent), especially the rhythm method (3.5 up to 6.7 per cent), a drop in use of oral contraception (13.4 down to 10.1 per cent), an increase in female sterilisation (12.6 up to 15.6 per cent) and little or no change with other methods. Promotion of the rhythm method was intense on the part of religious groups in Honduras in that period, spending power decreased, and there were attacks on modern methods by various groups as well. In 1989, the government voted down a bill to reduce high fertility and increase low contraceptive use, and a bill was then introduced that would have limited family planning services further. While this too was defeated, there was a lot of public debate on both sides and in the media. Access to modern methods was not reduced in this period, but it would appear that
T increased
Health Matters, No 9, May 1997
the efforts of the family planning programme were not successful in increasing overall reliance on and use of modern methods1 1. Hubacher D, Suazo M, Terrell S et al, 1996. Examining the increasing prevalence of traditional contraceptive methods in Honduras. International
Family PlanningPerspectives.
22(4):163-68.
Treating breast cancer before surgery N the continuing
attempts
to increase
sura new approach is being tried. It is based on various methods of measuring the effect of chemotherapy on the primary tumour, and the adjustment of treatment accordingly. Thus, chemotherapy has long been used to downstage advanced primary tumours before surgery. This practice might be extended prior to surgery to all operable tumours, and randomised trials along these lines are being carried out. It seems certain that immunophenotyping of cancer cells will lead to customisation of adjuvant treatment regimens. Thus, second-look surgery might be done more often so that any benefit from chemotherapy can be checked, or biopsy to check oestrogen receptor status before any decision to use tamoxifen. Use of chemotherapy before as well as after surgery seems well accepted by women who have had it, but the question of how long to wait before carrying out lumpectomy once drug treatment has been started will not be easy to answer, nor whether breast surgeons would accept the possibility of using drug treatment alone.’
1 vival rates for women with breast cancer,
1. Epstein R, 1996. Treating breast cancer before surgery (editorial). BMJ. 313(30 November):1345-46.
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