Effectiveness and efficacy rates of progestin-only pills: A comprehensive literature review.

OBJECTIVES: To synthesize published literature on POP effectiveness and efficacy. STUDY DESIGN: We searched PubMed Central, PubMed, and the Cochrane library through March 07, 2022. We included articles written in English reporting a Pearl Index or life table rate for pregnancy. We excluded articles only assessing formulations that: were never marketed globally, are only sold in combination with estrogen, are currently sold only for noncontraceptive purposes, or were not given to participants continuously. Four researchers independently extracted data and two analyzed data using Excel and R. RESULTS: We included 54 studies. Among studies at low or moderate risk of bias, the median Pearl Index rate (the failure rate during typical use) was 1.63 (range 0.00-14.20, IQR 4.03) and the median method failure Pearl Index rate (the failure rate during perfect use) was 0.97 (range 0.40-6.50, IQR 0.68). Excluding the newer formulations, Desogestrel and Drospirenone, which are closer to combined oral contraceptives in that they prevent pregnancy by inhibiting ovulation, the median Pearl Index rate is 2.00 (range 0.00-14.12, IQR 2.5) and the median method failure Pearl Index rate is 1.05 (range 0.00-10.90, IQR 1.38). CONCLUSIONS: Among studies at low or moderate risk of bias, the median Pearl Index rate during typical POP use was much lower than currently estimated (7.00), while the median perfect use rate was similar to current estimates. IMPLICATIONS: Future research should investigate the possibility that POPs may be much more effective during typical use than currently believed.

Social Support and Violence-prone Relationships as Predictors of Disclosure of HIV Status Among Newly Diagnosed HIV-positive South Africans.

Despite the salience of social support and violence as potential outcomes of disclosure, how pre-existing social support and relationship violence among people living with HIV shapes and influences HIV status disclosure has received limited attention. Following the Disclosure Process Model, this study investigated pre-disclosure support and violence-prone relationships as predictors of disclosure using data from a prospective study of 459 newly diagnosed South African women and men. Most (88%) disclosed their status to at least one person by their 8-month interview. Level of social support was unrelated to disclosure to a partner. However, those with higher levels of support had higher odds of disclosing to family and to others. Women in violence-prone relationships were more likely to report disclosure to a partner than were those not in such relationships, counter to expectations. The findings suggest that the same mechanisms may not explain processes of disclosure across all relationship types.

"I did not see a need to get tested before, everything was going well with my health": a qualitative study of HIV-testing decision-making in KwaZulu-Natal, South Africa.

Few studies have examined HIV-testing decision-making since the South African national HIV counseling and testing campaign in 2010-2011 and subsequent expansion in antiretroviral therapy (ART) eligibility in 2012. We describe HIV-testing decision-making and pathways to testing among participants in Pathways to Care, a cohort study of newly-diagnosed HIV-positive adults in KwaZulu-Natal. Our analysis is embedded within a theoretical framework informed by Arthur Kleinman's work on pluralistic healthcare systems, and the concept of diagnostic itineraries (i.e., the route taken to HIV testing). We conducted 26 semi-structured interviews in 2012, within one month of participants' diagnosis. Most (n = 22) deferred testing until they had developed symptoms, and then often sought recourse in non-biomedical settings. Of the eleven symptomatic participants who accessed professional medical services prior to testing, only three reported that a healthcare professional had offered or recommended an HIV test. Although ART emerged as an important motivator, offering hope of health and normalcy, fear of death and HIV-related stigma remained key barriers. Despite national policy changes in testing and treatment, health system and individual factors contributed to ongoing high levels of late diagnosis of HIV in this study population. Encouraging local health systems to direct clients toward HIV testing, and continuing to raise awareness of the benefits of routine testing remain important strategies to reduce delayed diagnoses.

Effectiveness and acceptability of medical abortion provided through telemedicine.

OBJECTIVE: To estimate the effectiveness and acceptability of telemedicine provision of early medical abortion compared with provision with a face-to-face physician visit at a Planned Parenthood affiliate in Iowa. METHODS: Between November 2008 and October 2009, we conducted a prospective cohort study of women obtaining medical abortion by telemedicine or face-to-face physician visits. We collected clinical data, and women completed a self-administered questionnaire at follow-up. We also compared the prevalence of reportable adverse events between the two service delivery models among all patients seen between July 2008 and October 2009. RESULTS: Of 578 enrolled participants, follow-up data were obtained for 223 telemedicine patients and 226 face-to-face patients. The proportion with a successful abortion was 99% for telemedicine patients (95% confidence interval [CI] 96-100%) and 97% for face-to-face patients (95% CI 94-99%). Ninety-one percent of all participants were very satisfied with their abortion, although in multivariable analysis, telemedicine patients had a higher odds of saying they would recommend the service to a friend compared with face-to-face patients (odds ratio, 1.72; 95% CI 1.26-2.34). Twenty-five percent of telemedicine patients said they would have preferred being in the same room with the doctor. Younger age, less education, and nulliparity were significantly associated with preferring face-to-face communication. There was no significant difference in the prevalence of adverse events reported during the study period among telemedicine patients (n = 1,172) (1.3%; 95% CI 0.8-2.1%) compared with face-to-face patients (n = 2,384) (1.3%; 95% CI 0.9-1.8%) (82% power to detect difference of 1.3%). CONCLUSION: Provision of medical abortion through telemedicine is effective and acceptability is high among women who choose this model. LEVEL OF EVIDENCE: II.

Safety and acceptability of the candidate microbicide Carraguard in Thai Women: findings from a Phase II Clinical Trial.

OBJECTIVE: To determine the safety and acceptability of vaginal application of Carraguard, a carrageenan-derived candidate microbicide gel. DESIGN: A randomized, placebo-controlled, triple-blinded clinical trial was conducted in Chiang Rai, northern Thailand. METHODS: Women were asked to insert one applicator of study gel vaginally at least three times per week (with or without sex) and to use gel with condoms every time they had sex. Safety was assessed by visual inspection of the vagina and cervix, changes in vaginal flora and self-reported symptoms at day 14, month 1 and then monthly for up to 1 year. Acceptability was assessed through reported use of the gel, return of used and unused applicators, and quarterly interviews. RESULTS: One hundred sixty-five women were randomized: 83 to Carraguard and 82 to the placebo (methylcellulose gel) group. Study gel use was similarly high in both groups throughout the trial with an average of four applicators per week. Carraguard use was not associated with abnormal genital clinical findings, abnormal vaginal flora, Pap smear abnormalities or other abnormal clinical signs or symptoms. Adverse events were mostly mild, not attributed to gel use, and similarly distributed between groups. Participants in both groups reported high acceptability. CONCLUSIONS: Carraguard can safely be used an average of four times per week with or without sex and is acceptable to Thai women. A Phase III efficacy trial of Carraguard is warranted and is currently ongoing in South Africa.

Oral contraceptives and cervical cancer: critique of a recent review.

A recent review article by Smith et al. in The Lancet purports to find a causal relationship between long-term use of oral contraceptives (OCs) and cervical cancer. While we endorse the search for such a relationship, we felt it important to critically examine Smith et al.'s review process and, as a result, we have questions about the validity of their conclusions. In our view, the findings of published articles as presented by Smith et al. do not confirm a causal connection between long-term use of OCs and cervical cancer. Our goal is not to conduct another formal review of the evidence, but to evaluate whether Smith et al. have met the burden of proof for establishing a causal relationship. Given the importance of OCs to women the world over, we urge reproductive health professionals to consider this issue carefully before accepting that a causal relationship exists.