The effect of alcohol, tobacco, and other drug use on vaccine acceptance, uptake, and adherence: a systematic review.

BACKGROUND: Vaccine hesitancy is increasingly recognized as a health challenge affecting populations worldwide. Given the biological vulnerabilities and structural barriers people who use substances and/or have behavioral addictions face, this systematic review aims to evaluate whether this subpopulation is less prone to adhere to vaccination recommendations. METHODS: Electronic searches of published original research were conducted in PubMed, EMBASE, Scopus, and PsycINFO from database inception to December 2022. Our strategy encompassed retrievals regardless of languages and date of publication. Animal studies, abstracts without a full manuscript, and studies which were considered to have lower robustness of scientific evidence were excluded. Outcomes measured were vaccine acceptance, uptake, and adherence. Results were interpreted through a narrative synthesis. RESULTS: The search yielded 103 retrievals encompassing data collected on 5 576 374 persons who were predominantly residents of Europe (n = 39) and North America (n = 27). Tobacco use, the substance for which many studies were found (n = 91), was significantly associated with poorer vaccine acceptance, uptake and adherence for influenza, COVID-19, human papillomavirus (HPV), and maternal and childhood vaccines. Peri-natal and parental substance use was identified as a risk factor for suboptimal vaccine-related outcomes concerning maternal COVID-19 and childhood vaccines. Finally, people identified as 'using', 'abusing', or 'misusing' drugs or substances may be at decreased odds of all outcomes in various vaccines. CONCLUSIONS: Collectively, the studies identified several groups with statistically significant greater vaccine hesitancy and decreased engagement among whom targeted measures could be beneficial. Timely evidence, especially on behavioral addictions and substances besides tobacco, is lacking, and warrants urgent attention.

The relationship between social determinants of health and neurocognitive and mood-related symptoms in the primary brain tumor population: A systematic review.

Social determinants of health (SDOH) impact cancer-related health outcomes, including survival, but their impact on symptoms is less understood among the primary brain tumor (PBT) population. We conducted a systematic review to examine the relationships between SDOH and neurocognitive and mood-related symptoms among the PBT population. PubMed, EMBASE, and CINAHL were searched using PROGRESS criteria (place of residence, race/ethnicity, occupation, gender/sex, religion, education, socioeconomic status, and social capital) on March 8th, 2022. Two individuals screened and assessed study quality using the NHLBI Assessment Tool for Observational Cohort and Cross-sectional Studies. Of 3006 abstracts identified, 150 full-text articles were assessed, and 48 were included for a total sample of 28 454 study participants. Twenty-two studies examined 1 SDOH; none examined all 8. Four studies measured place of residence, 2 race/ethnicity, 13 occupation, 42 gender, 1 religion, 18 education, 4 socioeconomic status, and 15 social capital. Fifteen studies assessed neurocognitive and 37 mood-related symptoms. While higher education was associated with less neurocognitive symptoms, and among individuals with meningioma sustained unemployment after surgery was associated with depressive symptoms, results were otherwise disparate among SDOH and symptoms. Most studies were descriptive or exploratory, lacking comprehensive inclusion of SDOH. Standardizing SDOH collection, reducing bias, and recruiting diverse samples are recommended in future interventions.

Challenges and limitations of clinical trials in the adolescent and young adult CNS cancer population: A systematic review.

Background: The adolescent and young adult (AYA) cancer population, aged 15-39, carries significant morbidity and mortality. Despite growing recognition of unique challenges with this age group, there has been little documentation of unmet needs in their care, trial participation, and quality of life, particularly in those with primary brain tumors. Methods: A systematic literature review of 4 databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Studies included editorials, reviews, and practice guidelines on the challenges and limitations faced by the AYA population. Papers had to address CNS tumors. Results: Sixty-eight studies met the inclusion criteria. The challenges and limitations in clinical trials in the AYA population were synthesized into 11 categories: molecular heterogeneity, tumor biology, diagnostic delay, access to care, physician factors, patient factors, primary brain tumor (PBT) factors, accrual, limited trials, long term follow up, and trial design. The published papers' recommendations were categorized based on the target of the recommendation: providers, coordination of care, organizations, accrual, and trial design. The AYA cancer population was found to suffer from unique challenges and barriers to care and the construction of trials. Conclusions: The AYA CNS cancer population suffers from unique challenges and barriers to care and construction of trials that make it critical to acknowledge AYAs as a distinct patient population. In addition, AYAs with primary brain tumors are underrecognized and underreported in current literature. More studies in the AYA primary brain tumor patient population are needed to improve their care and participation in trials.

Blood-based biomarkers of frailty in solid tumors: a systematic review.

This review examines the current literature to identify biomarkers of frailty across patients with solid tumors. We conducted the systematic review using preferred reporting items for systematic reviews and meta-analysis guidelines (PRISMA). PubMed, Web of Science, and Embase databases were searched from their inception to December 08, 2021, for reports of biomarkers and frailty. Two reviewers independently screened titles, abstracts, and full-text articles. A quality assessment was conducted using NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, and Quality Assessment of Case-Control Studies. In total, 915 reports were screened, and 14 full-text articles were included in the review. Most studies included breast tumors, were cross-sectional in design, and measured biomarkers at baseline or pre-treatment. Frailty tools varied with Fried Frailty Phenotype and the geriatric assessment most frequently used. Increased inflammatory parameters (i.e., Interleukin-6, Neutrophil Lymphocyte Ratio, Glasgow Prognostic Score-2) were associated with frailty severity. Only six studies were rated as good quality using assessment ratings. Together, the small number of studies and heterogeneity in frailty assessment limited our ability to draw conclusions from the extant literature. Future research is needed to identify potential target biomarkers of frailty in cancer survivors that may aid in early detection and referral.

Developing a peer-led intervention to promote COVID-19 testing in low-income housing settings.

Background: The Housing Collaborative project at Eastern Virginia Medical School has developed a method of adapting public health guidance from public housing communities, which face tremendous health challenges in cardiometabolic health, cancer, and other major health conditions. In this paper, we describe how academic and community partners in the Housing Collaborative came together to do this work with a focus on COVID-19 testing in the context of the emerging pandemic. Methods: The academic team used virtual community engagement methods to interact with the Housing Collaborative Community Advisory Board (HCCAB) and a separate cohort of research participants (N = 102) recruited into a study of distrust in COVID-19 guidance. We conducted a series of 44 focus group interviews with participants on related topics. Results from these interviews were discussed with the HCCAB. We used the collaborative intervention planning framework to inform adaptation of public health guidance on COVID-19 testing delivered in low-income housing settings by including all relevant perspectives. Results: Participants reported several important barriers to COVID-19 testing related to distrust in the tests and those administering them. Distrust in housing authorities and how they might misuse positive test results seemed to further undermine decision making about COVID-19 testing. Pain associated with testing was also a concern. To address these concerns, a peer-led testing intervention was proposed by the Housing Collaborative. A second round of focus group interviews was then conducted, in which participants reported their approval of the proposed intervention. Conclusion: Although the COVID-19 pandemic was not our initial focus, we were able to identify a number of barriers to COVID-19 testing in low-income housing settings that can be addressed with adapted public health guidance. We struck a balance between community input and scientific rigor and obtained high quality, honest feedback to inform evidence-based recommendations to guide decisions about health.

Heterogeneous clinicopathological findings and patient-reported outcomes in adults with MN1-altered CNS tumors: A case report and systematic literature review.

The uncommon MN1-altered primary central nervous system (CNS) tumors were recently added to the World Health Organization 2021 classification under the name Astroblastoma, MN1-altered. Another term used to describe them, "High-grade neuroepithelial tumor with MN1 alteration" (HGNET-MN1), makes reference to their distinct epigenetic profile but is currently not a recommended name. Thought to occur most commonly in children and predominantly in females, MN1-altered CNS tumors are associated with typical but not pathognomonic histological patterns and are characterized by a distinct DNA methylation profile and recurrent fusions implicating the MN1 (meningioma 1) gene. Diagnosis based on histological features alone is challenging: most cases with morphological features of astroblastoma (but not all) show these molecular features, whereas not all tumors with MN1 fusions show astroblastoma morphology. There is large variability in reported outcomes and detailed clinical and therapeutic information is frequently missing. Some patients experience multiple recurrences despite multimodality treatment, whereas others experience no recurrence after surgical resection alone, suggesting large clinical and biological heterogeneity despite unifying epigenetic features and recurrent fusions. In this report, we present the demographics, tumor characteristics, treatment, and outcome (including patient-reported outcomes) of three adults with MN1-altered primary CNS tumors diagnosed via genome-wide DNA methylation and RNA sequencing. All three patients were females and two of them were diagnosed as young adults. By reporting our neuropathological and clinical findings and comparing them with previously published cases we provide insight into the clinical heterogeneity of this tumor. Additionally, we propose a model for prospective, comprehensive, and systematic collection of clinical data in addition to neuropathological data, including standardized patient-reported outcomes.

The link between psychological distress and survival in solid tumor patients: A systematic review.

PURPOSE: Research has demonstrated that solid tumor patients experience high levels of psychological distress at the time of diagnosis. While distress has been associated with many adverse clinical outcomes, little is known about how this symptom may influence the disease trajectory for cancer patients, affecting outcomes such as progression, recurrence, and survival. The purpose of this systematic review was to explore the literature linking distress with survival in solid tumor patients, which may guide future work exploring clinical outcomes as a function of distress. METHODS: A systematic search of PubMed, Embase, and Web of Science was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with predefined eligibility criteria. Thirteen studies met the inclusion criteria and were selected for review. RESULTS: Findings from this review demonstrated a weak-to-moderate relationship between cancer patients' experience of distress and overall survival, with most included studies (11/13) finding at least one predictive analysis to be significant when controlling for confounders. However, significant heterogeneity in the literature, particularly with study sample characteristics and varying methodologies, made direct comparisons across studies challenging. CONCLUSION: Findings from this review suggest that psychological distress may have an impact on disease-related outcomes, including (but not limited to) survival. Future work should consider performing disease-specific analyses controlling for key prognostic factors to better understand the nuanced relationship between distress and clinical outcomes, which may allow further understanding of the biological underpinnings of this relationship and enable the development of targeted interventions for improving distress.

Comprehensive adjusted outcome data are needed to assess the impact of immune checkpoint inhibitors in cancer patients with COVID-19: Results of a systematic review and meta-analysis.

BACKGROUND: Determining how prior immune checkpoint inhibitor (ICI) therapy influences outcomes in cancer patients presenting with COVID-19 is essential for patient management but must account for confounding variables. METHODS: We performed a systematic review and meta-analysis of studies reporting adjusted effects of ICIs on survival, severe events, or hospitalisation in cancer patients with COVID-19 based on variables including age, gender, diabetes mellitus, hypertension (HTN), chronic obstructive pulmonary disease, and other comorbidities. When adjusted effects were unavailable, unadjusted data were analysed. RESULTS: Of 42 observational studies (38 retrospective), 7 reported adjusted outcomes for ICIs and 2 provided sufficient individual patient data to calculate adjusted outcomes. In eight studies, adjusted outcomes were based on ≤7 variables. Over all studies, only one included >100 ICI patients while 26 included <10. ICIs did not alter the odds ratio (95%CI) (OR) of death significantly (random effects model), across adjusted (n = 8) [1.31 (0.58-2.95) p = 0.46; I2  = 42%, p = 0.10], unadjusted (n = 30) [1.06 (0.85-1.32) p = 0.58; I2  = 0%, p = 0.76] or combined [1.09 (0.88;1.36) p = 0.41; I2  = 0%, p = 0.5)] studies. Similarly, ICIs did not alter severe events significantly across adjusted (n = 5) [1.20 (0.30-4.74) p = 0.73; I2  = 52%, p = 0.08], unadjusted (n = 19) [(1.23 (0.87-1.75) p = 0.23; I2  = 16%, p = 0.26] or combined [1.26 (0.90-1.77) p = 0.16; I2  = 25%, p = 0.14] studies. Two studies provided adjusted hospitalisation data and when combined with 13 unadjusted studies, ICIs did not alter hospitalisation significantly [1.19 (0.85-1.68) p = 029; I2  = 5%, p = 0.40]. Results of sensitivity analyses examining ICI effects based on 5 variables were inconclusive. Certainty of evidence was very low. CONCLUSIONS: Across studies with adjusted and unadjusted results, ICIs did not alter outcomes significantly. But studies with comprehensive adjusted outcome data controlling for confounding variables are necessary to determine whether ICIs impact COVID-19 outcomes in cancer patients.

Palliative Care Intervention Trials for Adults Living With Progressive Central Nervous System Diseases and Their Caregivers: A Systematic Review.

CONTEXT: Interest in implementing palliative care for adults living with progressive central nervous system diseases (PCNSD) and their caregivers is increasing. OBJECTIVES: To inform evidence-based practice and future research by critically evaluating randomized clinical trials (RCTs) investigating palliative care interventions (PCIs) for adults living with PCNSD and their caregivers using self-reported outcomes and the patient- and caregiver-reported outcome measures employed. METHODS: A systematic search using PRISMA methods of EMBASE, PubMed, Scopus, Web of Science databases using index and keyword methods for articles published from inception through February 28, 2021 was performed. RCTs investigating PCI as their primary aim using patient- and/or caregiver-reported outcomes to assess PCI effectiveness in adults living with PCNSD and their caregivers were included for qualitative synthesis. RESULTS: Five RCTs met criteria and used 21 unique outcome measures. Pooled patient diagnoses included multiple sclerosis, motor neuron disease and movement disorders, primarily Parkinson's Disease. All five RCTs assessed PCI effectiveness on patient symptom burden and caregiver burden, and three RCTs used patient QOL as a primary outcome. Overall risk of bias was low. Pooled positive findings were limited to very modest changes in patient QOL, specific physical symptoms and caregiver burden. Most outcome measures lacked clinimetric responsiveness to detect change whether caused by disease or an intervention to the patient or caregiver. CONCLUSION: Sparse, low-certainty evidence for PCI impact on patient QOL, symptom burden and caregiver burden indicate future research should consider refining study populations, interventions, outcomes assessed and outcome measures to detect any change due to PCI.

A Qualitative Study of Unfairness and Distrust in Smoke-free Housing.

Objectives: Whereas smoke-free housing (SFH) has the potential to protect residents from tobacco smoke, evidence suggests that SFH could lead to increased indoor smoking. In this study, we examine how perceptions of a residential smoking ban could be related to non-compliance. Methods: We conducted 8 focus group interviews of low-income housing residents living in Norfolk, Virginia (N=53). Interviews were semi-structured and based on a list of guided questions related to SFH compliance, developed in partnership with a standing community advisory board comprised of low-income housing residents. Results: Several themes emerged, including pervasive non-compliance, perceived unfairness and shame, barriers to compliance, and distrust of the housing authority. Smokers reported behavior primarily motivated by punishment avoidance, rather than out of any perceived obligation to comply with the ban. Conclusions: Results led us to consider Procedural Justice Theory as a conceptual framework, in which compliance is directly related to perceptions about the legitimacy of a rule or authority. When compliance is low due to a lack of perceived legitimacy, SFH should be adapted to promote changes in smoking behavior. We offer specific theory-supported adaptations to SFH focused on trust-building and improving perceived fairness.

A systematic literature review of disclosure practices and reported outcomes for medically actionable genomic secondary findings.

PURPOSE: Secondary findings (SFs) are present in 1-4% of individuals undergoing genome/exome sequencing. A review of how SFs are disclosed and what outcomes result from their receipt is urgent and timely. METHODS: We conducted a systematic literature review of SF disclosure practices and outcomes after receipt including cascade testing, family and provider communication, and health-care actions. Of the 1,184 nonduplicate records screened we summarize findings from 27 included research articles describing SF disclosure practices, outcomes after receipt, or both. RESULTS: The included articles reported 709 unique SF index recipients/families. Referrals and/or recommendations were provided 647 SF recipients and outcome data were available for 236. At least one recommended evaluation was reported for 146 SF recipients; 16 reports of treatment or prophylactic surgery were identified. We found substantial variations in how the constructs of interest were defined and described. CONCLUSION: Variation in how SF disclosure and outcomes were described limited our ability to compare findings. We conclude the literature provided limited insight into how the American College of Medical Genetics and Genomics (ACMG) guidelines have been translated into precision health outcomes for SF recipients. Robust studies of SF recipients are needed and should be prioritized for future research.

Effects of chloroquine or hydroxychloroquine treatment on non-SARS-CoV2 viral infections: A systematic review of clinical studies.

Chloroquine (CQ) and hydroxychloroquine (HCQ) have been used as antiviral agents for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. We performed a systematic review to examine whether prior clinical studies that compared the effects of CQ and HCQ to a control for the treatment of non-SARS-CoV2 infection supported the use of these agents in the present SARS-CoV2 outbreak. PubMed, EMBASE, Scopus and Web of Science (PROSPERO CRD42020183429) were searched from inception through 2 April 2020 without language restrictions. Of 1766 retrieved reports, 18 studies met our inclusion criteria, including 17 prospective controlled studies and one retrospective study. CQ or HCQ were compared to control for the treatment of infectious mononucleosis (EBV, n = 4), warts (human papillomavirus, n = 2), chronic HIV infection (n = 6), acute chikungunya infection (n = 1), acute dengue virus infection (n = 2), chronic HCV (n = 2), and as preventive measures for influenza infection (n = 1). Survival was not evaluated in any study. For HIV, the virus that was most investigated, while two early studies suggested HCQ reduced viral levels, four subsequent ones did not, and in two of these CQ or HCQ increased viral levels and reduced CD4 counts. Overall, three studies concluded CQ or HCQ were effective; four concluded further research was needed to assess the treatments' effectiveness; and 11 concluded that treatment was ineffective or potentially harmful. Prior controlled clinical trials with CQ and HCQ for non-SARS-CoV2 viral infections do not support these agents' use for the SARS-CoV2 outbreak.

Coming of age? Women's sexual and reproductive health after twenty-one years of democracy in South Africa.

This paper is a sequel to a 2004 article that reviewed South Africa's introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women's SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women's SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR.

The HIV epidemic and sexual and reproductive health policy integration: views of South African policymakers.

BACKGROUND: Integration of sexual and reproductive health (SRH) and HIV policies and services delivered by the same provider is prioritised worldwide, especially in sub-Saharan Africa where HIV prevalence is highest. South Africa has the largest antiretroviral treatment (ART) programme in the world, with an estimated 2.7 million people on ART, elevating South Africa's prominence as a global leader in HIV treatment. In 2011, the Southern African HIV Clinicians Society published safer conception guidelines for people living with HIV (PLWH) and in 2013, the South African government published contraceptive guidelines highlighting the importance of SRH and fertility planning services for people living with HIV. Addressing unintended pregnancies, safer conception and maternal health issues is crucial for improving PLWH's SRH and combatting the global HIV epidemic. This paper explores South African policymakers' perspectives on public sector SRH-HIV policy integration, with a special focus on the need for national and regional policies on safer conception for PLWH and contraceptive guidelines implementation. METHODS: It draws on 42 in-depth interviews with national, provincial and civil society policymakers conducted between 2008-2009 and 2011-2012, as the number of people on ART escalated. Interviews focused on three key domains: opinions on PLWH's childbearing; the status of SRH-HIV integration policies and services; and thoughts and suggestions on SRH-HIV integration within the restructuring of South African primary care services. Data were coded and analysed according to themes. RESULTS: Participants supported SRH-HIV integrated policy and services. However, integration challenges identified included a lack of policy and guidelines, inadequately trained providers, vertical programming, provider work overload, and a weak health system. Participants acknowledged that SRH-HIV integration policies, particularly for safer conception, contraception and cervical cancer, had been neglected. Policymakers supported public sector adoption of safer conception policy and services. Participants interviewed after expanded ART were more positive about safer conception policies for PLWH than participants interviewed earlier. CONCLUSION: The past decade's HIV policy changes have increased opportunities for SRH-HIV integration. The findings provide important insights for international, regional and national SRH-HIV policy and service integration initiatives.

A qualitative exploration of HIV-positive pregnant women's decision-making regarding abortion in Cape Town, South Africa.

HIV-positive women's abortion decisions were explored by: (i) investigating influencing factors; (ii) determining knowledge of abortion policy and public health services; and (iii) exploring abortion experiences. In-depth interviews were held with 24 HIV-positive women (15 had an abortion; 9 did not), recruited at public health facilities in Cape Town, South Africa. Negative perceptions towards HIV-positive pregnant women were reported. Women wanted abortions due to socio-economic hardship in conjunction with HIV-positive status. Respondents were generally aware that women in South Africa had a right to free abortions in public health facilities. Both positive and negative abortion experiences were described. Respondents reported no discrimination by providers due to their HIV-positive status. Most respondents reported not using contraceptives, while describing their pregnancies as 'unexpected'. The majority of women who had abortions wanted to avoid another one, and would encourage other HIV-positive women to try to avoid abortion. However, most felt abortions were acceptable for HIV-positive women in some circumstances. Data suggested that stigma and discrimination affect connections between abortion, pregnancy and HIV/AIDS, and that abortion may be more stigmatised than HIV/AIDS. Study results provide important insights, and any revision of reproductive health policy, services, counselling for abortion and HIV/AIDS care should address these issues.

Quantitative ultrasound in relation to risk factors for low bone mineral density in South African pre-menopausal women.

SUMMARY: The study describes the association between risk factors and quantitative ultrasound bone measures in black and mixed-race pre-menopausal South African women. Despite some differences between the two study groups, the findings generally lend support to the use of ultrasound for epidemiological studies of bone mass in resource-limited settings. INTRODUCTION: Quantitative ultrasound at the calcaneus is a convenient and inexpensive method of estimating bone strength well suited to community-based research in countries with limited resources. This study determines, in a large sample of pre-menopausal South African women, whether characteristics associated with quantitative ultrasound measures are similar to those shown to be associated with bone mineral density as measured by dual X-ray absorptiometry. METHODS: This cross-sectional study included 3,493 women (1,598 black and 1,895 mixed race), aged 18-44 living in Cape Town. Study nurses administered structured interviews on reproductive history, lifestyle factors, and measured height and weight. Calcaneus quantitative ultrasound measurements were obtained using the Sahara device. Adjusted means of ultrasound measures according to categories of risk factors were obtained using multivariable regression analysis. RESULTS: Associations between quantitative ultrasound measures and age, body mass index, age at menarche, parity, and primary school physical activity were similar to those known for bone mineral density as measured by dual X-ray absorptiometry. There were no clear associations between quantitative ultrasound measures and educational level, alcohol use, cigarette smoking, and current calcium intake. CONCLUSION: The data give qualified support to the use of quantitative ultrasound as an epidemiological tool in large studies of bone strength in pre-menopausal women.

Determinants of sexual activity and its relation to cervical cancer risk among South African women.

BACKGROUND: Invasive cervical cancer is the commonest cause of cancer morbidity and mortality in South African women. This study provides information on adult women's sexual activity and cervical cancer risk in South Africa. METHODS: The data were derived from a case-control study of hormonal contraceptives and cervical cancer risk. Information on age of sexual debut and number of lifetime sexual partners was collected from 524 incident cases and 1541 hospital controls. Prevalence ratios and adjusted prevalence ratios were utilised to estimate risk in exposures considered common. Crude and adjusted relative risks were estimated where the outcome was uncommon, using multiple logistic regression analysis. RESULTS: The median age of sexual debut and number of sexual partners was 17 years and 2 respectively. Early sexual debut was associated with lower education, increased number of life time partners and alcohol use. Having a greater number of sexual partners was associated with younger sexual debut, being black, single, higher educational levels and alcohol use. The adjusted odds ratio for sexual debut < 16 years and >/= 4 life-time sexual partners and cervical cancer risk were 1.6 (95% CI 1.2 - 2.2) and 1.7 (95% CI 1.2 - 2.2), respectively. CONCLUSION: Lower socio-economic status, alcohol intake, and being single or black, appear to be determinants of increased sexual activity in South African women. Education had an ambiguous effect. As expected, cervical cancer risk is associated with increased sexual activity. Initiatives to encourage later commencement of sex, and limiting the number of sexual partners would have a favourable impact on risk of cancer of the cervix and other sexually transmitted infections.

HIV and pre-neoplastic and neoplastic lesions of the cervix in South Africa: a case-control study.

BACKGROUND: Cervical cancer and infection with human immunodeficiency virus (HIV) are both major public health problems in South Africa. The aim of this study was to determine the risk of cervical pre-cancer and cancer among HIV positive women in South Africa. METHODS: Data were derived from a case-control study that examined the association between hormonal contraceptives and invasive cervical cancer. The study was conducted in the Western Cape (South Africa), from January 1998 to December 2001. There were 486 women with invasive cervical cancer, 103 control women with atypical squamous cells of undetermined significance (ASCUS), 53 with low-grade squamous intraepithelial lesions (LSIL), 50 with high-grade squamous intraepithelial lesions (HSIL) and 1159 with normal cytology. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multiple logistic regression. RESULTS: The adjusted odds ratios associated with HIV infection were: 4.4 [95% CI (2.3 - 8.4) for ASCUS, 7.4 (3.5 - 15.7) for LSIL, 5.8 (2.4 - 13.6) for HSIL and 1.17 (0.75 - 1.85) for invasive cervical cancer. HIV positive women were nearly 5 times more likely to have high-risk human papillomavirus infection (HR-HPV) present compared to HIV negative women [OR 4.6 (95 % CI 2.8 - 7.5)]. Women infected with both HIV and high-risk HPV had a more than 40 fold higher risk of SIL than women infected with neither of these viruses. CONCLUSION: HIV positive women were at an increased risk of cervical pre-cancer, but did not demonstrate an excess risk of invasive cervical cancer. An interaction between HIV and HR-HPV infection was demonstrated. Our findings underscore the importance of developing locally relevant screening and management guidelines for HIV positive women in South Africa.

Ten years of democracy in South Africa: documenting transformation in reproductive health policy and status.

The advent of democracy in South Africa in 1994 created a unique opportunity for new lows and policies to be passed. Today, a decade later, South African reproductive health policies and the laws that underwrite them are among the most progressive and comprehensive in the world in terms of the recognition that they give to human rights, including sexual and reproductive rights. This paper documents the changes in health policy and services that have occurred, focusing particularly on key areas of sexual and reproductive health: contraception, maternal health, termination of pregnancy, cervical and breast cancer, gender-based and sexual violence, HIV/AIDS and sexually transmitted infections and infertility. Despite important advances, significant changes in women's reproductive health status are difficult to discern, given the relatively short period of time and the multitude of complex factors that influence health, especially inequalities in socio-economic and gender status. Gaps remain in the implementation of reproductive health policies and in service delivery that need to be addressed in order for meaningful improvements in women's reproductive health status to be achieved. Civil society has played a major role in securing these legislative and policy changes, and health activist groups continue to pressure the government to introduce further changes in policy and service delivery, especially in the area of HIV/AIDS.