Hormonal Contraceptives and the Acquisition of Sexually Transmitted Infections: An Updated Systematic Review.

BACKGROUND: Evidence suggests that some forms of hormonal contraception (HC) increase women's risk of non-human immunodeficiency virus sexually transmitted infections (STIs), yet evidence has not been reviewed since 2008. We conducted an updated systematic review to incorporate studies published between January 2009 and June 2017 to examine the relationship between HCs and incident or recurrent STIs. METHODS: We searched PubMed and EMBASE to identify prospective studies comparing risk of Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Trichomonas vaginalis, between women using HC versus nonhormonal methods or no methods. We summarize results by type of STI and HC and study quality using an adapted Newcastle-Ottawa Quality Assessment Scale. RESULTS: Thirty articles met the inclusion criteria. Depo-medroxyprogesterone acetate (DMPA) reduces the risk of trichomoniasis (consistent evidence) and may increase the risk of HSV-2 (strong effect, few studies); inconclusive evidence exists for HPV, chlamydia, gonorrhea, and syphilis. Data on oral contraceptive pills (OCPs; generally not differentiated whether combined or progestin-only pills) suggest that use is associated with a reduced risk of trichomoniasis with inconclusive findings for HSV-2, HPV, chlamydia, gonorrhea, and syphilis. Very few studies included norethisterone enanthate (Net-En) injectable, implants or the levonorgestrel intrauterine device. CONCLUSIONS: Depo-medroxyprogesterone acetate and OCPs reduce the risk of trichomoniasis and DMPA may increase the risk of HSV-2. However, the potential for confounding cannot be ruled out. Future studies should specify the type of injectable or OCP used to increase understanding of biological pathways; more research is needed on implants and hormonal intrauterine devices.

Firearm legislation and firearm use in female intimate partner homicide using National Violent Death Reporting System data.

Firearms account for over half of female intimate partner homicides (IPH) in the National Violent Death Reporting System (NVDRS). Although firearm-related IPH is directly associated with state-level firearm prevalence and inversely associated with specific firearm legislation targeting intimate partner violence perpetrators, these associations may be due to the underlying nature of the perpetrator population rather than the legislation or policy. We explored the impact of firearm legislation on weapon use in IPH in a cross-sectional analysis using NVDRS data via the WISQARS online interactional system, through examination of firearm (F) and non-firearm (NF) age-adjusted mortality rates and firearm: non-firearm (F:NF) rate ratios across victim gender and in states with varying levels of firearm restrictions. Overall, for 2015 (27 states aggregated), the impact of gender was substantial: the F:NF ratio for male victims was 0.92, indicating a small lead for NF mechanisms, but for female victims, it was 1.5, with greater firearm use apparent. When looking only at female IPH, jurisdictions with high firearm restrictions show a pronounced trend for a F:NF ratio <1.0 whereas states with few of these restrictions demonstrate ratios >1.0. Numerous limitations apply, including: the cross sectional nature of the data, varying years for available state data; and lack of control for multiple demographic variables. Despite its limitations, this analysis extends prior research by comparing rates of NF use across jurisdictions, and suggests that availability of firearms by itself plays an important role in driving IPH rates higher in areas with fewer firearm restrictions.

HIV risk and testing behaviors among pregnant women tested for HIV in Florida by site type, 2012.

The numbers of perinatal human immunodeficiency virus (HIV) infections in the United States have continued to decline, but the prevalence of female adults and adolescents living with diagnosed HIV infection continues to rise. Opportunities still exist to prevent mother-to child HIV transmission. The objective of this study was to identify demographics, HIV risk, and testing behaviors among pregnant women and to compare these characteristics by HIV testing site type. Multivariable analyses were conducted to examine demographics, HIV risk, and testing behaviors among 24,836 records of pregnant women publicly tested for HIV in the state of Florida in 2012. The testing records indicated that Latina and non-Hispanic black (NHB) women had decreased odds of reporting partner risk compared to those from non-Hispanic white women (Latina: adjusted odds ratio [AOR] 0.20, 95 percent confidence interval [CI]: 0.14-0.28; and NHB AOR 0.14, 95 percent CI: 0.10-0.21), and women tested in prisons/jails had higher odds of reporting previous HIV testing compared to those tested in prenatal care sites (AOR 1.86, 95 percent CI: 1.03-3.39). An understanding of HIV risk and testing behaviors among pregnant women by site type may enhance current targeted testing and prevention strategies for pregnant women and facilitate timely linkage to care.

A Review: Associations Between Attention-deficit/hyperactivity Disorder, Physical Activity, Medication Use, Eating Behaviors and Obesity in Children and Adolescents.

In the past few years we have become increasingly aware of strong associations between obesity and ADHD. Both conditions are major public health issues, affecting children, adolescents and adults alike. OBJECTIVE: This review seeks to (1) examine prior research on the association between ADHD and obesity in children and adolescents; (2) discuss mechanisms and consequent behavioral attributes to gain understanding of the path association between ADHD and obesity, (3) review studies examining the role of physical activity, medication, eating behavior and gender on the relationship between ADHD and obesity in children and adolescents. METHOD: PubMed, CINAHL and PsycINFO databases were used to search for studies whose subjects were children and adolescents, ages 0-17 years and whose publication years were from 2000 to 2016. After screening 31 studies were included in the review. RESULTS: The literature suggests that there is a significant association between ADHD and obesity. Further, the inattentive and impulsive behaviors that characterize ADHD could contribute to dis-regulated eating behaviors and a lack of motivation to engage in physical activity. In addition, it is proposed that medication, gender and physical activity play a role in mediating and moderating the relationship between ADHD and obesity.

"This Method, I Think, Can Shed New Light": Haitian-American Women's Reflections on Risk, Culture, and Family Planning Decisions From a Short-Term Trial of a Cervical Barrier (Femcap™).

Improving the reproductive health of immigrant populations requires understanding the specific context of risk and need. As part of a field trial of the FemCap™, a woman-initiated cervical barrier contraceptive, we conducted postintervention focus group discussions (FGDs) with 20 women (five FGDs) of Haitian background, the majority of whom were born in Haiti and spoke Haitian Créole at home, at a community health center in south Florida. Participants discussed the role of religion and inequitable gender norms in Haitian traditions about family planning decisions and provided important insights into the gender-power nuances of their partnership dynamics vis à vis the use of female barrier methods. Encouraged by more equitable gender norms in the United States, participants were eager to serve as health education agents, with strong altruistic sentiments toward other Haitian girls and women who they felt could be encouraged to negotiate for greater reproductive decision-making power.

Hormonal contraceptive use and women's risk of HIV acquisition: priorities emerging from recent data.

PURPOSE OF REVIEW: Understanding whether hormonal contraception increases women's risk of HIV acquisition is a public health priority. This review summarizes recent epidemiologic and biologic data, and considers the implications of new evidence on research and programmatic efforts. RECENT FINDINGS: Two secondary analyses of HIV prevention trials demonstrated increased HIV risk among depot medroxyprogesterone acetate (DMPA) users compared with nonhormonal/no method users and norethisterone enanthate (NET-EN) users. A study of women in serodiscordant partnerships found no significant association for DMPA or implants. Two meta-analyses found elevated risks of HIV among DMPA users compared with nonhormonal/no method users, with no association for NET-EN or combined oral contraceptive pills. In-vitro and animal model studies identified plausible biological mechanisms by which progestin exposure could increase risk of HIV, depending on the type and dose of progestin, but such mechanisms have not been definitively observed in humans. SUMMARY: Recent epidemiologic and biologic evidence on hormonal contraception and HIV suggests a harmful profile for DMPA but not combined oral contraceptives. In limited data, NET-EN appears safer than DMPA. More research is needed on other progestin-based methods, especially implants and Sayana Press. Future priorities include updating modeling studies with new pooled estimates, continued basic science to understand biological mechanisms, expanding contraceptive choice, and identifying effective ways to promote dual method use.

'Men don't need to know everything': a field trial of a discreet, female-initiated, contraceptive barrier method (FemCap™) among Haitian-American women.

Worldwide, women report the need for safe, non-hormonal, woman-initiated methods of family planning. Cervical barriers provide such technology but are under-researched and under-promoted. In the USA, there are few studies of cervical barriers among women at high unmet need for contraception. A feasibility study of the FemCap™ was conducted among US women of Haitian origin. Participants were heterosexual and seeking to avoid pregnancy. At first visit, participants completed baseline assessments, underwent group counselling and were fitted with FemCap™. Women were asked to insert or use the cap at home. The second visit (2-3 weeks) included an interviewer-administered questionnaire and a focus-group discussion. Participants (n  =  20) were Haitian-born (70%), married (55%) and parous (85%). Their mean age was 32.6 years. Seventy percent reported recent unprotected sex. All women inserted the device at home and 9 women used it during intercourse, including 5 without prior partner negotiation. Of 20 women, 11 liked FemCap™ very much or somewhat; 7 considered it 'OK'; 2 disliked it. Best-liked attributes were comfort, discreet wear and reusability. Difficulties with removal abated over time. Qualitative data revealed a high value placed on lack of systemic side effects. Use of FemCap™ was feasible and acceptable, supporting expansion of research, particularly among relevant populations with unmet need.

Basic body knowledge in street-recruited, active drug-using women enrolled in a "body empowerment" intervention trial.

BACKGROUND: Drug-using women remain at high risk for HIV infection. Female condoms (FC) have proven potential and cervical barriers have promise to reduce HIV risk; their effective use may be boosted by familiarity and confidence about female anatomy. Women with high levels of crack cocaine use were assessed for their knowledge about reproductive anatomy, HIV/STI risk, as well as cancer screening behaviors. METHODS: Women were recruited for a randomized trial of a behavioral intervention via mobile vans in Philadelphia known for high crack use and sex exchange. Knowledge and behavioral data on 198 women were collected via interviewer-administered questionnaire. Women were randomized into control (n=99) and intervention (n=99) arms. Five weekly, small-group, intervention sessions stressed "body empowerment" and teaching use of female-initiated barrier methods. Follow-up body knowledge data were collected at 12 months. Changes in and correlates of body knowledge were analyzed and compared. RESULTS: Most participants were African-American (66%); their mean age was 39.6 years. At baseline, 44% of the sample erroneously believed women have sex and urinate from the same place; 62% erroneously believed that tampons could get lost in the abdominal cavity. Only 27% knew douching increased STI transmission risk; only 10% knew condoms reduce cervical cancer risk. At follow-up, overall body knowledge improved substantially, across both arms. Race was associated with high body knowledge at baseline but not at follow-up. CONCLUSIONS: Knowledge favoring use of women-initiated methods and cervical cancer prevention was very low in this hard-to-reach sample. Body knowledge improved substantially with enhanced voluntary counseling and testing (VCT) as well as the women-focused intervention. Body knowledge education must be targeted and tailored to drug-using women.

U.S. Women Need the Dapivirine Ring, Too: FDA as Structural Barrier to HIV Prevention for Women.

The dapivirine monthly vaginal ring-a discreet, anti-HIV microbicide created specifically for women-has received a positive scientific opinion by the European Medicines Agency and is included in the WHO HIV prevention guidelines. It has received regulatory approvals in several countries in southern and eastern Africa. During the review of the New Drug Application that was submitted in December 2020, FDA advised the developer, International Partnership for Microbicides, that it was unlikely to be approved in the United States; the application has since been withdrawn. This commentary will present the case for FDA approval for the dapivirine ring. Advocacy is urgently needed to protect U.S. women's access to user-controlled HIV prevention technologies, consistent with both global regulatory decisions to date and with a reproductive justice framework. Women continue to need the fullest range of HIV prevention methods to integrate into their lives in the most practical and effective way possible.

College-attending young men's sexual and reproductive health knowledge, attitudes and practices.

ObjectiveMale involvement in contraceptive practice remains low. Family planning and pediatric health associations have recommended an emphasis on long-acting reversible contraceptives (LARC) in clinical counseling with adolescents and young adults, raising concerns about the resulting adverse impact on sexually transmitted infection (STI) rates. Participants: College-attending men responded to an internet based questionnaire (n=31) and a phone-based qualitative interview (n=25). Methods: Our survey solicited attitudes toward and knowledge of contraceptive methods and assessed communication practices with sexual partners regarding use of contraception and disease prevention. Results: Knowledge about female methods of contraception was low, with a comparatively high level of knowledge about Plan B. Parents and health care providers were cited as the most helpful sources of information. Conversations about protection with sexual partners were reported by most men, due mainly to fear of unplanned pregnancy, not STI. Conclusion: Addressing couple communication and dual protection among college-attending men needs greater emphasis.

The relationship between hormonal contraception and cervical dysplasia/cancer controlling for human papillomavirus infection: A systematic review.

OBJECTIVE: Studies on the effect of long-term use of combined oral contraceptives (COCs) on cervical dysplasia and/or cancer risk have been inconsistent. Less is known about the effects of other forms of hormonal contraception (HC). We examine whether HC use increases the risk of incident cervical intraepithelial neoplasia (CIN) 2, 3 and/or cancer after accounting for preexisting human papillomavirus (HPV) infection. STUDY DESIGN: Systematic review of prospective studies on HC use as risk factor for cervical dysplasia with HPV infection documented prior to outcome assessment including PubMed and EMBASE records between January 2000 and February 2020 (Prospero #CRD42019130725). RESULTS: Among nine eligible studies, seven described recency and type of HC use and therefore comprise the primary analysis; two studies limit comparisons to ever versus never use and are summarized separately. All seven studies explored the relationship between oral contraceptive (OC) use and cervical dysplasia/cancer incidence: two found increased risk (adjusted odds ratio, aOR = 1.5-2.7), one found no association but decreased risk when restricted to women with persistent HPV (adjusted hazard ratio = 0.5), and four found no association. None of the seven studies differentiated between COC and progestin-only pills (POPs) by use recency or duration. The only study that included injectable progestin-only contraception (DMPA) found increased CIN3 incidence among current versus never users (aOR = 1.6). The one study that included Norplant found no association. Two studies included intrauterine device (IUD) use, but did not differentiate between hormonal and copper IUDs, and found no association. CONCLUSION: We found no consistent evidence that OC use is associated with increased risk for cervical dysplasia/cancer after controlling for HPV infection. There were too few studies of progestin-only injectables, implants or IUDs to assess their effect on cervical dysplasia/cancer risk. IMPLICATIONS: Use of single self-reported HC measures and insufficient distinction by hormonal constituent cloud our understanding of whether some HCs increase risk for cervical cancer. Methodologically rigorous studies with distinct HCs measured as time-varying exposures are needed to inform cervical cancer prevention efforts and improve our understanding of cervical cancer etiology.

Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial.

OBJECTIVES: Substance-using women need prevention technologies and programs to reduce risk of HIV/sexually transmitted infection (STI). We examined STI prevalence and identified risk correlates for female drug users. METHODS: We used interviewer-administered and computer-assisted surveys, and tested specimens for four, treatable STIs (trichomonas, early syphilis, gonorrhea, chlamydia) on 198 HIV-seronegative, street-recruited, substance-using women enrolled in a randomized trial to reduce HIV/STI risk. RESULTS: Most women were crack users (88%), reported sex exchange (80%) and were not in drug user treatment (74%). Two-thirds were African-American and nearly all were unemployed. Protection during sex was infrequent. African-American women reported fewer unprotected sex acts and fewer sexual partners, but greater crack use and more sex-for exchange, than whites or Hispanics. Trichomonas prevalence (36.9%) exceeded that for chlamydia (3.5%), syphilis (1.5%), and gonorrhea (0%). In multivariate logistic regression, having a primary and casual partner more than doubled (AOR 2.86) the risk of having trichomonas and being African-American raised the risk by more than 8 times (AOR 8.45). CONCLUSIONS: African-American, drug-using women, and women with multiple partner types, are in urgent need of effective STI/HIV prevention interventions.

Indirect violence exposure and mental health symptoms among an urban public-school population: Prevalence and correlates.

Available literature identifies the need for a deeper understanding of the role of gender, age and socioeconomic status in children's exposure to violence and associations with mental health (MH) outcomes. The 1548 participants for this study were enrolled from 28 public charter schools and 9 community-based settings; youth were administered a screener that assessed exposure to traumatic events and symptoms of post-traumatic stress disorder (PTSD) and depression. Respondents reported extremely high levels of exposure to indirect violence: 41.7% witnessed shooting/stabbing/beating; 18.3% witnessed murder; and 53.8% experienced the murder of someone close. Frequency of adverse MH outcomes was high: 21.2% screened positive for depression; 45.7% for lifetime PTSD; and 26.9% for current PTSD. More males than females reported witnessing shooting/stabbing/beating (p = .04); females more often reported experiencing the murder of someone close (p = .001). Indirect violence exposure generally increased with age. Youth attending schools with ≥90% free/reduced lunch participation (FRLP) showed significantly higher levels of violence exposure compared to youth in schools with <90% FRLP. Females endorsed significantly higher levels of depression (21.4% vs. 9.7%), and lifetime (53.9% vs. 34.9%) and current (32.5% vs. 19.6%) PTSD, compared with males (p < .0001, all comparisons). Female sex (aOR = 2.6), FRLP (aOR = 1.4 for ≥90% vs. <90%) and the number of different indirect violence exposures (aORs from 1.3 to 10.4), were significantly associated with a positive screen for any adverse MH outcome. Our data add important insights into gender heterogeneity of viewed violence, mental health symptoms, and their association-all of which are critical to guiding effective intervention efforts.

A neglected population: drug-using women and women's methods of HIV/STI prevention.

Women drug users are at extremely high risk of HIV and sexually transmitted infections (STIs) from sexual transmission, but remain seriously neglected in intervention research promoting women-initiated methods of HIV/STI prevention. Sparse available data indicate a high interest and enthusiasm for women-initiated methods among these women. Moreover, drug-using women may be in a position to capitalize most on the myriad advantages of women-initiated methods and be the least hindered by their disadvantages, as compared with other populations of at-risk women. These advantages include, for example, the potential for prior placement and use of a female condom without being noticed by a drunk or "high" partner, long-term and/or clandestine use of cervical barriers, and the "contraceptive justification" to partners or clients initially unwilling to accede to use of a female barrier. Targeted, community-based outreach and educational efforts to this extremely hard-to-reach group as well as expanded public funding for women's methods are urgent priorities.

Effectiveness of health education on Toxoplasma-related knowledge, behaviour, and risk of seroconversion in pregnancy.

We conducted a bibliographic literature search using MEDLINE to review the effectiveness of health education on Toxoplasma-related knowledge, behaviour, and risk of seroconversion in pregnant women. We pre-selected studies that used comparative study designs (randomized clinical trial, quasi-experimental design or historical control), that were conducted among pregnant women, and which employed specific, Toxoplasma-related outcome measures: knowledge, behaviour, or Toxoplasma infection rate. Four studies met the inclusion criteria. All had serious methodological flaws. A Belgian study reported a significant decrease in the incidence of Toxoplasma seroconversion after the introduction of intensive counselling for pregnant women about toxoplasmosis. In Poland, a significant increase in knowledge was observed after a multi-pronged, public health educational program was launched. In Canada, an increase in knowledge and prevention behaviours was reported in the intervention group receiving counselling by trained facilitators compared with the control group. In France, no significant changes in risk behaviour were observed following a physician-delivered intervention. This review highlights the weakness of the literature in the area and the lack of studies measuring actual seroconversion. There is suggestive evidence that health education approaches may help reduce risk of congenital toxoplasmosis but this problem requires further study using more rigorous research design and methodology.