Are sexual and reproductive health and rights taught in medical school? Results from a global survey.

Our aim was to investigate the inclusion of sexual and reproductive health and rights (SRHR) topics in medical curricula and the perceived need for, feasibility of, and barriers to teaching SRHR. We distributed a survey with questions on SRHR content, and factors regulating SRHR content, to medical universities worldwide using chain referral. Associations between high SRHR content and independent variables were analyzed using unconditional linear regression or χ2 test. Text data were analyzed by thematic analysis. We collected data from 219 respondents, 143 universities and 54 countries. Clinical SRHR topics such as safe pregnancy and childbirth (95.7%) and contraceptive methods (97.2%) were more frequently reported as taught compared with complex SRHR topics such as sexual violence (63.8%), unsafe abortion (65.7%), and the vulnerability of LGBTQIA persons (23.2%). High SRHR content was associated with high-income level (P = 0.003) and low abortion restriction (P = 0.042) but varied within settings. Most respondents described teaching SRHR as essential to the health of society. Complexity was cited as a barrier, as were cultural taboos, lack of stakeholder recognition, and dependency on fees and ranking.

How the coronavirus disease 2019 pandemic is impacting sexual and reproductive health and rights and response: Results from a global survey of providers, researchers, and policy-makers.

INTRODUCTION: We aimed to give a global overview of trends in access to sexual and reproductive health and rights (SRHR) during the coronavirus disease 2019 (COVID-19) pandemic and what is being done to mitigate its impact. MATERIAL AND METHODS: We performed a descriptive analysis and content analysis based on an online survey among clinicians, researchers, and organizations. Our data were extracted from multiple-choice questions on access to SRHR services and risk of SRHR violations, and written responses to open-ended questions on threats to access and required response. RESULTS: The survey was answered by 51 people representing 29 countries. Eighty-six percent reported that access to contraceptive services was less or much less because of COVID-19, corresponding figures for surgical and medical abortion were 62% and 46%. The increased risk of gender-based and sexual violence was assessed as moderate or severe by 79%. Among countries with mildly restrictive abortion policies, 69% had implemented changes to facilitate access to abortion during the pandemic, compared with none among countries with severe restrictions (P < .001), 87.5% compared with 46% had implemented changes to facilitate access to contraception (P = .023). The content analysis showed that (a) prioritizations in health service delivery at the expense of SRHR, (b) lack of political will, (c) the detrimental effect of lockdown, and (d) the suspension of sexual education, were threats to SRHR access (theme 1). Requirements to mitigate these threats (theme 2) were (a) political will and support of universal access to SRH services, (b) the sensitization of providers, (c) free public transport, and (d) physical protective equipment. A contrasting third theme was the state of exception of the COVID-19 pandemic as a window of opportunity to push forward women's health and rights. CONCLUSIONS: Many countries have seen decreased access to and increased violations of SRHR during the COVID-19 pandemic. Countries with severe restrictions on abortion seem less likely to have implemented changes to SRHR delivery to mitigate this impact. Political will to support the advancement of SRHR is often lacking, which is fundamental to ensuring both continued access and, in a minority of cases, the solidification of gains made to SRHR during the pandemic.

What makes orphans in Kigali, Rwanda, non-adherent to antiretroviral therapy? Perspectives of their caregivers.

INTRODUCTION: Every year, approximately 260,000 children are infected with HIV in low- and middle-income countries. The timely initiation and high level of maintenance of antiretroviral therapy (ART) are crucial to reducing the suffering of HIV-positive children. We need to develop a better understanding of the background of children's ART non-adherence because it is not well understood. The purpose of this study is to explore the background related to ART non-adherence, specifically in relation to the orphan status of children in Kigali, Rwanda. METHODS: We conducted 19 focus group discussions with a total of 121 caregivers of HIV-positive children in Kigali. The primary data for analysis were verbatim transcripts and socio-demographic data. A content analysis was performed for qualitative data analysis and interpretation. RESULTS: The study found several contextual factors that influenced non-adherence: among double orphans, there was psychological distance between the caregivers and children, whereas economic burden was the primary issue among paternal orphans. The factors promoting adherence also were unique to each orphan status, such as the positive attitude about disclosing serostatus to the child by double orphans' caregivers, and feelings of guilt about the child's condition among non-orphaned caregivers. CONCLUSIONS: Knowledge of orphan status is essential to elucidate the factors influencing ART adherence among HIV-positive children. In this qualitative study, we identified the orphan-related contextual factors that influenced ART adherence. Understanding the social context is important in dealing with the challenges to ART adherence among HIV-positive children.

Implementing primary health care-based PMTCT interventions: operational perspectives from Muhima cohort analysis (Rwanda).

INTRODUCTION: In countries with high burden of HIV, major programmatic challenges have been identified to preventing new infections among children and scaling up of treatment for pregnant mothers. We initiated this study to examine operational approaches that were used to enhance implementation of PMTCT interventions in Muhima health Centre (Kigali/Rwanda) from 2007 to 2010. METHODS: The prospective cohort study was conducted at Muhima health centre. A sample size of 656 was the minimum number required for the study. The main outcome was cumulative incidence of mother - to - child transmission of HIV-1 measured at 6 weeks of life among live born children. RESULTS: Among the 679 live born babies and followed up in this study, the overall cumulative rate of HIV-1 mother - to - child transmission observed was 3.2% at 6 weeks of age after birth. Disclosure of HIV status to partner was significantly associated with HIV-1 status of infants at 6 weeks of age (non-disclosure of HIV status adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p. CONCLUSION: The Muhima type of decentralized health facility offered an appropriate platform for implementation of PMTCT interventions, with the following operational features: family - centered approach; integrated service delivery for PMTCT/MCH interventions, task shifting; subsidized membership fees for people living with HIV, allowing for access to the community-based health insurance benefits.

Socio-economic, clinical and biological risk factors for mother - to - child transmission of HIV-1 in Muhima health centre (Rwanda): a prospective cohort study.

BACKGROUND: Three decades since the first HIV-1 infected patients in Rwanda were identified in 1983; the Acquired Immunodeficiency Syndrome epidemic has had a devastating history and is still a major public health challenge in the country. This study was aimed at assessing socioeconomic, clinical and biological risk factors for mother - to - child transmission of HIV- in Muhima health centre (Kigali/Rwanda). METHODS: The prospective cohort study was conducted at Muhima Health centre (Kigali/Rwanda).During the study period (May 2007 - April 2010), of 8,669 pregnant women who attended antenatal visits and screened for HIV-1, 736 tested HIV-1 positive and among them 700 were eligible study participants. Hemoglobin, CD4 count and viral load tests were performed for participant mothers and HIV-1 testing using DNA PCR technique for infants.Follow up data for eligible mother-infant pairs were obtained from women themselves and log books in Muhima health centre and maternity, using a structured questionnaire.Predictors of mother-to-child transmission of HIV-1 were assessed by multivariable logistic regression analysis. RESULTS: Among the 679 exposed and followed-up infants, HIV-1 status was significantly associated with disclosure of HIV status to partner both at 6 weeks of age (non-disclosure of HIV status, adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p < 0.05; compared to disclosure) and at 6 months of age (non-disclosure of HIV status, AOR, 3.41, CI 1.09 to 10.65, p < 0.05, compared to disclosure).A significant association between mother's viral load (HIV-1 RNA) and infant HIV-1 status was found both at 6 weeks of age (> = 1000 copies/ml, AOR 7.30, CI 2.65 to 20.08, p < 0.01, compared to <1000 copies/ml) and at 6 months of age (> = 1000 copies/ml, AOR 4.60, CI 1.84 to 11.49, p < 0.01, compared to <1000 copies/ml). CONCLUSION: In this study, the most relevant factors independently associated with increased risk of mother - to - child transmission of HIV-1 included non-disclosure of HIV status to partner and high HIV-1 RNA. Members of this cohort also showed socioeconomic inequalities, with unmarried status carrying higher risk of undisclosed HIV status. The monitoring of maternal HIV-1 RNA level might be considered as a routinely used test to assess the risk of transmission with the goal of achieving viral suppression as critical for elimination of pediatric HIV, particularly in breastfeeding populations.

High risk of ART non-adherence and delay of ART initiation among HIV positive double orphans in Kigali, Rwanda.

BACKGROUND: To reduce HIV/AIDS related mortality of children, adherence to antiretroviral treatment (ART) is critical in the treatment of HIV positive children. However, little is known about the association between ART adherence and different orphan status. The aims of this study were to assess the ART adherence and identify whether different orphan status was associated with the child's adherence. METHODS: A total of 717 HIV positive children and the same number of caregivers participated in this cross-sectional study. Children's adherence rate was measured using a pill count method and those who took 85% or more of the prescribed doses were defined as adherent. To collect data about adherence related factors, we also interviewed caregivers using a structured questionnaire. RESULTS: Of all children (N = 717), participants from each orphan category (double orphan, maternal orphan, paternal orphan, non-orphan) were 346, 89, 169, and 113, respectively. ART non-adherence rate of each orphan category was 59.3%, 44.9%, 46.7%, and 49.7%, respectively. The multivariate analysis indicated that maternal orphans (AOR 0.31, 95% CI 0.12-0.80), paternal orphans (AOR 0.35, 95% CI 0.14-0.89), and non-orphans (AOR 0.45, 95% CI 0.21-0.99) were less likely to be non-adherent compared to double orphans. Double orphans who had a sibling as a caregiver were more likely to be non-adherent. The first mean CD4 count prior to initiating treatment was 520, 601, 599, and 844 (cells/ml), respectively (p<0.001). Their mean age at sero-status detection was 5.9, 5.3, 4.8, and 3.9 (year old), respectively (p<0.001). CONCLUSIONS: Double orphans were at highest risk of ART non-adherence and especially those who had a sibling as a caregiver had high risk. They were also in danger of initiating ART at an older age and at a later stage of HIV/AIDS compared with other orphan categories. Double orphans need more attention to the promote child's adherence to ART.