Women: an endangered species?

PIP: During the 11th International Congress on Women's Health Issues, a different angle of the AIDS epidemic was reviewed. It showed how the epidemic affects millions of lives, especially African children, because of the loss of their mothers or both parents to AIDS. According to Newsweek, an estimated 10.4 million African children under age 15 years will have lost their mothers to AIDS by the end of year 2000. Furthermore, WHO estimates that there will be many orphans in African countries and there will be insufficient women to care for them or enough teachers to provide education, thus resulting in a whole generation of uneducated Africans. In addition to the danger of AIDS, the deadly impact of violence against women is another factor that endangers women. The ¿Hopkins Report¿ revealed that worldwide at least 1 woman in every 3 has been beaten, coerced into sex, or otherwise abused in her lifetime, and even murdered. At the closing of the 11th International Congress, the probable need to interest conservationists in considering women an endangered species was expressed.^ieng

Transmission of HIV from injecting drug users to their wives in India.

We aimed to identify factors associated with transmission of human immunodeficiency virus (HIV) from injecting drug users (IDUs) to their wives in Manipur, northeast India, where the prevalence of HIV among IDUs is 80% via a case-control study. One hundred and sixty-one HIV-infected IDUs and their wives were recruited from September 1996 to August 1997 inclusive. HIV status was determined by enzyme-linked immunosorbent assay (ELISA) plus Western blot, Interviews were administered anonymously. Regression analysis identified factors associated with transmission of HIV from IDU husbands to their non-injecting wives. Seventy-two wives (45%) were HIV-positive. Only 15% of the couples reported regular usage of condoms during intercourse. On multivariate analysis, a sexually transmitted disease (STD) in either member, reported by the husband, estimated duration of HIV in the husband for >8 years, and a history of blood transfusions were associated with infection in the wife. In conclusion, STDs are associated with transmission of HIV from husband to wife. Improved control of STDs, condom promotion, and improved blood screening are urgently needed in Manipur.

AIDS-related information exposure in the mass media and discussion within social networks among married women in Bombay, India.

Married women are at high risk of acquiring HIV infection in India and health education remains the most feasible preventive tool in their context. In a survey conducted among 350 married women in Bombay, it was found that a majority had acquired information about AIDS from the mass media, especially television. Although 87% of women who knew of AIDS had been exposed to AIDS-related information in the mass media in the past four weeks, only 57% had discussed it within their social networks. Those with more exposure to AIDS information in the mass media were significantly more likely to discuss AIDS within social networks. The women were most likely to discuss AIDS with their husbands as a general social issue, followed by friends and family members and least likely to talk to husbands about AIDS as a personal issue relating to their sexual relationship. Increased frequency and duration of AIDS messages on television will have a positive influence on AIDS knowledge in this group.

PIP: Health education remains the most feasible preventive tool in the context of married women who are at high risk for acquiring HIV infection in India. The sample for the study reported in this paper comprised 350 married women in Bombay. Results showed that a majority of them had acquired information about AIDS from the mass media, particularly television. Sociodemographic analysis revealed 87% of women who knew of AIDS had been exposed to AIDS-related information in the mass media in the past four weeks and that 57% had discussed it within their social networks. Women were most likely to discuss AIDS with their husbands as a general social issue, followed by friends and family members. They were least likely to talk to their husbands about AIDS as a personal risk issue relating to their sexual relationships. Women's strategies for risk assessment may be inadequate owing to their dependency on knowledge and perceptions of AIDS acquired from brief and impersonal messages on television.

Predicting Neisseria gonorrhoeae and Chlamydia trachomatis infection using risk scores, physical examination, microscopy, and leukocyte esterase urine dipsticks among asymptomatic women attending a family planning clinic in Kenya.

BACKGROUND: Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups. OBJECTIVES: To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women. METHODS: One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly. CONCLUSIONS: The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment.

PIP: This cross sectional study presents a risk scoring system that would identify women at highest risk for sexually transmitted infections (STIs). 1058 randomly selected women participated in the study in Nairobi, Kenya; of these, 1048 participants were included in the analysis. The study was conducted from May 1994 to July 1995 at a clinic sponsored by the Family Planning Association of Kenya. Information pertaining to the demographic, behavioral and social characteristics of the participants was gathered. In addition, a clinical algorithm, which includes physical examination, microscopy, and leukocyte esterase (LE) urine dipsticks, was employed to detect gonorrhea and chlamydia infections among asymptomatic women. The results revealed that the prevalence of STIs, including HIV-1, was high among women attending this urban family planning clinic. Standard demographic, behavioral, and clinical characteristics were only weakly associated with infection, resulting in poor sensitivity and specificity calculations in the risk scores. Detection of cervical infections gave a sensitivity of 85% and a specificity of 30%. A positive LE urine dipstick had a sensitivity of 63% and a specificity of 47%. Although the addition of physical examination and LE dipstick to the work-up improved the sensitivity of case detection, it did not improve the overall validity of the scoring system.

What high-risk women are telling us about access to primary and reproductive health care and HIV prevention services.

Focus group discussions on barriers to health care and attitudes toward family planning, reproductive health services, and condom use were conducted with 63 women at high risk for HIV due to their own injection drug use, sex with injection drug users, sex industry work, or a history of multiple sexually transmitted diseases. Barriers identified include the high cost of health care, perceived poor quality of care and experiences of discrimination and stigmatization, geographic accessibility, fear of legal/social services punitive actions, misperceptions about the efficacy of birth control methods and condom usage, lack of sterilization services, and lack of male involvement. Where possible, findings from the focus groups are supported with quantitative survey data from a sample of high-risk women (n = 723). Recommendations are made for improving care for high-risk women.

PIP: This article identifies barriers to care for women at high risk for HIV through analysis of both the qualitative data from the focus groups and the quantitative data from both the outreach and the clinic survey conducted in the US. Focus group discussions were conducted with 63 women at high risk for HIV due to their own injection drug use, sex with injection drug users, sex industry work, or a history or multiple sexually transmitted diseases. Results of the focus group study indicated that women at high risk for HIV were concerned about both pregnancy prevention and HIV prevention. The identified barriers include high cost of health care, perceived poor quality of care and experiences of discrimination and stigmatization. Additional to these barriers were geographic accessibility, fear of legal/social services punitive actions, misperceptions about the efficacy of birth control methods and condom usage, lack of sterilization services, and lack of male involvement. Recommendations based on the findings are cited in the article.

Pregnancy plans despite AIDS risk.

PIP: This article briefly summarizes findings from Ahluwalia's study of risk factors associated with reproductive decision making among women at risk of HIV/AIDS. Data were obtained from a survey during 1987-92 among a sample of 1921 women who were at risk of contracting HIV because of their own or their partner's use of injected drugs. A follow-up survey at 6 months was conducted. Findings indicate that most women had extensive knowledge about AIDS and considered themselves at risk. 55% had been tested for HIV, of whom 13% were HIV-positive. 12% indicated a desire for childbearing in the near future. In the follow-up sample, 12% of the women who wanted to conceive and 3% who did not intend to conceive were pregnant. Among the pregnant women at follow-up, 15% and 22%, respectively, were HIV-positive. Multivariate analysis indicates that reproductive decisions were influenced by background characteristics. Reproductive intentions were associated with the odds of becoming pregnant. AIDS knowledge and perceived risk were not associated with the risk of wanting to become pregnant or becoming pregnant. Researchers concluded that women at risk have some control over reproductive decision-making. IEC should account for demographic and contextual factors in attempts to prevent the spread of HIV/AIDS.^ieng

Psychosocial factors associated with the stages of change for condom use among women at risk for HIV and STDs: implications for intervention development.

This study examined the prevalence of consistent condom use among inner-city women at risk for HIV, measured the distribution of these women across the stages of change for condom use, determined psychosocial factors associated with the stages, and suggested intervention strategies based on the results. The 5-city sample of women aged 15-34 years consisted predominantly of African Americans. Only 18% reported consistent condom use with main partners and 45% with other partners. Logistic regressions compared women in each stage of change with those in higher stages for each partner type. Results indicated that women who practice or intend to practice consistent condom use were more likely to talk with others about condoms, acknowledge the advantages of condoms, have higher self-efficacy for condom use, and indicate that people important to them favored condom use. Intervention approaches are suggested for women in different stages of change for condom use.

PIP: This cross-sectional study examines the prevalence of consistent condom use among inner-city women at risk for HIV and measured the distribution of these women across the stages of change for condom use. It further determined the psychosocial factors that could be used by program planners to design interventions for these women in different stages of change. The study sample was composed of women aged 15-34 years who were mostly African-Americans (79%). In the results, only 18% reported consistent condom use with main partners and 45% with other partners. The results further indicated that women who practice or intend to practice consistent condom use were more likely to talk with others about condoms, acknowledge the advantages of condoms, have higher self-efficacy for condom use, and state that people important to them favored condom use.

Youth research. Naked wire and naked truths: a study of reproductive health risks faced by teenage girls in Honiara, Solomon Islands, November 1997.

PIP: A qualitative research project conducted in 1997 in the Solomon Islands used questionnaires, focus groups discussions, and in-depth interviews to gather information on reproductive health risks faced by young, unmarried women in Honiara. In this setting, urbanization and poverty, migration, unemployment, and low levels of education increase the risk for youth of acquiring HIV/AIDS or a sexually transmitted disease (STD). Young women, who must yield to the authority of their male relatives, often have clandestine sexual relationships beginning as early as age 12 and are unable to negotiate safe sex behavior. Commercial sexual exchanges are also on the increase. Sex education is generally confined to secondary schools, although most girls drop-out after primary school. The main source of sex information is the media and friends. While there is concern about adolescent pregnancy rates, contraceptive access is restricted to young, unmarried women. The reaction of a family to an adolescent pregnancy is initial anger and ultimate acceptance. Condom use is low, largely because it is believed that it interferes with sexual pleasure. Because the young women are unable to negotiate safe sex, they are at risk of pregnancy, STDs, and HIV/AIDS. The situation can be improved by creating an enabling environment for young women through policy initiatives, improving knowledge, promoting condom use, providing reproductive health services, and improving communication channels.^ieng

Prevention works. Cameroon.

PIP: This special report presents a profile on sexually transmitted diseases (STDs) and HIV/AIDS, their prevention and control, exacerbating factors, contraceptive availability, prevention strategies, and interventions. The "Report on the Global HIV/AIDS Epidemic" of UNAIDS informs that about 16,000 new cases of HIV infection are added yearly. 30.6 million lived with HIV/AIDS in 1997. 20.8 million of these lived in sub-Saharan Africa, of whom about 10 million were women. The World Health Organization (WHO) reports that about 165 million cases of STDs occur yearly among women aged 15-49 years (syphilis, 6.5 million; gonorrhea, 31.3 million; chlamydia, 47 million; trichomonas, 80 million). Diagnosis and treatment are constrained by lack of symptoms, difficulty in diagnosing, and low and inconsistent use of health services. Risk factors include age, gender, the large surface area of mucus membranes in the vagina and cervix, blood transfusions, lack of understanding about the woman's body, asymptomatic STDs, the WHO syndromic approach, douching with pharmaceutical products, use of intravaginal substances, female genital mutilation, anal sex, and alcohol consumption. A variety of contraceptives are available in Cameroon, but the infrastructure suffers from lack of services in some rural areas, shortages of supplies, misinformation, stigma, attitudes of health providers, fear of exposure by relatives, and fear of disagreement with a spouse or partner. Six general practices are discussed for prevention. Eight researchable topics are identified.^ieng

Combating sexual exploitation at the macro and micro levels.

PIP: The Third World Movement against the Exploitation of Women (TW-MAE-W) is an international nongovernmental organization based in the Philippines which conducts advocacy upon global issues such as the root causes of exploitation and campaigns against sex tourism and military prostitution. TW-MAE-W began providing direct services at the local level in 1987, and now has 7 drop-in centers and 3 homes around the country, run by 35 female staff members. In addition, the Bethany Transition Home in Quezon City, Manila, houses 10-20 women, all who have outside employment. The girls and women who come to TW-MAE-W's facilities have all been exploited in some way. For example, they may be battered wives, women who have experienced incest, or girls who have been sold or tricked into prostitution. They arrive after either calling a telephone hotline on their own or being referred by social workers and nongovernmental organizations. Following an initial 3-month course of recuperation, center residents are helped to either continue their academic training, receive vocational training, or find a job. Basic health services are provided to the residents and drop-in center clients.^ieng

Where, and why, women are at risk. Country focus: Ethiopia.

PIP: The first evidence of HIV infection in Ethiopia was found in 1984, and the first AIDS case was reported in 1986. By 1993 and 1996, an estimated 3.2% and 5.2%, respectively, of adults in the country had been infected. According to the Ethiopian government's epidemiology and AIDS control department, more than 400,000 people may have already developed AIDS since the beginning of the epidemic. However, only a small proportion of these cases has ever been recorded in the official health statistics. In urban areas, probably more than 11% of adults are infected with HIV, most who do not know that they are infected. The main mode of HIV transmission is through heterosexual intercourse. The number of male cases in Ethiopia approximately equals the number of female cases. Among 15-19 year olds, however, there are far more females than males infected. Unequal power relations, the failure of faithfulness, lack of communication and knowledge, arranged marriages, economic dependence, illiteracy, excessive workloads, and poverty leading to prostitution for survival are risk factors which predispose women in Ethiopia to exposure to HIV.^ieng

U.S. experts warn of Honduras AIDS risk to women. International.

Honduras, the Central American country hardest hit by AIDS, may suffer from a particularly aggressive strain of HIV that is especially dangerous to women, US experts said. "We are investigating the presence in Honduras of (HIV) sub-type B, which is more aggressive than others and could be the reason why it is worse in this country," Winslow Klaslala, professor at the University of Miami, Florida, said. According to the Health Ministry, 7664 Hondurans have been infected with HIV since 1985, and 995 have died. That is 60% of the total number of HIV sufferers in the six countries of Central America and the incidence in women is unusually high at 36%. A team of experts, including members from Harvard University and the WHO, have been taking blood samples, primarily from HIV infected women, Klaslala said. They will analyze the blood to look for sub-type B, described by Klaslala as highly "aggressive and adaptable." "If it is present," he said, "women are particularly at risk." Honduran health authorities were paying close attention to the investigations. "If they show that the sub-type that attacks in Honduras is more aggressive, we will have to redesign our campaign for combatting the disease," said Enrique Zelaya, a top Health Ministry official.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy.

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

PIP: The authors assessed the applicability of the transtheoretical model of behavior change to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Data were collected in 1992 from the US Centers for Disease Control's multisite Prevention of HIV in Women and Infants Demonstration Project. In the transtheoretical model, which originated from smoking cessation and psychotherapy research, behavior change is a gradual, continuous, dynamic process in which people move through a sequence of five stages. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess the use of oral contraceptives and hormonal implants, but that measurement of condom use requires separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. SE scores rose significantly across stages, from recontemplation to maintenance, and a shift in decisional balance was observed for two of three behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

Inequalities cause reproductive deaths.

PIP: A US organization, Population Action International, is reported in this article to have released findings on the health risks for women in 118 countries. Countries are ranked on 10 indicators, including such indicators as the number of births to women aged under 19 years, the availability of legal abortion, maternal mortality, and level of prenatal care. Italy, Denmark, Norway, and Sweden are identified as countries with low reproductive risk for women. The worst ranked countries are identified as Zaire, Angola, and Somalia. 21 countries were placed in the high risk group, of which only two, Haiti and Afghanistan, are not located in Africa. Editorial comment in the report is described in this article as reflecting the position that countries fail in investing in women's health, with devastating consequences. Some poor countries, such as Cuba, Tunisia, and Costa Rica, are cited for their investments in health care and family planning. The report is described as asserting that low status also prevents women from maintaining good health. Both access to reproductive health services and changing social norms supporting traditional roles in early and frequent childbearing are important to women's improved health status. It is also important for women to have educational and economic opportunities. Population Action International is seeking greater foreign aid contributions for family planning services in developing countries, emergency care in childbirth, health education, AIDS education, and access to safe abortion services.^ieng

A pregnancy-prevention program in women of childbearing age receiving isotretinoin.

BACKGROUND: Isotretinoin is effective in treating severe acne, but it is also teratogenic. To minimize pregnancies among exposed women, the manufacturer, together with the U.S. Food and Drug Administration, implemented a multicomponent Pregnancy Prevention Program in 1988. We report the results of an ongoing survey designed to assess compliance with this program. METHODS: Treated women enrolled in the survey through their physician, by filling out a form in the medication package, or by calling a toll-free telephone number. They were randomly assigned to be followed by telephone or by mail. Telephone interviews were conducted at the start of therapy, in the middle of it, and 6 months after it ended; mailed questionnaires were completed 6 months after therapy ended (median duration of therapy, 20 weeks). RESULTS: Between 1989 and 1993, 177,216 eligible women enrolled in the survey. Interviews with 24,503 women within one month of enrollment revealed that 99 percent had been told to avoid pregnancy. At that time, approximately 54 percent were not sexually active (of whom 37 percent used contraception) and 42 percent were sexually active (of whom 99 percent used contraception); 4 percent were infertile. Among 124,216 women with completed telephone or mail follow-up results, there were 402 pregnancies during therapy (3.4 per 1000 courses of isotretinoin); 72 percent of the pregnant women had elective abortions, 16 percent spontaneous abortions, 3 percent ectopic pregnancies, and 8 percent live births. CONCLUSIONS: The pregnancy rate among women receiving isotretinoin therapy was substantially lower than that in the general population and was compatible with the characteristics and behavior of the enrolled women.

PIP: Isotretinoin is effective in treating severe acne, but it is also teratogenic. To minimize pregnancies among exposed women, the manufacturer, together with the US Food and Drug Administration, implemented a multicomponent Pregnancy Prevention Program in 1988. The results of an ongoing survey designed to assess compliance with this program are reported. Treated women enrolled in the survey through their physician, by filling out a form in the medication package, or by calling a toll-free telephone number. They were randomly assigned to be followed by telephone or by mail. Telephone interviews were conducted at the start of therapy, in the middle of it, and 6 months after it ended; mailed questionnaires were completed 6 months after therapy ended (median duration of therapy, 20 weeks). Between January 1, 1989, and December 31, 1993, 177,216 eligible women enrolled in the survey. First telephone interviews were completed with 24,503 women within 1 month of enrollment. The median age of these women was 26 years, the median number of years of education was 14, and the median duration of acne was 8 years. 99% had been told to avoid pregnancy; 85% were told of the importance of using effective contraception for 1 month before starting isotretinoin. At that time, approximately 54% were not sexually active (of whom 37% used contraception); 42% were sexually active (of whom 99% used contraception); and 4% were infertile. As of June 30, 1994, 124,216 women had completed telephone or mail follow-up. There were 402 pregnancies during therapy (0.3% or 3.4 per 1000 20-week courses of isotretinoin); 46 were pregnant when therapy began, and 356 became pregnant during therapy. 290 (72%) of the 402 pregnant women had elective abortions, 63 (16%) had spontaneous abortions, 13 (3%) had ectopic pregnancies, and 32 (8%) had live births. Of the 32 liveborn infants, the survey teratologist examined 13, of whom 5 were judged to have defects compatible with the isotretinoin embryopathy. The pregnancy rate among women receiving isotretinoin therapy was substantially lower than that in the general population and was compatible with the characteristics and behavior of the enrolled women.

Family planning in genitourinary medicine: an opportunistic service?

OBJECTIVE: To evaluate and serve the need for contraception in those not using conventional sources of family planning services. SETTING: South London outpatient genitourinary medicine department at King's College Hospital. DESIGN AND SUBJECTS: Prospective study of 200 women seen consecutively in the clinic by the same doctor (LM) during 1993. Women at risk of unwanted pregnancy were identified, and offered immediate contraceptive provision or referral. RESULTS: 15 women (7.5%) were using no contraception, despite being sexually active and not wishing to conceive; of these two presented with an unwanted pregnancy. A further 23 women (11.5%) were not using their chosen contraception effectively, and another 20 women were unclear about contraceptive methods and wanted advice. Young women were most at risk; 14% of those aged 25 years and under were using no contraception. Eight women wished to defer contraceptive advice; of these four defaulted from follow up. Eighteen women (9%) wanted immediate contraceptive supplies. Ten of 18 returned a follow up questionnaire; all these women were satisfied with the contraceptive advice service received. CONCLUSIONS: Absent or ineffective contraception is common in women attending an inner city genitourinary medicine clinic. Immediate provision of contraceptive education, advice and supplies is welcomed by patients.

PIP: The objective was to evaluate and serve the need for contraception in those not using conventional sources of family planning services. In a prospective study a structured interview was held with 200 women seen consecutively by the same doctor during 1993 in the South London outpatient genitourinary (GU) medicine department at King's College Hospital. Of 200 women seen, 94 (47%) were Caucasian, 79 (39.5%) Black Caribbean, 9 (4.5%) Black African, and 18 (9%) were of other origins. The majority were 30 years or younger and sexually active at the time of interview. 15 women (7.5%) were classed as high risk; they were using no contraception. Two of these presented with an unwanted pregnancy. 12 (80%) of the high-risk group were under 25 years old (p = 0.019, odds ratio 5.02). 10% of the women said they had not been sexually active during the last 3 months, 73% said they had been in monogamous relationships, 12.5% said they had had 2 or more regular partners, and 4.5% had had casual partners only. 73 (36.5%) had had at least 1 pregnancy termination. 45 (22.5%) said that they did not want any more children. 23 women (18% of those using contraception) were not using their chosen contraception effectively in addition to the 15 who were completely unprotected. Another 20 women wanted contraceptive advice. 58 women (29%) were unclear about contraceptive methods and needed advice, including the entire at risk group who were using no contraception at all. 18 patients (9%) wanted contraceptive supplies at the first appointment. Eight preferred to wait until a follow up visit, but 4 then failed to return and 3 subsequently declined further contraceptive advice. 10 of the 18 women (56%) given a new method of contraception returned the follow up questionnaire, and all of these were satisfied with the family planning service they had received at the GU clinic. Immediate provision of contraceptive education, advice, and supplies is welcomed by patients.

AIDSCAP initiative expands prevention efforts for women.

PIP: By 2000, women will likely comprise 50% of HIV-infected persons worldwide. Women, regardless of number of sexual partners, are especially vulnerable to HIV. One act of intercourse puts women at an 18 times greater risk than men of acquiring HIV. Traditional gender roles denying women the power to protect their own health exacerbate their biological susceptibility to HIV infection. AIDSCAP's Women's Initiative (AWI) aims to secure culturally and gender-sensitive AIDSCAP interventions and strategies and to advance AIDSCAP's leadership role in developing HIV/AIDS prevention models for women. More than 50% of AIDSCAP current projects target women. AWI integrates a broader gender perspective into AIDSCAP's project design, technical assistance, evaluation and monitoring, and policy projects. It has expanded target women's groups beyond the groups traditionally considered at high risk. To date, various AIDSCAP projects have trained and educated about one million women. The Christian Reformed World Relief Committee (CRWRC) is involved in HIV/AIDS prevention activities. Its AIDS and Sexually Transmitted Disease (STD) Health Promotion Prevention Program with Market Women in Senegal targets self-employed market women and urban female youth in Dakar, Kaoloack, and Thies. CRWRC worked with two women's groups to develop a sexual health promotion package with HIV/AIDS and STD IEC (information, education, and communication) materials and has trained 20 facilitators to use the promotion package. It helps the two collaborating groups to develop their organization capacities so they can implement and evaluate sustainable HIV/STD prevention programs. AIDSCAP also supports training of Kenyan family planning provider activities in HIV prevention of the JSI Family Planning Sector Project. It collaborates with the Center of Women Workers in Haiti to provide women factory workers IEC and condoms to promote risk reduction behavior. AWI also conducts research and policy activities (e.g., perceptions of the female condom in 3 countries).^ieng

[Contraceptives, HIV, and other sexually transmitted diseases]. / Anticonceptivos, VIH y otras enfermedades de transmisión sexual.

The large majority of women who acquire Human Immuno-Deficiency Virus (HIV) and other sexually transmitted diseases (STDs) are in their childbearing years and are current or potential users of contraceptive methods. Certain STDs augment women's risk for HIV due to damage which these diseases produce in the integrity of the epithelial lining of the vagina and the vulva. There also exists evidence that some contraceptive methods, such as the intrauterine device and certain hormonal products, may increase the risk of HIV and other STDs. Condoms and spermicides offer good levels of protection against these diseases, but are not highly effective contraceptives. The interrelations among these risks are important and create a great problem for women's reproductive health. Moreover, the high vulnerability of the female population for these diseases is also related to a variety of social factors which are referred to as gender relations (power of females in society relative to that of females). Among the gender-related inequalities which affect women are their lack of power to successfully control many aspects of sexual relations. Another problem has to do with the fact that there are no highly reliable female controlled methods for preventing infection by HIV and other STDs. Improvement in the reproductive health care of women depends on the development of new disease prevention products and structural changes in the delivery of care, as well as continued research efforts on the interrelations among contraceptive methods, HIV and other STD.

PIP: Until recently, some behaviors were viewed as entailing a high risk of HIV infection, but HIV is now considered a great risk for the female population in general. The number of HIV infected women is increasing rapidly even in areas such as Mexico and South America where women form a minority of AIDS patients. Most women infected with HIV and other sexually transmitted diseases (STDs) are sexually active and at risk of pregnancy. Some STDs, notably those producing genital ulcers, increase the risk of HIV infection. It is not yet known whether STDs not producing ulcers also increase the risk. There is controversy over the extent to which specific contraceptive methods increase or perhaps reduce the risk of HIV infection. Some unconfirmed assumptions are that the cervical ectopy produced by oral contraceptives (OCs) results in affected zones more vulnerable to trauma and thus perhaps to HIV infection, and that combined OCs by reducing menstrual bleeding also reduce risk of infection. OCs containing only progestins may increase the risk of transmission by inducing irregular bleeding, thickening the cervical mucus, and thinning the vaginal epithelium. Injectables may increase risk by increasing bleeding, thinning the vaginal epithelium, or through use of contaminated needles in application. IUDs may increase menstrual bleeding and are not advisable in any event for women at high risk of other STDS. Condoms and spermicides offer some protection against STDs, but are not highly effective contraceptives. The interrelations between risk of pregnancy and of disease are a great and largely unresolved problem in women's reproductive health. Few family planning services are able to address prevention of STDs and especially AIDS adequately. Methodological and logistical problems impede study of the interrelations between contraception and STDs, and resources are limited. Studies of commercial sex workers in different countries have offered a partial solution. Women's lack of power to negotiate successfully concerning sexual relations and their lack of access to a means of preventing STDs under their own control are factors in their vulnerability. Improved reproductive health of women will require development of new products to control disease, structural changes in health services, and continued research.

Intermediate variables as determinants of adverse pregnancy outcome in high-risk inner-city populations.

A probability sample survey of high-risk inner-city women with a live birth in the last 3 years shows that maternal medical risks and health behaviors during pregnancy are important intermediate variables influencing preterm delivery and birthweight. Women who developed two or more medical risks had about three-and-a-half times the risk of preterm delivery and two-and-a-half times the risk of low birthweight compared to those without such risks. Women with prior fetal loss had twofold increase in the risk of preterm delivery and low birthweight. Unintended pregnancy resulted in one-and-a-half to twofold increase in preterm delivery and low birthweight, respectively. Inadequate gestational weight increased the risk of preterm delivery by about 50%. Smoking during pregnancy raised the risk of low birthweight slightly more than one-and-a-half times.

PIP: A probability sample survey of 1004 women from Pittsburgh, Pennsylvania, who had a live birth in the preceding three years indicated that the impact of poverty on pregnancy outcome is mediated by maternal medical risk factors and health behaviors during pregnancy. Study subjects were predominantly Black and drawn from inner-city areas with high poverty rates. None of the sociodemographic or economic variables included in the analysis (e.g., maternal age, race, household income, education, and marital status) was a significant predictor of the two adverse pregnancy outcomes considered: deliveries under 37 weeks' gestation and birth weights under 2500 g. Women with two or more medical problems during pregnancy had a 3.5 times greater risk of preterm delivery and twice the risk of low birth weight than those with no such problems. There was a two-fold increase in the risk of both adverse outcomes among the 22% of respondents who had experienced a prior pregnancy loss. Among the 54% of respondents who indicated the most recent pregnancy was unwanted, the risk of these outcomes was increased by 1.5-2.0 times. Maternal weight gain during pregnancy of less than 25 pounds was associated with a two-fold increase in low birth weight, while smoking during pregnancy increased this risk by 1.6 times.

Women and AIDS: agenda for action.

PIP: The Fourth World Conference on Women will be held in Beijing, China, September 1995, during a period when women are increasingly and disproportionately being affected by HIV and AIDS. Relatively few women were touched by AIDS during the 1980s. Now, however, more than six million women are infected with HIV and another million will become infected in 1994. By the year 2000, more than 13 million women will have been infected and four million will have died. The sexual and economic subordination of women fuels the HIV/AIDS pandemic. Measures must be taken to allow women to make informed choices and improve the quality of their lives. Women must empower themselves by networking, forming alliances, and advocating for change. Furthermore, top-level political commitment is needed to reduce the social vulnerability of women to HIV infection by improving their health, education, and legal and economic prospects. Effective HIV/AIDS prevention and care efforts along with sound policies and programs targeting women affected by HIV/AIDS need to be developed and integrated into existing national structures, particularly at the community and family levels. Recommendations are made in the interest of reducing the vulnerability of women to HIV/AIDS.^ieng