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The Pop Reporter®

Volume 4, Number 37
13 September 2004

"The Pop Reporter" (R) Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs INFO Project. When you click on any link below, your Internet browser will access a Web site not connected to "The Pop Reporter." Information accessed through these links and contained in this issue of "The Pop Reporter" does not necessarily state or reflect the views of the INFO Project, Johns Hopkins University, or the US Agency for International Development. All links were verified at the date of mailing. Your computer and/or network configuration regarding Java script, cookies, and other security issues may not allow you to view certain Web sites. Consult your computer technician if you are having problems.

GUEST EDITORIAL

Hormonal Contraception and Cervical Infections

by Ronald Gray, MD, MSc

rgray@jhsph.edu

A carefully conducted study by Morrison et al. assessed the acquisition of Chlamydia and gonorrhea in 819 women newly initiating combined oral contraceptives (COC) or DMPA, compared with women not using a hormonal method (1). They found a significantly increased risk of cervical infection among DMPA users (adjusted hazard ratio [HR] = 3.6; 95%CI 1.6-8.5), but no significantly increased risk on COC users (adj HR = 1.5, 95%CI 0.6-3.5). It must be noted, however, that if women became pregnant they were removed from the analysis of infection risk. In my view this is unfortunate because a) pregnancies are likely to differ between hormonal and non-hormonal contraceptors, b) we need to balance the risk of unwanted pregnancy against a possible risk of infection during contraceptive use and during a subsequent pregnancy. What are we to make of these findings and how should they affect policies on family planning?

The dilemma faced in this study, and all other studies of hormonal contraception and the risk of sexually transmitted infections (STIs) is that women self-select their method of family planning, and many factors determine contraceptive choice. For example, women with higher sexual frequency often opt for more effective hormonal methods, and this was apparent in the Morrison study in which both COC and DMPA users had a higher coital frequency than non-hormonal contraceptive users. The key concern is whether there was confounding between the characteristics and behaviors determining contraceptive choice and the behaviors that placed women at risk of STIs? To overcome this problem, investigators use multivariate analyses to try to adjust for potential confounders, but the question still remains whether this adjustment is adequate.

We conducted a study of hormonal contraception and HIV acquisition and found that HIV incidence was higher among COC and DMPA users than non-users (2). However, after adjustment, particularly for differences in sexual behaviors, HIV risk was not increased.

These investigations, called observational studies, can only measure associations; they cannot prove causality. The plausibility that an association is causal is a judgment call, based on the strength of the association, the consistency between studies, the rigor in design and analysis, and the biologic plausibility of the findings. The findings by Morrison et al. of an association between DMPA and acquisition is only partially supported by one other study, but their finding of no association between COC use and Chlamydia contradicts several other studies. When studies contradict one another, as is the case with hormonal contraception and STIs or HIV acquisition, it is impossible to determine where the truth lies. The ultimate arbiter is the randomized trial, but it is questionable whether one could ethically randomize women to hormonal and non-hormonal contraception in order to conduct such trials.

Experience with postmenopausal hormone replacement therapy (HRT) provides a cautionary tale. Multiple observational studies found that women taking HRT had lower risks of cardiovascular disease postmenopausal; subsequent clinical trails showed the opposite. The reason for this contradiction was that women who self-selected to use HRT lived a healthier life style than women not using these drugs, so the observational studies were hopelessly confounded by these inherent differences which could not be corrected by multivariate statistical methods. The trials overcame this problem by allocating women to HRT by random chance and thus minimizing self-selection.

Where does this leave the practitioner and policy maker? It is unwise to base policy on one uncorroborated observational study, so more research is needed. In settings where testing for STIs is possible, it would be prudent to test and treat all sexually active women for STIs, irrespective of their contraceptive choice. In settings where STI testing in not possible, the risks of unwanted pregnancy make contraception, hormonal or otherwise, the safest option for women.

Ronald Gray, MD, MSc, is Robertson Professor of Reproductive Epidemiology, Johns Hopkins University, Bloomberg School of Public Health.

References:

1. Morrison CS, Bright P, Wong EL, Kwok C, Yacobson I, Gaydos CA, Tucker HT, Blumenthal PD. Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections. Sex Transm Dis 2004;31(9):561-7.

2. Kiddugavu M, Makumbi F, Wawer MJ, Serwadda D, Sewankambo NK, Wabwire-Mangen F, Lutalo T, Meehan M, Xianbin, Gray RH; Rakai Project Study Group. Hormonal contraceptive use and HIV-1 infection in a population-based cohort in Rakai, Uganda. AIDS. 2003;17(2):233-40.

Information on Recent Depo-Provera and STIs Publication

by Margaret Neuse

You should be aware of a study, published [last] week in the journal Sexually Transmitted Diseases, that found an association between use of depot-medroxyprogesterone acetate (DMPA or Depo-Provera) and the risk of acquiring chlamydial or gonococcal infections (a three-fold increased risk). This study was jointly funded by the U.S. Agency for International Development and the National Institute of Child Health and Human Development. It follows two recently published but less well-designed studies that found an increased risk of chlamydial, but not gonococcal, infections among DMPA users.

While of concern, in the view of GH/PRH technical staff this new research does not call for changes in the provision or use of DMPA. Notably, there is no increased risk of infection for women who remain in monogamous relationships with uninfected partners. The research findings do underscore the continuing need to counsel DMPA users who are not in a mutually monogamous relationship with an uninfected partner that they should limit their number of sexual partners and use condoms correctly
and consistently with each sexual act.

In summary, the results of the present study:

o Should be taken seriously, but does not call for change in the provision of DMPA.
o Are of no concern for DMPA users who know that they are in
mutually faithful monogamous relationships with an uninfected partner and thus face no risk of acquiring an STI.
o Are of little concern for DMPA users who use condoms consistently and correctly, since such condom use only rarely fails to provide protection.
o Reinforce the need for all women at STI risk (including any married woman who is unsure of the faithfulness of her partner) to use latex condoms consistently and correctly. This long-accepted recommendation remains unchanged regardless of the method of contraception a woman uses.
o Provide women and their partners with important, new knowledge about making contraceptive choices that are appropriate for their individual situations and best for their overall reproductive health. Sexually active women who choose to use DMPA need to remember that this method is safe and highly effective for preventing unintended pregnancy, but that only consistent condom use and mutually monogamous relationships among uninfected individuals protect against STIs.
o Offer an opportunity for providers to emphasize contraceptive choice. If a woman decides to discontinue DMPA use, a provider should emphasize the other contraceptive options available to her.

Further details:

The study compared three groups of women: those starting oral contraceptives, those starting DMPA injections, and those who did not use hormonal contraceptives. No significant increase in risk of chlamydial or gonococcal infections was found for users of oral contraceptives containing both estrogen and progestin, although a moderate increase in risk associated with oral contraceptive use could not be ruled out.

The study had the strengths of being prospective and carefully designed to assess various sexual risk factors. However, women were not randomized to contraceptive method, and the possibility remains that women using DMPA were different in some ways from the control group, many of whom were not using contraception. Moreover, while the results were highly statistically significant, there could have been some role of chance in the finding. This is because the elevation in risk was based on a total of 12 cases of gonorrhea or chlamydia among DMPA users.

It is also important to note that 77% of the 819 women participating in the study conducted in Baltimore and Towson, Maryland, USA, were single. Study results may not apply to married women who comprise the large majority of women seen in family planning clinics in the developing world. However, any married woman who is unsure of the faithfulness of her partner should consider herself at risk of acquiring a sexually transmitted infection (STI), and that risk may be heightened if she is a DMPA user.

For additional information, please contact Jeff Spieler (jspieler@usaid.gov) and Jim Shelton (jshelton@usaid.gov).

Margaret Neuse is Director, Office of Population, USAID.

Additional commentary from Jeff Spieler, Chief, Research, Technology and Utilization Division, Office of Population and Reproductive Health, Bureau for Global Health, USAID:

With the results of this study being interpreted in a variety of ways, I think it is important to reiterate the bottom line message: The findings of this study do not justify preventing a woman from choosing this safe, highly effective contraceptive method if she determines it is her best option to prevent pregnancy. A woman who is in a mutually faithful, monogamous relationship with an uninfected partner is not at risk of any sexually transmitted diseases if she uses Depo Provera. There is also little chance of infection for a woman who relies on Depo Provera to prevent pregnancy, and who also uses condoms consistently and correctly at every act of intercourse. This study is an important reminder that if a woman chooses a contraceptive other than condoms as her primary means of preventing pregnancy, she needs to honestly evaluate her risk of contracting an STI and assess how best to protect herself against infection.

Health care providers should be sure to remind women that Depo Provera - like every contraceptive method other than condoms - does not protect against STIs. Further, a woman who is sexually active - but not in a monogamous relationship with an uninfected partner - must be counseled about the importance of using condoms and instructed on how to use them, about getting tested and treated for STDs, and about reducing the number of partners to reduce her risk of infection, regardless of which contraceptive method she is using. A very big mistake would be for women, especially women at very low or no risk of STIs, to stop using Depo Provera and then experience an unplanned pregnancy before adopting another effective method of contraception.

FAMILY PLANNING/REPRODUCTIVE HEALTH RESEARCH

Using Evidence to Improve Reproductive Health Quality along the Thailand-Burma Border (research abstract)
In 2001, The Mae Tao Clinic, located on the Thailand-Burma border, launched a project with the primary aim of improving reproductive health services and the secondary aim of building clinic capacity in monitoring and evaluation. This paper presents the project's methods and key results and identifies lessons learned from introducing M&E in a resource-constrained setting.

Changes in HIV/AIDS/STI Knowledge, Attitudes and Practices among Commercial Sex Workers and Military Forces in Port Loko, Sierra Leone (PubMed abstract)
ARC International compares a 2001 baseline survey of sex workers and military respondents on their knowledge, attitudes and practices surrounding HIV/AIDS with a comparable follow-up in 2003. Increases in knowledge and condom use demonstrate that, despite the challenges inherent in a post-conflict country, good-quality AIDS-prevention programmes can be effective.

Condom Programs in High HIV Prevalence Countries Should Include the General Population (resource material)
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This 2-page "Issue Brief" from Population Services International argues that promoting condoms to the general population - a personal protection strategy that allows people to reduce their risk by "about 90% when used consistently and properly" - is justified by the evidence.

Progress in Reproductive Health Research (Issue 66) (resource material)
(You need Adobe Acrobat Reader to access this document)
This issue of "Progress in Reproductive Health Research" contains the following articles: research on family planning at WHO: what's new; the search for new and better contraceptive methods; family planning in the era of HIV/AIDS; how safe and effective are existing family planning methods?; quality of care and family planning; and evidence-based guidance on family planning. The "Progress in Reproductive Health Research" is a quarterly newsletter that disseminates information on the activities of the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Social Identity and Community Effects on Contraceptive Use and Intentions in Southern Ethiopia (research abstract)
In this study, data gathered in southern Ethiopia are used to explain how ethnic and religious identities affect current or intended contraceptive use. Findings suggest that exposure to ethnic and religious diversity in the community of residence substantially increases the likelihood of emergent birth limitation, especially among the predominant Muslim Silte population.

FAMILY PLANNING/REPRODUCTIVE HEALTH NEWS

Kenya: Big Family Threatens a Come-Back (news article)
With the decline in family planning funding, some fear the reversal of positive gains made in population control efforts, including the decline of family size.

India: Where Religion Is a Barrier to Family Planning (feature article)
In tribal areas of Jharkhand in eastern India, where free sex is no taboo, family planning methods are frowned upon by religious leaders.

India: Muslim Law Board Ready to Discuss Family Planning (news article)
Joining the debate on high growth rate among Muslims, the All India Muslim Personal Law Board said that it was ready to discuss promotion of family planning and literacy in the country.

FAMILY PLANNING/REPRODUCTIVE HEALTH LAW AND POLICY

Chinese Law Addresses AIDS for First Time (news article)
China's lawmakers have addressed the AIDS threat directly for the first time ever in a sign the government hopes to curb the disease before it becomes an epidemic, state media said. Amendments to the law on infectious diseases urge officials at all levels to step up the control of AIDS and take measures to prevent the spread of the disease.

Population Forum Passes Yangtze Declaration (news article)
Members of an alliance of developing countries, Partners in Population and Development proclaimed Thursday they would continue their strong commitment to the Programme of Action of the International Conference on Population and Development. With the adoption of the Yangtze Declaration, the Partners celebrated its first South-South Collaboration Day in Wuhan along the Yangtze River. The declaration wrapped up the three-day International Forum on Population and Development.

The Divergence of AIDS, and Sexual and Reproductive Rights (feature article)
AIDS prevention efforts and initiatives to support sexual and reproductive health would seem to be natural allies. Why is it then that projects to advance these causes so often proceed in isolation of each other? This report states that this question took center stage recently at 'Countdown 2015: Sexual and Reproductive Health and Rights for All', a three-day conference held in London.

EU Acts Against HIV/AIDS Scourge (news article)
Leading healthcare officials will meet in Lithuania later this month to discuss EU action to tackle the resurging rise of the HIV/AIDs virus. The United Nations' AIDS agency (UNAIDS) reports a large increase in the number of those infected by the disease across Europe. In the EU and neighbouring countries the number of carriers is reported to be 1.3 million, up from 160,000 in 1995. UNAIDS has identified several of the new EU member states as some of the worst affected countries.

Philippines: Muslim Heads Back Family Planning (news article)
Muslim religious leaders in Mindanao have issued an edict, or fatwah, on family planning in support of the government's reproductive health campaign, a Population Commission official announced recently.

HIV/AIDS RESEARCH

Determinants of Personal Demand for an AIDS Vaccine in Uganda: Contingent Valuation Survey (research article)
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This study exmines the factors affecting demand for an HIV/AIDS vacine among yong adults in their prime earning and childbearing years and the impact of vaccination on risk behaviour in a high-prevalence, low-income country. Findings show household wealth, vaccine price and risk behaviors as significant determinants of individual demand.

HIV/AIDS, Peacekeeping and Conflict Crises in Africa (research abstract)
This article investigates the impact of the spread of HIV/AIDS on the African military and its ability to act as an effective instrument of conflict resolution in the continent.

Progress Toward an HIV Vaccine (research abstract)
In this article, Norman L. Letvin­ of the Harvard Medical School reviews aspects of the biology of HIV that make it a uniquely difficult target for vaccine protection. He summarizes the reasons that traditional approaches to creating an antiviral vaccine have failed to provide protection against HIV infection. He then describes novel vaccination strategies being explored as potential approaches to generating protective immunity. Finally, the author reviews experimental findings in nonhuman primate models suggesting that currently available vaccine technologies may allow the elicitation of cellular immune responses that can attenuate the clinical disease induced by HIV, even if they do not actually prevent infection.

HIV/AIDS NEWS

An Unsustainable Battle? (feature article)
This feature article from the BBC presents a difficult scenario: In 1991, the Nigerian president announced that his country was going to lead the way in AIDS treatment. In many respects his government scheme has been successful, but what happens when the money runs out?

China: Nation to Invest Hugely in HIV/AIDS Prevention, Control (news article)
The Chinese government remarkably increased its budget for HIV/AIDS prevention and control annually, according to the China's Population and Development Country Report issued on September 7. The report said in 2001, the central government substantially increased its budget for HIV/AIDS prevention and control annually from US$1.81 million to US$12.09 million. In 2003, this allocation jumped again to US$47.16 million. In 2001, US$150 million from national bonds, combined with US$120 million in matching funds from local governments, were contributed to the construction of blood banks and equipment purchase in the central and western parts of China.

Doctors and Nurses with HIV and AIDS in Sub-Saharan Africa (editorial)
According to this author, vice chancellor of the Durban Institute of Technology and editor of the South African Medical Journal, an additional threat from the AIDS pandemic that has received little or no attention in the literature is the possible impact of illness and death due to the pandemic, specifically among healthcare professionals in countries with high HIV prevalence rates.

South Africa: Moving Towards Marketable Microbicides (feature article)
Microbicides could avert an estimated 2.5 million HIV infections globally over the next three years, according to the South African Medical Research Council.

Premature Sex Blamed for Spread of AIDS in Sub-Saharan Africa (news article)
Premature debut to casual and careless sex has been blamed for the spread of HIV/AIDS and STDs in sub-Saharan Africa. Studies have found that girls in rural areas in this region start sexual activities as early as 8 years of age, while boys begin at 12. The figure was revealed by Ibrahim Kabole, manager of the STD/HIV/AIDS multi-sectoral council planning tools project, at the African Medical and Research Foundation meeting held in Dar es Salaam.

Chinese Walls Come Down (feature article)
China will have the world's worst AIDS epidemic by 2020. But the spread of the disease could also hasten political reform.

Swaziland: Holistic Approach to Combating HIV/AIDS (news article)
An HIV/AIDS testing and counselling centre that will be the template for other such facilities in Swaziland's urban areas opened this week in the centrally located town of Manzini.

MATERNAL AND CHILD HEALTH RESEARCH

Valuation in the Costs of Delivering Routine Immunization Services in Peru (research article)
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This paper exmines variations in costs of delivering routine immunization services in three diverse districts of Peru: Ayacucho (mountainous), San Martin (jungle), and Lima (coastal). Outcomes show wide cost variability across geographical regions and type of facilities. Information on how costs vary can be used as a basis from which to generalize to other settings and provide more accurate estimates for decision-makers lacking disaggregated data on local vaccine expenses.

Acceptability and Utilisation of Voluntary HIV Testing and Nevirapine to Reduce Mother-to-child Transmission of HIV-1 Integrated into Routine Clinical Care (research abstract)
The authors assessed the effect of regular audit and targeted interventions on the utilization of the nevirapine for prevention of mother-to-child transmission program. Results demonstrate significant increases in HIV testing and nevirapine use, acceptability of voluntary counselling and testing for HIV and use of nevirapine, and the importance of ongoing audits in overcoming obstacles to HIV detection and neverapine uptake in women and children in this South African setting.

Level of Knowledge and Attitude of Primary Care Physicians in Eastern Anatolian Cities in Relation to Child Abuse and Neglect (PubMed abstract)
Results from this study indicate that primary care physicians working in the eastern cities of Turkey do not have adequate knowledge and proper attitudes toward the identification and reporting of suspected child abuse. The authors write that there is a need for educational programs to primary care physicians and other health personals working with child abuse and neglect to increase their knowledge and skills in detection, assessment, reporting, treatment, and prevention of child abuse and neglect.

Impact of Maternal Depression on Infant Nutritional Status and Illness in Pakistan (research abstract)
Maternal depression in the prenatal and postnatal periods was found to be a predictor of poor growth and higher risk of diarrhea in a community sample of infants. This study suggests that early treatment of prenatal and postnatal depression could benefit not only the mother's mental health but also the infant's physical health and development.

Child Sexual Abuse in Tanzania and Kenya (research abstract)
This paper examined the various commentaries and reports extant, toward an overview of the nature and frequency of child sexual abuse in Tanzania and Kenya. Conclusions indicate that child sexual abuse is under-researched in Tanzania and Kenya. Given the high incidence of AIDS/HIV in both countries, the authors assert that nationwide surveys of the general population are needed to know if the epidemic is increasing the risk of rape or incest for children.

MATERNAL AND CHILD HEALTH NEWS

China: Maternal and Child Mortality Rates Achieve International Goal (news article)
China has identified reduction of maternal and child mortality rates over the past decades, achieving the goal set by the International Conference on Population and Development (ICPD) Program of Action ahead of schedule, according to China Population and Development Country Report published Tuesday.

Turkmenistan: National Breast-feeding Campaign Concludes (news article)
A week-long national breast-feeding promotion campaign has been under way in Turkmenistan, aimed at raising the population's awareness of its significance and benefits.

The Child-Mothers of Uganda (feature article)
This article reveals the plight of young displaced Ugandan mothers, created by an 18-year-old war between President Museveni and the Lord's Resistance Army.

MEN'S HEALTH NEWS

A Role for Men in Gender Equality Fight (news article)
When the international community meets next year to review the status of women 10 years after a ground-breaking conference on gender, the role of men in the quest for the equality of sexes will be high on the agenda. It stems from the increasing awareness that men have to be roped into the battle for gender equality, say experts participating in a week-long conference here to review the status of women in the Asia-Pacific region.

South Korea: Despite Low Birth Rate, Vasectomies Still Popular (news article)
Vasectomies are still common even as the low birth rate has become a social problem. According to the Ministry of Health and Welfare, 47,197 vasectomies were performed in the first half of the year.

Ghana: More Men are Embracing Vasectomy (news article)
Ghana Health Services lauds the increasing number of men opting for vasectomy as a family planning method. During the first half of the year, some 50 men had voluntarily undergone the surgical process, as compared to the 26 recorded during the same period in 2003.

POPULATION RESEARCH

Long-term Effects of Reproductive History on All-cause Mortality Among Adults in Rural Bangladesh (research abstract)
Researchers examined the association between reproductive history and all-cause mortality among ever-married women and men after age 45 in Matlab, Bangladesh. No association was found between parity and mortality among women, but a small decrease in men's mortality was found to be associated with their wives' parity. Survival for both sexes was greatly enhanced by an increasing number of surviving children, regardless of parity or other social factors. The authors write that a "healthy pregnant woman effect" coupled with the social and economic advantages of having surviving children may explain the observed effects.

POPULATION NEWS

Kenya: A Land of Unwanted Babies (news article)
A large number of children born in Kenya today are either totally unwanted or should have postponed their arrival. Data collected across the country and released in the authoritative 2003 Kenya Demographic and Health Survey says nearly 20% of births in Kenya are not wanted while a quarter arrived at the wrong time.

Russia Wants to Develop Cooperation with UN on Population Issues (news article)
Russia is interested in increasing cooperation with the United Nations Population Fund (UNFPA). Russian Deputy Foreign Minister Yury Fedotov on Tuesday met with Sietske Steneker, who represents UNFPA in Russia, the Russian Foreign Ministry reported.

Singapore: Birth Rate Last Year Lower than Estimated (news article)
Nearly 1,000 fewer babies were born last year to Singaporeans and permanent residents than was previously estimated, making the 35,000 births the lowest resident birth figure in decades.

More Shanghai Families Want 2 Kids (news article)
This report from Xinhuanet news service reports that an increasing number of families are applying to have two children as Shanghai cancels its one-child family reward incentive.

WOMEN'S HEALTH RESEARCH

Reproductive Health in Afghanistan: Results of a Knowledge, Attitudes and Practices Survey among Afghan Women in Kabul (PubMed abstract)
A reproductive-health knowledge, attitudes and practices (KAP) survey was carried out in a convenience sample of Afghan women selected from attendees in the outpatient departments of four health facilities in Kabul. Reproductive-health indicators were noted to be poor even among these women living in Kabul, a group often considered to be the most privileged. To meet the reproductive-health needs of Afghan women, the socio-cultural aspects of their situation - especially their decision-making abilities - will need to be addressed through a long-standing commitment from agencies and donors and an emphasis on education of women as part of the reconstruction process of Afghanistan.

What’s “Normal”: Female Genital Mutilation, Psychology, and Body Image (feature article)
This article focuses on the psychological effects of FGM through the example of a patient who had undergone the procedure in childhood and now felt that her closed appearance was "normal" and that to be opened would be "abnormal." The author writes that Western advocates must educate themselves about the various cultural forces that lead to FGM in order to help women who have undergone the procedure heal psychologically, thereby breaking the pattern of abuse from generation to generation.

Analysis of Ruptured Uterus in Debre Markos Hospital, Ethiopia (research abstract)
This study aimed to determine the incidence of uterine rupture in a rural hospital and to examine its cause, type and outcome. Investigators found that uterine rupture is relatively common, mainly as a result of obstructed labour and multiparity. Improved healthcare delivery, accesss to prenatal care and family planning could improve the situation.

WOMEN'S HEALTH NEWS

Women Across Globe See Impact of Cairo Pact (feature article)
Hundreds of health care advocates from around the world gathered in London last week to assess the impact midway through a two-decade journey to achieve universal access to sexual and reproductive health care services by 2015.

UK: Sex Health Risk as Women Ditch Condoms for Trust (news article)
A report at the British Psychological Society reveals that young women could be risking their sexual health because they desire trust in a relationship. Research has found that some women feel using a condom can imply either partner is not to be trusted. And that could lead them to risk contracting STIs that could leave them infertile.

YOUTH HEALTH RESEARCH

Early Marriage and HIV Risks in Sub-Saharan Africa (research abstract)
This article examines the effects of girls' early marriage on their risk of acquiring HIV/AIDS. By comparing several underlying HIV risk factors, it explores the counterintuitive finding that married adolescent girls in urban centers in Kenya and Zambia have higher rates of HIV infection than do sexually active unmarried girls.

Innovations in Adolescent Reproductive and Sexual Health Education in Santiago de Chile: Effects of Physician Leadership and Direct Service (research article)
This article discusses the creation of the Centro de Medicina Reproductiva y Desarrollo Integral de la Adolescencia clinic, a comprehensive adolescent reproductive health center in Santiago de Chile, and its reproductive and sexual health (RSH) education programs. In particular, the authors discuss the role of the physician in originating and leading the RSH education efforts, the controversy associated with RSH education in Chile, and the effects of comprehensive RHS education on the local and regional adolescent populations.

Determinant Factors in Ecuador Related to Pregnancy among Adolescents Aged 15 or Less (research article)
A study to determine social factors related to pregnancy among young adolescents found that low socio-economic population, early sexual initiation, poor reproductive health knowledge, and the disruption of family structure were the main social factors related to pregnancy among adolescents aged 15 or less.

Child Marriage Briefing: Ethiopia (resource material)
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Related resource material: Child Marriage Briefing: Nigeria
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Related resource material: Child Marriage Briefing: Mali
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Related resource material: Child Marriage Briefing: Mozambique
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Related resource material: Child Marriage Briefing: Zambia
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Early marriage is a neglected human rights abuse that affects millions of girls worldwide. The Population Council has developed two-page country-specific briefing sheets to inform and draw greater attention to this issue. Briefing sheets are currently available for Ethiopia, Mali, Mozambique, Nigeria, and Zambia.

YOUTH HEALTH NEWS

Vietnam: Youth House offers a secure place for young people to ask about sex (news article)
The Youth House provides a safe and open environment for young Hanoians who have questions and problems regarding reproductive health

India: Use School Textbooks to Fight AIDS (news article)
Health experts in India urge the inclusion of AIDS education in regular school curriculums as an effective measure in combating the surge in infections. Current methods are considered inadequate in light of a disease that has affected over 5 million people in India.

Madagascar: Youth Clinics Raise HIV/AIDS Awareness (feature article)
The use of condoms has steadily climbed among Malagasy youth as the government and NGOs increase their efforts to raise awareness about the dangers of unsafe sex.

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