Monday, November 5, 2007

Other prevention programmes

America’s most dramatic success in HIV prevention has been the reduction in transmission from mother to child. The estimated rate of infections among babies peaked at 1,650 in 1991 and fell to around 144-236 in 2002.5 This decline was caused by the use of antiretroviral drugs and avoidance of breastfeeding. Routine (opt-out) screening of pregnant women for HIV helped to maximise the impact of these interventions.

The success of routine screening of pregnant women has encouraged the US to move towards routine HIV testing in all medical settings, and to target more prevention work at people who are already infected with HIV, as part of an initiative called Advancing HIV Prevention. The Centers for Disease Control and Prevention – a US government agency – hopes that this change of approach will help to reduce the rate of new infections, which has remained at around 40,000 per year since the early 1990s. Among the new developments is greater support for partner notification schemes.

One subject not included in the Advancing HIV Prevention strategy is harm reduction for injecting drug users. In particular, it does not advocate for more needle exchanges, even though studies have shown that these reduce the sharing of injecting equipment and reduce HIV transmission without encouraging drug use. Experts believe that an expansion of needle exchange services helped to reverse an extensive HIV epidemic among drug users in New York City during the 1990s.6 Nevertheless, the US is the only country in the world that prohibits federal funding of needle exchanges; they are illegal in some states, and poorly funded in most others.

As of May 2006, there were 185 needle exchange schemes operating in 36 states, as well as Washington D.C., Puerto Rico, and Native American Lands.7 This is fewer schemes than in Scotland, where the population is around sixty times smaller.8 Many US politicians object to harm reduction, despite its proven benefits, because they think it involves condoning illegal drug use.

Ideological objections also hamper HIV prevention for young people. Much federal money is spent teaching “abstinence only”, which studies have found to be less effective than comprehensive sex education at preventing sexually transmitted infections.9

MSM and HIV – the global picture

Worldwide, it’s estimated that sex between men accounts for between 5 and 10% of HIV infections. The situation varies between countries however, and in much of the developed world – including the USA, Canada, the UK, Australia and New Zealand – more people have become infected with HIV through male-male sex than through any other transmission route.

Sex between men is also a prominent feature in the spread of HIV in less developed regions. In Latin America, sex between men accounted for a quarter of new HIV infections during 2005. In Asia, HIV prevalence levels among MSM have reached as high as 18% in Andhra Pradesh, India, 15% in Phnom Penh, Cambodia, and 28% in Bangkok, Thailand – figures that are many times higher than those found among these countries’ overall populations. In Japan, around 60% of HIV-positive people are MSM.2 In Africa – a region not commonly associated with male-male HIV-transmission – there’s evidence from some countries that transmission through this route is a significant problem. In Senegal for instance, one study recorded that 22% of MSM were living with HIV.3

Although statistics like these give an idea of the impact that AIDS is having on MSM, data is still extremely scarce in many countries. This is largely due to the fact that MSM often have no separate social identity, and are simply counted as part of the general population. It is also due to the reluctance of governments to acknowledge MSM, and to monitor this group.

Another factor blurring statistics is that it’s not always possible to tell how a man became infected. If he is having sex with women as well, he may well report that HIV was transmitted to him from a woman (or even if he is only having sex with other men, he may lie because of stigma). This can distort figures.

From the information that is available, it’s clear that HIV is a significant burden to communities of MSM around the world. But why is this the case? To answer this question, we need to look at the factors that put MSM at risk.

I’m not gay… I just like having sex with men

In the context of the global AIDS epidemic, sex between men is significant because it involves anal sex – a practice that, when no protection is used, carries a higher risk of HIV transmission than unprotected vaginal sex. Historically, AIDS was first discovered among self-identified young gay men in the USA, and throughout the course of the global epidemic, consistently high levels of HIV infection have been found among MSM in many countries.

Organisations representing MSM have also played an active and outspoken role in the response to AIDS. In the USA and the UK for example, gay men’s organisations have raised a great deal of awareness about HIV and AIDS. These groups continue to provide many services to both prevent people becoming infected with HIV, and to help those who are HIV-positive. Another example is Brazil, where groups of gay men exerted a lot of pressure on the government to protect the rights of HIV-positive people in the early years of the nation’s AIDS epidemic.

In many countries however, MSM are not so visible. Sex between men is stigmatised, officially denied and criminalised in various parts of the world. This adds to the vulnerability of MSM, making it difficult to monitor them, and making it near impossible to carry out relevant HIV prevention campaigns in some countries. In places where homosexuality is not tolerated, MSM often hide their same-sex relations from their friends and families to avoid persecution. Many have wives, or have sex with women as well as men, and this means that they may transmit HIV to their female partners if they become infected. The significant impact that HIV is having on MSM is therefore not an isolated problem, but one that is very much linked to countries’ wider HIV epidemics.

Contraceptive Measures After Unprotected Sex

Emergency hormonal contraception is sometimes called "the morning after pill." It is actually a short course of oral contraceptives taken at a high dose. The exact regimen (the number of pills and the number of days) depends on the type of oral contraceptive used. All oral contraceptives contain hormones.

This high dose of hormones blocks the implantation of the fertilized egg in the uterus. In turn, this action reduces the chances of a woman becoming pregnant after unprotected sexual intercourse by 75% or more if the woman is not already pregnant, adequate doses are prescribed, and the woman follows the regimen as directed. To be considered a possible candidate for emergency contraceptive pills a woman should receive medical attention within 72 hours of unprotected intercourse. (In contrast, emergency contraception with an IUD may be possible 5-7 days after intercourse, see below.) The only known contraindication to emergency contraception is pregnancy.

There are no serious side effects, but the pills may cause nausea in 30 to 50% and vomiting in 15 to 20% of women. These side effects may be controlled by taking an anti-nausea drug such as dimenhydrinate (Dramamine). Frequently a doctor will give a prescription nausea medication, such as Compazine , at the same time as the emergency contraceptive pill. A woman may also experience breast tenderness and a temporary disruption of her menstrual cycle.

Both current products on the market include the progesterone hormone levonorgestrel. Preven uses four hormone pills, each of which supply estrogen alone with levonorgestrel. The other emergency contraception treatment approved by the Food and Drug Administration (FDA) is Plan B, which consists of two tablets of levonorgestrel only. This lower dose results in less nausea and vomiting. Levonorgestrel-only medication may be more effective and causes less nausea compared to the Preven product.

Emergency hormonal contraception has the same restrictions as the hormonal contraceptive pill. A woman with a history of stroke, heart attack, liver tumor, or breast cancer needs careful evaluation and counseling before taking emergency hormonal contraception. The pills do not protect a woman from sexually transmitted infections.

This strategy is not meant to be a long-term contraception. Once the emergency is over, a woman should receive proper counseling so that she can select an effective and appropriate contraceptive method to use on a regular basis if she continues to be sexually active.

Birth Control At A Glance

Many methods of birth control and contraception are available today. There are many options. Unfortunately, most of these choices offer little or no protection against sexually transmitted infections (sexually transmitted diseases, STDs), especially against HIV, the human immunodeficiency virus that causes AIDS.

For some individuals, economic considerations dictate their choice of contraceptive method. Abstinence is 100% effective and costs nothing, but may not always be a popular choice. "Natural" methods cost essentially nothing (if one does not use test kits or electronic monitors) but they require considerable discipline to be effective. Barrier methods, such as spermicides and condoms, are affordable to most people and can be effective if they are used consistently and correctly. The hormonal methods, such as "the pill," are highly effective but their cost can add up if they must be purchased and regularly repeated.

The choice of a particular method of contraceptive also depends on a person's age, health, and personal situation. For example, behavioral methods (fertility awareness or withdrawal), IUDs, and tubal ligation are not methods recommended for teenagers. A vasectomy or tubal ligation are not appropriate for a man or woman who wishes to have children in the future because surgical reversal is not guaranteed. Certain medical conditions can rule out a woman using a hormone-based method of birth control.

Introduction to birth control

If a woman is sexually active and she is fertile — physically able to become pregnant — she needs to ask herself, "Do I want to become pregnant now?" If her answer is "No," she must use some method of birth control (contraception).

If a woman does not want to get pregnant at this point in her life, when does she plan to become pregnant? Soon? Much later? Never? Her answers to these questions can determine the method of birth control that she and her male sexual partner use — now and in the future.

There are a number of different ways to describe birth control. Terms include contraception, pregnancy prevention, fertility control, and family planning. But no matter what the process is called, sexually active people can choose from a plethora of methods to reduce the possibility of their becoming pregnant. Nevertheless, no method of birth control available today offers perfect protection against sexually transmitted infections (sexually transmitted diseases, or STDs), except abstinence.

It is estimated that there are 3.6 million unplanned pregnancies every year in the United States. Half of these unplanned pregnancies happen because a couple does not use any birth control at all, and the other half occur because the couple uses birth control, but not correctly.

In simple terms, all methods of birth control are based on either preventing a man's sperm from reaching and entering a woman's egg (fertilization) or preventing the fertilized egg from implanting in the woman's uterus (her womb) and starting to grow.

Birth control methods can be reversible or permanent. Reversible birth control means that the method can be stopped at essentially any time without long-term effects on fertility (the ability to become pregnant). Permanent birth control usually means that the method cannot be undone or reversed, most likely because it involved surgery. Examples of permanent methods include vasectomy for the man or tubal ligation for the woman.

Birth control methods can also be classified according to whether they are a barrier method (for example, a condom) that blocks sperm, a mechanical method (for example, an intrauterine device), or a hormonal method (for example, the "pill").

"Natural" methods do not rely on devices or hormones but on observing some aspect of a woman's body physiology in order to prevent fertilization.

The direct responsibility for most of the methods of birth control that are currently available rests with the woman. The input of a health care provider may sometimes be essential in choosing appropriate birth control. New methods of birth control are being developed and tested all the time. And what is appropriate for a couple at one point may change with time and circumstances.

Unfortunately, no birth control method, except abstinence, is considered to be 100% effective.