C. B. Sekadde-Kigondu

Is the intrauterine device appropriate contraception for HIV-1-infected women?

Objective To assess whether the risk of complications is higher in HIV‐1‐infected women compared with non‐infected women in the two years following insertion of the intrauterine contraceptive device.

Effect of intrauterine device use on cervical shedding of Hiv-1 Dna

OBJECTIVE Hormonal contraception has been associated with an increased prevalence of cervical shedding of HIV-1 DNA among infected women. We conducted this study to evaluate the effect of the use of an intrauterine device (IUD) on the detection of HIV-1 DNA in cervical secretions. DESIGN A prospective study of HIV-1-seropositive women undergoing IUD insertion at two public family planning clinics in Nairobi, Kenya. METHODS Cervical swab samples were collected before IUD insertion and approximately 4 months thereafter for the detection of HIV-1-infected cells using polymerase chain reaction (PCR) amplification of HIV-1 gag DNA sequences. RESULTS Ninety-eight women were enrolled and followed after IUD insertion. The prevalence of HIV-1 DNA cervical shedding was 50% at baseline and 43% at follow-up [odds ratio (OR) 0.8, 95% confidence interval (CI) 0.5-1.2]. There was no statistically significant difference between the baseline and follow-up shedding rates in a multivariate model that controlled for previous hormonal contraceptive use, condom use, cervical ectopy, friable cervix, cervical infections at an interim visit, and CD4 lymphocyte levels (OR 0.6, 95% CI 0.3-1.1). CONCLUSION The insertion of an IUD did not significantly alter the prevalence of cervical shedding of HIV-1-infected cells. The use of IUDs, in conjunction with condoms, may be an appropriate method of contraception for HIV-1-infected women from the standpoint of potential infectivity to the male partner through exposure to genital HIV-1.

Checklist for ruling out pregnancy among family-planning clients in primary care.

Where pregnancy tests are unavailable, health providers, fearing possible harm to fetuses, often deny contraception to nonmenstruating clients. In Kenya, a trial of a simple checklist to exclude pregnancy showed a good negative predictive value, which could improve access to service and reduce unwanted pregnancies and their sequelae.

Use of sexually transmitted disease risk assessment algorithms for selection of intrauterine device candidates.

Sexually transmitted diseases (STD) are an important contraindication for intrauterine device (IUD) insertion. Nevertheless, laboratory testing for STD is not possible in many settings. The objective of this study is to evaluate the use of risk assessment algorithms to predict STD and subsequent IUD-related complications among IUD candidates. Among 615 IUD users in Kenya, the following algorithms were evaluated: 1) an STD algorithm based on US Agency for International Development (USAID) Technical Working Group guidelines: 2) a Centers for Disease Control and Prevention (CDC) algorithm for management of chlamydia; and 3) a data-derived algorithm modeled from study data. Algorithms were evaluated for prediction of chlamydial and gonococcal infection at 1 month and complications (pelvic inflammatory disease [PID], IUD removals, and IUD expulsions) over 4 months. Women with STD were more likely to develop complications than women without STD (19% vs 6%; risk ratio = 2.9; 95% CI 1.3-6.5). For STD prediction, the USAID algorithm was 75% sensitive and 48% specific, with a positive likelihood ratio (LR+) of 1.4. The CDC algorithm was 44% sensitive and 72% specific, LR+ = 1.6. The data-derived algorithm was 91% sensitive and 56% specific, with LR+ = 2.0 and LR- = 0.2. Category-specific LR for this algorithm identified women with very low (< 1%) and very high (29%) infection probabilities. The data-derived algorithm was also the best predictor of IUD-related complications. These results suggest that use of STD algorithms may improve selection of IUD users. Women at high risk for STD could be counseled to avoid IUD, whereas women at moderate risk should be monitored closely and counseled to use condoms.

Monitoring technologist reading skills in a sperm morphology quality control program

OBJECTIVE The value of sperm morphology as a predictor of a mans fertilizing potential has often been challenged because of different classification systems used to distinguish between normal and abnormal spermatozoa. The study aimed to monitor the reading skills of 53 laboratory technologists who are enrolled in a continuous quality control program for sperm morphology assessment. DESIGN Prospective analytical study. SETTINGS Academic hospital and academic institution setting. PATIENT(S) Sperm samples from the sperm donor program and andrology technicians from sub-Saharan Africa. INTERVENTION(S) Papanicolaou-stained sperm slides were prepared and shipped on a quarterly basis to participating laboratories. Papanicolaou-prestained sperm morphology slides were used as test material for 21 months. MAIN OUTCOME MEASURE(S) Percentage normal spermatozoa.A new statistical model was developed to record reading skills of the participating technicians. Reading skills were classified as marginal (5.7% of cases), good (11.3% of cases), and excellent (83% of cases). RESULT(S) Participants maintained their morphological reading skills and agreed with the reference laboratory by not exceeding a SD limit of 0.2 to set stringent standards for the program. CONCLUSION(S) Technician proficiency can be monitored using the results of a quality control program. A continuous quality control program can be initiated only after intensive training, because baseline values at the onset of the quality control program serves as an internal reference value.

Pharmacodynamic effects of depot-medroxyprogesterone acetate (DMPA) administered to lactating women on their male infants

Normal postpartum women, who had a spontaneous vaginal delivery of one full-term male infant, free of congenital abnormalities and other diseases, were recruited for this study. Thirteen women received 150 mg depot-medroxy-progesterone acetate (DMPA), intramuscularly on days 42 + 1 and 126 + 1 postpartum. Infants of nine mothers, who did not receive DMPA, served as controls. Blood samples were collected from treated mothers on days 44, 47, 74, 124, 128, and 130 postpartum for medroxyprogesterone acetate (MPA) measurements. Four-hour urine collections were obtained from all 22 infants in the morning on days 38, 40, 42, 44, 46, 53, 60, 67, 74, 88, 102, 116, 122, 124, 126, 128, 130, and 137. Urinary follicle stimulating hormone (FSH), luteinizing hormone (LH), unconjugated testosterone, and unconjugated cortisol were measured by radioimmunoassay, and serum MPA and urinary MPA metabolites were measured by gas chromatography-mass spectrometry (GC-MS). No MPA metabolites could be detected in the urine of the infants from the DMPA-receiving mothers. Hormonal profiles in the urine samples were not suppressed in comparison with those of the control infants. The present study demonstrates that DMPA, administered to the mother, does not influence the hormonal regulation of the breast-fed normal male infant.