Heather Bradley

Use of metformin in polycystic ovary syndrome: A meta-analysis

OBJECTIVE: To update the state of evidence on the efficacy of metformin, used either alone or in combination with clomiphene citrate in women with polycystic ovary syndrome, by examining three outcomes: ovulation, pregnancy, and live birth. Sources of heterogeneity among the published randomized controlled trials are systematically assessed. DATA SOURCES: An electronic literature search was performed using MEDLINE, EMBASE, SCOPUS, CENTRAL, Cochrane, and U.S. Food and Drug Administration databases, restricted to studies conducted on humans and published in English. METHODS OF STUDY SELECTION: Of the 406 potentially relevant articles identified, 17 met criteria for inclusion in the meta-analysis, rendering a total sample of 1,639 women. Study quality was examined in terms of randomization scheme, masking process, adequacy of allocation concealment, statistical power, and loss to follow-up; publication bias was also assessed. Meta-analytic procedures were used to compare metformin with placebo, and metformin plus clomiphene with clomiphene alone, for all study outcomes. Exploratory analyses were conducted to assess differences in treatment effects between clomiphene-resistant and nonresistant patients, obese and nonobese patients, and trials with long and short durations of follow-up. TABULATION, INTEGRATION, AND RESULTS: Metformin improved the odds of ovulation in women with polycystic ovary syndrome when compared with placebo (odds ratio [OR] 2.94; 95% confidence interval [CI] 1.43–6.02; number-needed-to-treat 4.0) and appears more effective for non–clomiphene-resistant women. Metformin and clomiphene increased the likelihood of ovulation (OR 4.39; 95% CI 1.94–9.96; number-needed-to-treat 3.7) and pregnancy (OR 2.67; 95% CI 1.45–4.94; number-needed-to-treat 4.6) when compared with clomiphene alone, especially in clomiphene-resistant and obese women with polycystic ovary syndrome. These treatment effects were greater for trials with shorter follow-up. CONCLUSION: Using all available evidence, this meta-analysis suggests that metformin increases the likelihood of ovulation and, in combination with clomiphene, increases the odds of both ovulation and pregnancy in women with polycystic ovary syndrome.

Educational attainment and HIV status among Ethiopian voluntary counseling and testing clients.

We examined the association between HIV infection and educational attainment level among a population of 34,512 voluntary counseling and testing (VCT) clients in Ethiopia, using client data from the Family Guidance Association of Ethiopia (FGAE). Overall, more than 50 percent of the VCT clients report at least secondary level educational attainment, and HIV prevalence is 8.5 percent for men and 14.3 percent for women. HIV prevalence decreases significantly with each increase in education level for both men and women, and this association persists at secondary and higher education levels in the multivariate model. Male and female VCT clients with more than secondary level education are 58 percent and 66 percent (respectively) less likely to be HIV-positive than those with no education. HIV prevention and treatment interventions in Ethiopia should target less educated segments of the population including women, who have higher HIV prevalence and lower educational attainment than men.

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia.

Abstract Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2–13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9–7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.

Client Characteristics and HIV Risk Associated with Repeat HIV Testing Among Women in Ethiopia

In Ethiopia, the number of HIV tests administered doubled from 2007 to 2008. However, very little is known about the number of clients testing repeatedly in one year, or their motivations for doing so. We examine repeat HIV testing among 2,027 Ethiopian women attending eight VCT facilities in 2008. Multivariate logistic regression was used to examine associations between repeat HIV testing and demographic, behavioral, and psychosocial characteristics, as well as HIV status. Nearly 40% of clients had tested previously for HIV. Women with high sexual risk are nearly four times more likely than those with no sexual risk to have tested previously, but HIV prevalence was lower among repeat testers (6.5%) than first-time testers (8.5%). Moderate perceived vulnerability, or feeling powerless to prevent HIV infection, is associated with a 50% increased likelihood of being a repeat tester. High perceived behavioral risk is associated with a 40% reduction in the likelihood a woman is testing for at least the second time. Costs associated with repeat testing should be balanced against identification of new HIV cases and prevention benefits.

Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: client, counselor and facility-level considerations

Background:Governments and donors encourage the integration of family planning into voluntary HIV counseling and testing (VCT) services. We aimed to determine whether VCT counselors could feasibly offer family planning and whether clients would accept such services. Design and methods:We employed a quasi-experimental, pre and postintervention survey design, interviewing 4019 VCT clients attending eight Ethiopian public sector facilities and 4027 additional clients 18 months after introducing family planning services in the same facilities. We constructed sex-stratified multilevel models assessing three outcomes: whether clients received contraceptive counseling, whether clients obtained contraceptive methods during VCT and whether clients intended to use condoms consistently after VCT. Results:Clients demonstrated lower than expected immediate need for contraception. After intervention, only 29% of women had sex in the past 30 days, and 74% of these women were already using contraceptives. Despite the relatively low risk this population had for unwanted pregnancy, family planning counseling in VCT increased from 2 to 41% for women and from 3 to 29% for men (P < 0.01). Approximately, 6% of clients received contraceptive methods. However, sexually active men and women and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher client loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower client loads. Male and female clients whose counselors perceived contraceptive availability to be adequate were four and two times more likely, respectively, to receive contraceptive methods than those counseled by providers who felt supplies were inadequate (P < 0.01). Conclusion:Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted.

Developing scales to measure perceived HIV risk and vulnerability among Ethiopian women testing for HIV

Abstract HIV prevention services are increasingly being used by individuals in developing countries, but we know very little about how self-assessed HIV risk determines health-seeking behavior. People may feel they are at risk of HIV infection for many reasons, including both risky behavior and anxiety associated with heightened HIV awareness. In order to improve the measurement of perceived HIV risk, we developed scales measuring two constructs. Perceived risk is ones self-assessed likelihood of becoming HIV-infected based on HIV knowledge and behavior. Perceived vulnerability is felt susceptibility to HIV infection even in the absence of risk behavior. Items measuring these constructs were included in a voluntary HIV counseling and testing (VCT) client survey, conducted in mid-2008 with 2027 women attending eight Ethiopian VCT facilities. We also conducted in-depth interviews with 22 women in two of the facilities and added items to the scales based on findings from these interviews. All items were validated in a post-enumeration survey. Factor structures of both constructs were examined using exploratory factor analysis. We also calculated Pearsons correlations between the scales and comparable constructs and behaviors. Cronbachs alpha for the perceived risk scale was 0.87 in the initial survey and 0.89 in the validation survey. For the perceived vulnerability scale, Cronbachs alpha was only 0.66 in the initial survey but increased to 0.74 after adding items indicated by the in-depth interviews. The scales are moderately correlated, indicated by a Pearsons correlation of 0.65. Both scales have high construct validity. Perceived risk has a higher correlation with HIV status than does perceived vulnerability, at 39% vs 28%. Conversely, perceived vulnerability is more highly correlated with HIV salience than is perceived risk, at 39% compared to 25%. These findings suggest perceived HIV risk and perceived HIV vulnerability should be measured separately. More information is needed about how these constructs may motivate people to seek HIV prevention services.