Manjula Lusti-Narasimhan

The serious threat of multidrug-resistant and untreatable gonorrhoea: the pressing need for global action to control the spread of antimicrobial resistance, and mitigate the impact on sexual and reproductive health

STIs remain a major cause of morbidity and mortality worldwide. The WHO estimated that >498 million new cases of syphilis, gonorrhoea, chlamydial infection and trichomoniasis occurred globally in 2008 in adults (15–49 years of age). More than 106 million were gonococcal infections.1 Accordingly, gonorrhoea remains a major global public health problem with serious health, social and economic consequences. Inadequate control and treatment can result in severe complications, such as pelvic inflammatory disease, leading to infertility or ectopic pregnancy, and neonatal eye infections which can cause blindness. Up to 10% of women who remain untreated (or inadequately treated) for chlamydial and gonococcal infections may become infertile. Urogenital gonorrhoea is also asymptomatic in at least 50% of women, which leaves the infections undetected and untreated with the risk of severe complications. On a global scale, up to 4000 newborn babies, annually, may become blind because of gonococcal and chlamydial ophthalmia neonatorum.2 In men, gonococcal infections cause symptomatic urethritis which, if untreated, can result in epididymitis in 10%–30% of cases,w1 that may lead to infertility. Gonorrhoea also significantly enhances the transmission of HIV. The burden of gonococcal infections is highest in countries that are least able to manage them because of several factors, including stigma, inadequate resources and lack of appropriate diagnostics, surveillance and antimicrobial treatment. The problem is further compounded by the ability of Neisseria gonorrhoeae to develop antimicrobial resistance (AMR) within a relatively short time span.3 w2 w3 Historically, since the advent of the antibiotic era, …

The role of men as partners and fathers in the prevention of mother-to-child transmission of HIV and in the promotion of sexual and reproductive health.

Abstract Despite ample evidence documenting the positive impact of men on the prevention of mother-to-child transmission (PMTCT) and other sexual and reproductive health programs, men’s engagement remains very low. This paper examines the current level and nature of male involvement and identifies opportunities for the advancement of men’s constructive engagement in PMTCT and sexual and reproductive health. Conceptual and policy barriers have encouraged the inadvertent exclusion of men from PMTCT and other reproductive health services. The historic institutionalization of reproductive health as women’s health has generally resulted in health services that are not welcoming of men and has undermined efforts to engage couples. This paper argues that to maximize the health outcomes of PMTCT and sexual and reproductive health programs for women and men, we must move beyond seeing men as simply “facilitating factors” that enable women to access health-care services. Men need to instead be recognized as a constituent part of reproductive health policy and practice. The paper proposes strategies for policy makers and program leaders to engage men and couples to foster communication and shared decision-making. This approach can both help to achieve health goals and engender more equitable relationships between men and women. Résumé En dépit de nombreuses données documentant l’impact positif qu’ont les hommes sur la prévention de la transmission mère-enfant (PTME) et d’autres programmes de santé sexuelle et génésique, leur engagement demeure très faible. Cet article examine le niveau actuel et la nature de la participation masculine, et identifie les possibilités de faire avancer l’engagement constructif des hommes dans la PTME et la santé génésique. Des obstacles conceptuels et politiques ont encouragé l’exclusion involontaire des hommes de la PTME et d’autres services de santé génésique. L’institutionnalisation historique de la santé génésique comme santé de la femme a généralement abouti à des services de santé peu accueillants pour les hommes et a miné les efforts pour y associer les couples. L’article avance que pour maximiser les résultats sanitaires de la PTME et des programmes de santé sexuelle et génésique pour les femmes et les hommes, nous ne devons plus voir les hommes comme de simples « facilitateurs » qui permettent aux femmes d’avoir accès aux services de santé. Les hommes doivent plutôt être reconnus comme partie prenante de la politique et la pratique de santé génésique. L’article propose des stratégies pour les décideurs et les directeurs de programmes afin d’inciter les hommes et les couples à favoriser la communication et la prise de décision partagée. Cette approche peut aider à atteindre les objectifs de santé et engendrer des relations plus équitables entre hommes et femmes. Resumen A pesar de existir abundancia evidencia que documenta el impacto positivo de los hombres en la prevención de la transmisión materno-infantil (PTMI) y en otros programas de salud sexual y reproductiva, la participación de los hombres continúa siendo muy baja. En este artículo se examina el nivel actual y la naturaleza de la participación de los hombres y se identifican oportunidades para promover su participación constructiva en los programas de PTMI y de salud sexual y reproductiva. Las barreras conceptuales y políticas han fomentado la exclusión involuntaria de los hombres de los servicios de PTMI y otros servicios de salud reproductiva. La histórica institucionalización de la salud reproductiva como salud de la mujer generalmente ha producido servicios de salud que no acogen a los hombres y ha socavado los esfuerzos por motivar la participación de parejas. Se argumenta que para maximizar los resultados de salud de los programas de PTMI y de salud sexual y reproductiva para mujeres y hombres, debemos ir más allá de ver a los hombres simplemente como “factores facilitadores” que les permiten a las mujeres obtener servicios de salud. Al contrario, debemos reconocer a los hombres como una parte constituyente de las políticas y prácticas de salud reproductiva. En este artículo se proponen estrategias para que formuladores de políticas y líderes de programas puedan motivar la participación de hombres y parejas para fomentar comunicación y compartir la responsabilidad de tomar decisiones. Este enfoque puede ayudar a lograr los objetivos de salud y a engendrar relaciones más equitativas entre hombres y mujeres.

Sexual health in older women

However, the sexual health of the older members of these aging populations is often overlooked in aca-demic and media discourse.The subject of sexuality in older people remains largely taboo in many cultures, yet older women the world over are known to have sexual desire and to engage in sexual activity ( Fig. 1).

Ensuring the Sexual and Reproductive Health of People Living with HIV: Policies, Programmes and Health Services

IN 2006 there were some 39.7 million people living with HIV half of them under the age of 25.* People living with HIV have sexual and reproductive health needs and concerns some of which are related to having HIV and others which they have in common with their noninfected peers. Yet sexual and reproductive health policies programmes and services often fail to take into consideration the needs and wishes of people living with HIV. Most programmes currently revolve around voluntary testing and counselling for HIV access to antiretroviral and other AIDS-related treatment and hospital and home-based care for those with HIV- and AIDS-related illnesses. In relation to sexual and reproductive health care HIV prevention predominates. There are condom social marketing and other safer sex promotion programmes and recent initiatives to promote family planning for people with HIV. Prevention of mother-to-child transmission of HIV in antenatal and delivery care has also begun to get greater programmaticattention and support. (excerpt)

Sexual and reproductive health in HIV-related proposals supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria

OBJECTIVE To assess the sexual and reproductive health interventions included by countries in HIV-related proposals approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). METHODS We examined the Global Fund database for elements and indicators of sexual and reproductive health in all approved HIV-related proposals (214) submitted by 134 countries, from rounds 1 to 7, and in an illustrative sample of 35 grant agreements. FINDINGS At least 70% of the HIV-related proposals included one or more of the four broad elements: sexual and reproductive health information, education and communication; condom promotion/distribution; diagnosis and treatment of sexually transmitted infections; and prevention of mother-to-child transmission of HIV. Between 20% and 30% included sexual health counselling, gender-based violence, and the linking of voluntary counselling and testing for HIV with sexual and reproductive health services. Less than 20% focused on adolescent sexual and reproductive health, the rights and needs of people living with HIV, or safe abortion services. All these elements were rarely featured, if at all, in the grant agreements reviewed. Overall, however, sexual and reproductive health indicators did appear in most HIV-related proposals and in more than 80% of the grant agreements. CONCLUSION Country coordinating mechanisms and national-level stakeholders see in funding for sexual and reproductive health a means to address the problem of HIV infection in their respective national settings. However, we highlight some missed opportunities for linking HIV and sexual and reproductive health services.

Ensuring successful development and introduction of multipurpose prevention technologies through an innovative partnership approach

Unintended pregnancies and the spread of sexually transmitted infections (STIs), including HIV, remain critical public health issues. Despite the apparent public health potential of comprehensive prevention methods, research and development for contraception and prevention of HIV and other STIs have historically remained separate because of different funding streams, policies and regulatory mechanisms. The result has led to missed opportunities to effectively and adequately address these interconnected sexual and reproductive health (SRH) risks. One global collaborative partnership to advance the comprehensive SRH prevention field is the Initiative for Multipurpose Prevention Technologies (IMPT). Begun in 2009, the aim of this cross-sector initiative is to advance the development and eventual introduction of combination products for women that provide simultaneous protection from multiple SRH risks. To date, the IMPT has engaged product developers, scientific researchers, healthcare providers, funders and community-based advocates in China, India, the USA and across Africa and western Europe behind this common agenda. The IMPT defines multipurpose prevention technologies (MPTs) as products that combine protection against unintended pregnancy and STIs, including HIV. The vision for MPTs is a suite of accessible products that are womaninitiated, efficient and easy to use. MPTs currently in development include intravaginal rings that combine a contraceptive hormone with anti-viral drugs for HIV and herpes simplex virus type 2 prevention; on-demand products such as a diaphragm loaded with an anti-HIV drug; and co-administered or co-formulated multipurpose injectables. These products could represent a powerful means of achieving high public health impact in at-risk populations around the world. The IMPT is in its fifth year and is navigating the boundaries of collaborative decision-making around a complex product development agenda. This editorial describes the structured and innovative approach developed by the Initiative to facilitate MPT development, funding and introduction.

Making the case for multipurpose prevention technologies: the socio‐epidemiological rationale

This paper summarises the public health rationale for multipurpose prevention technologies (MPTs) by examining recent epidemiological data and trends in sexual and reproductive health indicators. MPTs are products that combine protection against unintended pregnancy, HIV and other sexually transmitted infections. The successful introduction of new woman‐controlled MPTs provides a compelling response to the multiple sexual and reproductive health risks that women face worldwide.

Linking HIV and sexual and reproductive health services to enhance program outcomes.

Sexual and reproductive health services provide an opportunity to achieve universal access to HIV prevention and care and should be part of a national strategic response. There is recognition that HIV is a sexually transmitted infection or associated with pregnancy, childbirth, and breastfeeding. Both address the same target population and the vulnerability to risk and underlying causes are essentially the same. Providing comprehensive services that prevent HIV transmission, including to infants, those that meet the fertility intentions of people living with HIV, and management and prevention of sexually transmitted infections are some of the key elements of these linkages. Approaches that have shown success in HIV prevention and care include those in which a combination of strategies has been deployed, both in prevention and treatment regimens, and the combination of services delivery should yield equally positive results. Some strategies and recommendations detailed at the International Federation of Gynecology and Obstetrics (FIGO) World Congress in 2009 are discussed that could increase the effective response to the global response to HIV.

Lessons learnt from sexual and reproductive health and HIV linkages for multipurpose prevention technology service delivery

Provision of comprehensive sexual and reproductive health (SRH) services that meet the complex and diverse needs of women, in particular, within resource‐constrained settings, is often exacerbated by separate and uncoordinated reproductive health (RH) and HIV policies and programmes. A Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages was developed to assess bi‐directional linkages between SRH and HIV at policy, systems and service delivery levels, as well as to identify gaps and contribute to the development of country‐specific action plans. Findings from the implementation of this Assessment Tool are of particular relevance to the successful delivery and uptake of multipurpose prevention technologies (MPTs), which are products in the development pipeline addressing multiple SRH needs of women, including HIV. The findings highlight the need for better coordination between SRH and HIV programmes in countries; support and training for healthcare providers on SRH, HIV and human rights; supporting SRH and HIV integration at the service delivery level through relevant policies, strategic and operational plans; and strengthening logistics and supplies systems to provide a combination approach to prevention. These lessons learnt could help programme managers and service providers to better understand the strategies for positioning multipurpose prevention products in national policy and service contexts.

Gonococcal antimicrobial resistance: challenges for public health control

Prevention strategies will be the first-line approach to control the spread of antimicrobial resistance in Neisseria gonorrhoeae , but the next option will be the provision of an efficacious antimicrobial agent. In view of the threat of N gonorrhoeae becoming increasingly less susceptible to the cephalosporins and occasional cases of treatment failure being reported worldwide, treatment of gonorrhoea has become a public health issue requiring a global response. The mix of articles in this supplement is an attempt to assess the current position and activities taking place globally to respond to the threat of untreatable gonorrhoea and highlight the gaps and shortfalls that need to be tackled. Some of the key findings as each region takes stock are as follows: 1. There is a lack of systematic surveillance in some countries of the world. For example, the article summarising the situation in Africa points to the lack of good surveillance systems for sexually transmitted infections (STIs) in general and virtually no systematic or regular surveillance for antimicrobial susceptibility of gonorrhoea. The question posed in one of the papers is what would be the best way to establish antimicrobial susceptibility surveys at the national level. 2. There is a lack of adequate laboratory facilities, clinical skills and human resource to monitor antimicrobial resistance patterns. Most of the countries in Africa and a significant number in south-east Asia adopted the syndromic approach to the diagnosis and management of STIs. This has resulted in a loss of a number of laboratory skills including collecting and processing genital swabs, culturing N gonorrhoeae and performing antimicrobial susceptibility testing, and re-training is required. 3. In better-resourced countries, the availability of advanced diagnostic tools, such as nucleic acid amplification tests has replaced culture-based methods for the diagnosis of gonorrhea, and again the basic laboratory skills have been reduced …