Manjulaa Narasimhan

Multipurpose prevention technologies: the future of HIV and STI protection

Every day, more than 1 million people are newly infected with sexually transmitted infections (STIs) that can lead to morbidity, mortality, and an increased risk of human immunodeficiency virus (HIV) acquisition. Existing prevention and management strategies, including behavior change, condom promotion, and therapy have not reduced the global incidence and prevalence, pointing to the need for novel innovative strategies. This review summarizes important issues raised during a satellite session at the first HIV Research for Prevention (R4P) conference, held in Cape Town, on October 31, 2014. We explore key STIs that are challenging public health today, new biomedical prevention approaches including multipurpose prevention technologies (MPTs), and the scientific and regulatory hurdles that must be overcome to make combination prevention tools a reality.

Safer disclosure of HIV serostatus for women living with HIV who experience or fear violence: a systematic review

Globally 56% of all married women are using a modern method of contraception up from less than 10% in 1960. In sub-Saharan Africa however only 19% of married women are using a modern method of contraception. Since nearly all family planning services require assistance from a health worker access to health workers is a principal supply-side determinant of family planning service use. This technical brief presents findings from a study that explored if and how health workforce measures differ between eastern and western Africa in an effort to identify factors that may have helped some countries to achieve important gains in contraceptive prevalence while other countries have not. The findings raise questions about whether government commitment and certain policy choices vis-a-vis health workforce distribution and qualifications—even when absolute levels of health worker density are low—could make a difference in the provision of family planning services in resource-constrained countries.Supporting individuals as they disclose their HIV serostatus may lead to a variety of individual and public health benefits. However, many women living with HIV are hesitant to disclose their HIV status due to fear of negative outcomes such as violence, abandonment, relationship dissolution and stigma.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

A temperature-monitoring vaginal ring for measuring adherence.

Background Product adherence is a pivotal issue in the development of effective vaginal microbicides to reduce sexual transmission of HIV. To date, the six Phase III studies of vaginal gel products have relied primarily on self-reporting of adherence. Accurate and reliable methods for monitoring user adherence to microbicide-releasing vaginal rings have yet to be established. Methods A silicone elastomer vaginal ring prototype containing an embedded, miniature temperature logger has been developed and tested in vitro and in cynomolgus macaques for its potential to continuously monitor environmental temperature and accurately determine episodes of ring insertion and removal. Results In vitro studies demonstrated that DST nano-T temperature loggers encapsulated in medical grade silicone elastomer were able to accurately and continuously measure environmental temperature. The devices responded quickly to temperature changes despite being embedded in different thickness of silicone elastomer. Prototype vaginal rings measured higher temperatures compared with a subcutaneously implanted device, showed high sensitivity to diurnal fluctuations in vaginal temperature, and accurately detected periods of ring removal when tested in macaques. Conclusions Vaginal rings containing embedded temperature loggers may be useful in the assessment of product adherence in late-stage clinical trials.

Human rights and the sexual and reproductive health of women living with HIV – a literature review

A female sterilization method using intraluminal thread and a silver clip for occlusion of fallopian tubes were tried on 1381 women aged 20 to 43. The operation procedure involves 1st pulling a piece of nylon thread into lumen of fallopian tube on each side using needle 7; 2nd clamping the tubes with silver clip s at the location where nylon threads went through. The purposes of putting thread into lumen before clamping tubes are multiple. The thread could be pulled when clips are mounted on the tubes to adjust the appropriate tightness and the thread in the lumen could ensure that clips may not be too tight to cut off the tubes. Also the recanalization is much easier with this method by removing the clips and thread. 32.6% of women en rolled were under 30 years of age and 79.5% had had 2 deliveries. During the clinical trial all the cases were followed-up for at least 3 months except 6. The total follow-up time was 21273 months including 1344 censored and 15 cases of failure. The effectiveness was 97.7% calculated by life table method. No failure occurred to 272 breast-feeding women during 2058 months of follow-up. The difference in failure between women who received the procedure during their menstrual period and those who had their procedure after baby delivery or abortion were statistically significant with the former group lower than the latter. 10.9% of cases complained about backache and 5.3% about increase or decrease in menstrual bleeding following the procedure. Reversible sterilization has been a concern in the development of birth control methods. This technique is worth of pursuing in the future research.Even as the number of women living with HIV around the globe continues to grow, realization of their sexual and reproductive health and human rights remains compromised. The objective of this study was to review the current state of knowledge on the sexual and reproductive health and human rights of women living with HIV to assess evidence and gaps.

Elective cesarean section for women living with Hiv: a systematic review of risks and benefits

Objective and design: To inform WHO guidelines, we conducted a systematic review and meta-analysis to assess maternal and perinatal outcomes comparing cesarean section (c-section) before labor and rupture of membranes [elective c-section (ECS)] with other modes of delivery for women living with HIV. Methods: We searched PubMed, CINAHL, Embase, CENTRAL, and previous reviews to identify published trials and observational studies through October 2015. Results were synthesized using random-effects meta-analysis, stratifying for combination antiretroviral therapy (cART), CD4+/viral load (VL), delivery at term, and low-income/middle-income countries. Results: From 2567 citations identified, 36 articles met inclusion criteria. The single randomized trial, published in 1999, reported minimal maternal morbidity and significantly fewer infant HIV infections with ECS [odds ratio (OR) 0.2, 95% confidence interval (CI) 0.0–0.5]. Across observational studies, ECS was associated with increased maternal morbidity compared with vaginal delivery (OR 3.12, 95% CI 2.21–4.41). ECS was also associated with decreased infant HIV infection overall (OR 0.43, 95% CI 0.30–0.63) and in low-income/middle-income countries (OR 0.27, 95% CI 0.16–0.45), but not among women on cART (OR 0.82, 95% CI 0.47–1.43) or with CD4+ cell count more than 200/VL less than 400/term delivery (OR 0.59, 95% CI 0.21–1.63). Infant morbidity moderately increased with ECS. Conclusion: Although ECS may reduce infant HIV infection, this effect was not statistically significant in the context of cART and viral suppression. As ECS poses other risks, routine ECS for all women living with HIV may not be appropriate. Risks and benefits will differ across settings, depending on underlying risks of ECS complications and vertical transmission during delivery. Understanding individual client risks and benefits and respecting womens autonomy remain important.

Food insecurity, sexual risk behavior, and adherence to antiretroviral therapy among women living with HIV: A systematic review

ABSTRACT Gender inequalities shape the experience of food insecurity among women living with HIV (WLHIV). We systematically reviewed the impact of food insecurity on sexual risk behaviors and antiretroviral therapy (ART) adherence among WLHIV. We included qualitative or quantitative peer-reviewed articles, extracted data in duplicate, and assessed rigor. Seven studies, from sub-Saharan Africa, North America, and Europe, met inclusion criteria. Food insecurity was associated with increased sexual risk through transactional sex and inability to negotiate safer sex. Hunger and food insecurity were barriers to ART initiation/adherence. Multidimensional programming and policies should simultaneously address poverty, gender inequality, food insecurity, and HIV.

Advancing the sexual and reproductive health and human rights of women living with HIV.

Many women living with HIV can have safe, healthy and satisfying sexual and reproductive health, but there is still a long way to go for this to be a reality, especially for the most vulnerable amongst them who face repeated violations of their rights.

Health systems and the SDGs: lessons from a joint HIV and sexual and reproductive health and rights response.

joint HIV and sexual and reproductive health and rights response Charlotte E Warren*, Jonathan Hopkins, Manjulaa Narasimhan, Lynn Collins, Ian Askew, and Susannah H Mayhew Population Council, Suite 280, 4301 Connecticut Avenue NW, Washington, DC 20008, USA, International Planned Parenthood Foundation, 4 Newhams Row, London SE1 3UZ, UK, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, UNFPA, 605 Third Avenue, New York, NY 10158, USA and Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

Sexual and reproductive health and human rights of women living with HIV: a global community survey.

Abstract Objective To determine the sexual and reproductive health priorities of women living with human immunodeficiency virus (HIV) and to allow the values and preferences of such women to be considered in the development of new guidelines. Methods A core team created a global reference group of 14 women living with HIV and together they developed a global community online survey. The survey, which contained mandatory and optional questions, was based on an appreciative enquiry approach in which the life-cycle experiences of women living with HIV were investigated. The same set of questions was also used in focus group discussions led by the global reference group. Findings The study covered 945 women (832 in the survey and 113 in the focus groups) aged 15–72 years in 94 countries. Among the respondents to the optional survey questions, 89.0% (427/480) feared or had experienced gender-based violence, 56.7% (177/312) had had an unplanned pregnancy, 72.3% (227/314) had received advice on safe conception and 58.8% (489/832) had suffered poor mental health after they had discovered their HIV-positive status. Conclusion The sexual and reproductive health needs and rights of women living with HIV are complex and require a stronger response from the health sector. The online survey placed the voices of women living with HIV at the start of the development of new global guidelines. Although not possible in some contexts and populations, a similar approach would merit replication in the development of guidelines for many other health considerations.