Mi-Suk Kang

Findings from SHAZ!: A Feasibility Study of a Microcredit and Life-Skills HIV Prevention Intervention to Reduce Risk Among Adolescent Female Orphans in Zimbabwe

This study tested the feasibility of a combined microcredit and life-skills HIV prevention intervention among 50 adolescent female orphans in urban/peri-urban Zimbabwe. Quantitative and qualitative data were collected on intervention delivery, HIV knowledge and behavior, and economic indicators. The study also tested for HIV, HSV-2, and pregnancy. At 6 months, results indicated improvements in knowledge and relationship power. Because of the economic context and lack of adequate support, however, loan repayment and business success was poor. The results suggest that microcredit is not the best livelihood option to reduce risk among adolescent girls in this context.

Manual Versus Electric Vacuum Aspiration for Early First-Trimester Abortion: A Controlled Study of Complication Rates

OBJECTIVE: Manual vacuum aspiration is an alternative to electric suction curettage for first-trimester elective abortion. Although many studies have demonstrated that manual vacuum aspiration is safer than sharp curettage for abortion, only a few studies have directly compared it with electric suction curettage. These studies proved the methods to be equally effective and acceptable but were too small to adequately compare safety. We compared immediate complication rates for abortions performed by manual and electric vacuum aspiration. METHODS: We conducted a retrospective cohort analysis of all women undergoing elective abortion at up to 10 weeks’ gestation at San Francisco General Hospital over a 3.5-year period. A total of 1726 procedures were included: 1002 manual and 724 electric vacuum aspirations. Clinical data were collected from medical records. Rates of uterine reaspiration and other immediate complications occurring at our institution were compared. RESULTS: We found no difference in the rate of uterine reaspiration after abortions performed with the manual or electric suction device (2.2% versus 1.7%, respectively, P = .43). We had 80% statistical power to detect a 2% difference in uterine reaspiration rates with an μa error of .05. Overall major complication rates were 2.5% with manual and 2.1% with electric suction curettage, P = .56. Multivariable regression analyses controlling for potential confounders showed no difference in uterine reaspiration rates (electric odds ratio [OR] = 0.71, 95% confidence interval [CI] 0.32, 1.6) or overall complications (electric OR = 0.81, 95% CI 0.40, 1.7). CONCLUSION: Manual vacuum aspiration is as safe as electric suction curettage for abortions at up to 10 weeks’ gestation. Expanded use in an office setting might increase abortion access. LEVEL OF EVIDENCE: II-2

Maternal versus paternal orphans and HIV/STI risk among adolescent girls in Zimbabwe

Abstract The AIDS epidemic has contributed to a drastic increase in the number of orphans in Zimbabwe. Orphans (whether orphaned by AIDS or other causes) have been shown to have economic and educational disadvantages as well as poor reproductive health outcomes. We recruited a convenience sample of 200 girls in a peri-urban area of Zimbabwe to examine the impact of orphan status (compared to non-orphans) on household composition, education, risk behaviour, pregnancy and prevalent HIV and HSV-2 infection. In our population, maternal orphans were more likely to be in households headed by themselves or a sibling, to be sexually active, to have had an STI, to have been pregnant and to be infected with HIV. Paternal orphans were more likely to have ever been homeless and to be out of school. Our findings suggest that maternal care and support is important for HIV prevention. This finding corroborates previous research in Zimbabwe and has implications for intervention strategies among orphan girls.

Predictors of diaphragm use as a potential sexually transmitted disease/HIV prevention method in Zimbabwe:

Background: Women who are the most vulnerable to sexually transmitted diseases/HIV are often unable to consistently use condoms. One potential alternative method currently under investigation is the diaphragm. Goals: The goals of this study were to assess diaphragm uptake and use over time in Zimbabwe and to identify factors associated with self-reported consistent diaphragm use. Study: Women attending family planning clinics who were inconsistent condom users received a diaphragm intervention and were followed for 6 months. Results: Of the 186 participants, 99% ever reported using the diaphragm, and, at study exit, 96% had used it in the previous 2 months. Consistent diaphragm use since the previous visit was reported by 13% to 16% of the women, and in multivariate regression analysis, it was significantly associated with never using condoms (adjusted odds ratio, 24.08; 95% confidence interval, 6.71–86.34). Other factors included discreet use, preferring diaphragms to condoms, timing of insertion, domestic violence, and contraception. Conclusion: Diaphragms were well accepted among women at risk for sexually transmitted diseases/HIV.

Improving the accuracy of fetal foot length to confirm gestational duration

OBJECTIVE: To establish normative fetal foot length ranges using last menstrual period (LMP) and ultrasound dating by biparietal diameter and to examine variations in these ranges by ethnicity. METHODS: A consecutive series of 1,099 eligible subjects receiving abortions had fetal foot lengths measured directly. Models of fetal foot length were developed by using assessment of gestational duration by LMP alone, ultrasonography alone, and “best estimate” (LMP confirmed by ultrasonography). RESULTS: The full sample model using ultrasound dating (n = 1,099) yielded the following equation: foot length = −30.3 + days of gestation × 0.458 (R2 of 0.92). Regression by LMP-determined gestational duration by using the “best estimate” sample (n = 491) provided an almost identical equation (foot length = −29.8 + days of gestation × 0.45) and a similar R2 value of 0.87, although the standard errors were larger. Gestational duration by ultrasonography alone produced a better model fit than duration by LMP alone. Regressions by ethnicity were not significantly different compared with the simple regression, regardless of method used to determine gestational duration. CONCLUSION: A reconsideration of fetal foot length measurements to confirm gestational duration is important. More accurate tables of these measurements allow for greater precision in correlating gestational duration and foot length. Fetal foot length tables using ultrasonographically confirmed gestational duration and current statistical standards should replace tables currently used. Biparietal diameter as a single measurement provides adequate estimation of gestational duration in the second trimester for pregnancy termination, proving more reliable than LMP dating. LEVEL OF EVIDENCE: II-2

FEMALE CONDOM UPTAKE AND ACCEPTABILITY IN ZIMBABWE

As the first phase of a two-phase prospective cohort study to assess the acceptability of the diaphragm as a potential HIV/STI prevention method, we conducted a 2-month prospective study and examined the effect of a male and female condom intervention on female condom (FC) use among 379 sexually active women in Harare, Zimbabwe. Reported use of FC increased from 1.1% at baseline to 70.6% at 2-month follow-up. Predictors of FC uptake immediately following the intervention included interest in using FC, liking FC better than male condoms, and believing one could use them more consistently than male condoms. Women reported 28.8% of sex acts protected by FC in the 2 weeks prior to last study visit. Though FC may not be the preferred method for the majority of women, with access, proper education, and promotion they may be a valuable option for some Zimbabwean women.

The Importance of Discreet Use of the Diaphragm to Zimbabwean Women and their Partners

We conducted a 6-month acceptability study of diaphragms as a potential HIV/STI prevention method among Zimbabwean women. We examined partner involvement in diaphragm use, and importance of discreet use (use without partner awareness). Of the 181 women who completed the study, 45% said discreet use was “very or extremely important” and in multivariate logistic regression, women were more likely to value discretion if their partners: had other partners; drank alcohol; or were believed to prefer condoms to diaphragms. Qualitative data confirmed these findings. Both women and their partners reported that diaphragms can be used discreetly and saw this as advantageous, for both sexual pleasure and female control. However, many were concerned that use without partner approval could lead to marital problems. Discreet use should be considered in development of barrier methods and in diaphragm promotion, if proven effective against HIV/STI.

Introducing Diaphragms into the Mix: What Happens to Male Condom Use Patterns?

The objective of this analysis was to assess the effect of introducing the diaphragm on condom use patterns. Participants included One hundred eighty nine women attending family planning clinics in Harare, Zimbabwe who reported less than 100% condom use. The proportion of acts where at least one method was used significantly increased over using follow-up; male condom use remained stable. A diaphragm was used with 50% to 54% of acts; male condoms were also used about 50% of the time. The proportion of acts where a female condom was used decreased. Women who used both male and female condoms were more likely to use diaphragms than those who reported not using female condoms. Introducing the diaphragm increased the overall proportion of protected acts. The proportion of acts where a male condom was used did not change. Female condoms use declined because concurrent use with the diaphragm is not possible.

HIV sentinel surveillance among women seeking elective pregnancy termination, San Francisco.

Objective: The objective of this study was to measure HIV prevalence, HIV incidence, and risk factors for infection among women seeking elective pregnancy termination in San Francisco. Study: The authors conducted a cross-sectional survey comprising a consecutive sample of women seeking elective pregnancy termination in San Francisco’s county hospital from August 2002 to July 2003. Demographic and risk behavior information was abstracted from routine clinic records. HIV testing was conducted on blood specimens collected for other purposes after removing identifying information. Results: Based on 11 HIV-positives among 1,992 tested, HIV prevalence among women seeking pregnancy termination was 0.55% (95% confidence interval [CI], 0.28–0.99). One recent HIV seroconversion was detected for an annual incidence of 0.11% per year (95% CI, 0.23–0.88). In addition, risk factors significantly associated with HIV infection included sex with a known HIV-positive man, history of an abnormal Pap smear, history of genital herpes infection, history of trichomoniasis, and age 25 to 29 years. Conclusions: Women electing pregnancy termination can serve as a sentinel population to track trends in the HIV epidemic. However, barriers remain to wider implementation of the approach as a surveillance tool.