Susannah Mayhew

Population dynamics and climate change: what are the links?

Climate change has been described as the biggest global health threat of the 21(st) century. World population is projected to reach 9.1 billion by 2050, with most of this growth in developing countries. While the principal cause of climate change is high consumption in the developed countries, its impact will be greatest on people in the developing world. Climate change and population can be linked through adaptation (reducing vulnerability to the adverse effects of climate change) and, more controversially, through mitigation (reducing the greenhouse gases that cause climate change). The contribution of low-income, high-fertility countries to global carbon emissions has been negligible to date, but is increasing with the economic development that they need to reduce poverty. Rapid population growth endangers human development, provision of basic services and poverty eradication and weakens the capacity of poor communities to adapt to climate change. Significant mass migration is likely to occur in response to climate change and should be regarded as a legitimate response to the effects of climate change. Linking population dynamics with climate change is a sensitive issue, but family planning programmes that respect and protect human rights can bring a remarkable range of benefits. Population dynamics have not been integrated systematically into climate change science. The contribution of population growth, migration, urbanization, ageing and household composition to mitigation and adaptation programmes needs urgent investigation.

Protecting the unprotected: mixed-method research on drug use, sex work and rights in Pakistan's fight against HIV/AIDS.

Objectives: To investigate the nature and extent of human rights abuses against three vulnerable groups (injecting drug users (IDUs) and male and female sex workers), to understand the social and sexual linkages between them and to examine how protecting their rights could enhance the impact of HIV prevention policies. Methods: In-depth interviews were carried out with 38 high-risk respondents (IDUs and female, male and transgender sex workers) and a bio-behavioural survey was performed of 813 IDU/sex worker respondents in Rawalpindi. Results: People in all vulnerable groups interacted both sexually and socially. All groups experienced human rights abuses by state and non-state actors which increased their HIV risk. Non-state actors, including relations and sex worker clients, are responsible for verbal, physical and sexual violence. State actors (particularly police) perpetrate harassment, exploitation and abuse of all vulnerable groups with impunity. Health service providers fail to provide adequate services for vulnerable groups. Conclusions: High levels of discrimination and abuse of human dignity of all groups studied were revealed. This violates their physical and mental integrity and also leads to an increased risk of HIV. The sexual and social interactions between groups mean that human rights abuses experienced by one high-risk group can increase the risk of HIV both for them and other groups. The protection of human rights needs to become an integral part of a multisector response to the risk of HIV/AIDS by state and non-state agencies. The Government of Pakistan should work at both legal and programme levels to protect the rights of, and minimise discrimination against, groups vulnerable to HIV in order to reduce the potential for the spread of HIV before the epidemic takes hold.

Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.

BackgroundIn sub-Saharan Africa (SSA) there are strong arguments for the provision of integrated sexual and reproductive health (SRH) and HIV services. Most HIV transmissions are sexually transmitted or associated with pregnancy, childbirth, and breastfeeding. Many of the behaviours that prevent HIV transmission also prevent sexually transmitted infections and unintended pregnancies. There is potential for integration to increase the coverage of HIV services, as individuals who use SRH services can benefit from HIV services and vice-versa, as well as increase cost-savings. However, there is a dearth of empirical evidence on effective models for integrating HIV/SRH services. The need for robust evidence led a consortium of three organizations – International Planned Parenthood Federation, Population Council and the London School of Hygiene & Tropical Medicine – to design/implement the Integra Initiative. Integra seeks to generate rigorous evidence on the feasibility, effectiveness, cost and impact of different models for delivering integrated HIV/SRH services in high and medium HIV prevalence settings in SSA.Methods/designA quasi-experimental study will be conducted in government clinics in Kenya and Swaziland – assigned into intervention/comparison groups. Two models of service delivery are investigated: integrating HIV care/treatment into 1) family planning and 2) postnatal care. A full economic-costing will be used to assess the costs of different components of service provision, and the determinants of variations in unit costs across facilities/service models. Health facility assessments will be conducted at four time-periods to track changes in quality of care and utilization over time. A two-year cohort study of family planning/postnatal clients will assess the effect of integration on individual outcomes, including use of SRH services, HIV status (known/unknown) and pregnancy (planned/unintended). Household surveys within some of the study facilities’ catchment areas will be conducted to profile users/non-users of integrated services and demand/receipt of integrated services, before-and-after the intervention. Qualitative research will be conducted to complement the quantitative component at different time points. Integra takes an embedded ‘programme science’ approach to maximize the uptake of findings into policy/practice.DiscussionIntegra addresses existing evidence gaps in the integration evaluation literature, building on the limited evidence from SSA and the expertise of its research partners.Trial registrationCurrent Controlled Trials NCT01694862

Prevalence of HIV, HCV and sexually transmitted infections among injecting drug users in Rawalpindi and Abbottabad, Pakistan: evidence for an emerging injection-related HIV epidemic

Objectives: To measure the prevalence of hepatitis C virus (HCV), HIV and sexually transmitted infections (STI) among injecting drug users (IDUs) in Rawalpindi and Abbottabad and to examine risk factors associated with HIV and HCV. Methods: Two cross-sectional surveys were performed of community-recruited IDUs with collection of clinical specimens for testing of HCV, HIV and other STIs. Behavioural data were collected through interviewer-administered questionnaires. Characteristics and risk behaviours were compared across cities. Univariate and multivariate analyses explored risk factors associated with HIV and HCV. Results: The prevalence of HIV was 2.6% (95% CI 0.83% to 4.5%) in Rawalpindi (n = 302) and zero in Abbottabad (n = 102). The prevalence of HCV was significantly higher in Rawalpindi at 17.3% (95% CI 13.0% to 21.6%) than in Abbottabad at 8% (95% CI 2.6% to 13.4%). The prevalence of other STIs was low in both cities, with <2% of participants having current gonorrhoea or Chlamydia and <3% with active syphilis. Injecting risk behaviours were greater in Rawalpindi. An increased risk of HCV was associated with using informal sources as a main source of new needles/syringes (OR 2.8, 95% CI 1.3 to 6.0) compared with pharmacies and a history of drug treatment (OR 3.7, 95% CI 0.9 to 11.6). Reporting symptoms of an STI was associated with decreased odds of HIV in Rawalpindi (OR 0.02, 95% CI 0.03 to 0.9). Conclusions: The findings suggest recent transmission of HIV and HCV and point to the urgent need for the provision of clean needles/syringes to IDUs and a review of how needles/syringes are currently provided via healthcare establishments.

Governing the UN sustainable development goals: interactions, infrastructures, and institutions.

Three of the eight Millennium Development Goals (MDGs) concerned health. There is only one health goal in 17 proposed Sustainable Development Goals (SDGs). Critiques of the MDGs included missed opportunities to realise positive interactions between goals. Here we report on an interdisciplinary analytical review of the SDG process, in which experts in different SDG areas identified potential interactions through a series of interdisciplinary workshops. This process generated a framework that reveals potential conflicts and synergies between goals, and how their interactions might be governed.

Maternal mortality in low‐income countries: What interventions have been evaluated and how should the evidence base be developed further?

This article reviews the evidence for the effectiveness of non‐clinical interventions to reduce maternal mortality in low‐income settings and identifies the gaps in the evidence base.

Reproductive health and health sector reform in developing countries: establishing a framework for dialogue

It is not clear how policy-making in the field of reproductive health relates to changes associated with programmes for the reform of the health sector in developing countries. There has been little communication between these two areas, yet policy on reproductive health has to be implemented in the context of structural change. This paper examines factors that limit dialogue between the two areas and proposes the following framework for encouraging it: the identification of policy groups and the development of bases for collaborative links between them; the introduction of a common understanding around relevant policy contexts; reaching agreement on compatible aims relating to reproductive health and health sector change; developing causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy-making; and strengthening policy-making structures, systems, skills, and values.

Hegemony, Politics and Ideology: the Role of Legislation in NGO-Government Relations in Asia

In the wake of debate on the ‘New Policy Agenda’ of good governance and the increasing prominence of Non-Government Organisations (NGOs) in public service delivery, serious questions are being asked about the role of NGOs in development, their accountability, their relationships with donors, with the state and with their beneficiaries. As southern NGOs receive increasing amounts of funding from donors and northern NGOs, their profile is being raised, prompting government response. The nature of legislative responses of governments to increasingly high profile NGO communities range from open hostility and suspicion, to indifference. National legislative frameworks are neglected in the literature, yet they may profoundly influence the accountability, legitimacy, organisation and vision of local NGOs as well as the way northern NGOs can operate in a country. The article illustrates the potential for conflict over legislation on NGOs but also important opportunities and benefits, maintaining that legislation is necessary, because it can act as a catalyst to spark and focus debate on the role of NGOs, the extent to which they legitimately represent civil society, to whom they are accountable and how they can be protected. Open, balanced negotiation between stakeholders is necessary to avoid conflict and focus discourse on NGO and government roles and accountability. Governments, donors and NGOs each have a role to play in shaping NGO legitimacy, ensuring their upwards and downwards accountability.

Donor Dealings: The Impact of International Donor Aid On Sexual and Reproductive Health Services

Since the Cairo International Conference on Population and Development (ICPD) in 1994 international donors to population and AIDS programs have been called on to respond to the ICPD goals for expanded and holistic reproductive health services. How have they met the call? Do donors really support post-Cairo sexual and reproductive health services or do we need to look for new models of assistance? To explore these questions I look first at the changing face of donors to sexual and reproductive health the nature of their support and the inherent problems associated with their support. I then consider whether and how donors support the Cairo agenda and discuss the opportunities presented by recent health systems changes. (excerpt)

Access of Roma to sexual and reproductive health services: Qualitative findings from Albania, Bulgaria and Macedonia

Abstract The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.