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Male hormonal contraception has been shown to confer reversible infertility for at least one year; however, while clinical trials refine hormonal regimens, their acceptability, cultural meanings, and implications for study of men's sexualities remain under examined. This paper presents findings from interviews conducted with men and their female partners in a male hormonal contraception clinical trial in Jakarta and Palembang, Indonesia, and describes the ideas expressed about this new contraceptive technology. Fourteen men and their partners in Jakarta and ten men and their partners in Palembang were interviewed about their motivations to participate in the trial and their perceptions of the injection's physical, psychological and social effects. Concerns such as excess fertility and attendant economic liability shaped one quarter of motivations reported by men, while many women highlighted how a male method could help them prevent pregnancy without physical complications. Intimacy and sexual relations between couples were key themes within interpretations of contraceptive acceptability. Taken together, the narratives presented in this study call attention to the need for more nuanced analyses of contraceptive acceptability, as well as to the importance of studies of new male contraceptives for the understanding of masculinities. [ABSTRACT FROM AUTHOR]

BACKGROUND: Low maternal serum retinol level is a risk factor for mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Multiple-large-dose vitamin A supplementation of HIV-positive children reduces mortality. The World Health Organization recommends single-large-dose vitamin A supplementation for postpartum women in areas of prevalent vitamin A deficiency; neonatal dosing is under consideration. We investigated the effect that single-large-dose maternal/neonatal vitamin A supplementation has on MTCT, HIV-free survival, and mortality in HIV-exposed infants. METHODS: A total of 14,110 mother-infant pairs were enrolled < or =96 h after delivery, and both mother and infant, mother only, infant only, or neither received vitamin A supplementation in a randomized, placebo-controlled trial with a 2 x 2 factorial design. All but 4 mothers initiated breast-feeding. A total of 4495 infants born to HIV-positive women were included in the present analysis. RESULTS: Neither maternal nor neonatal vitamin A supplementation significantly affected postnatal MTCT or overall mortality between baseline and 24 months. However, the timing of infant HIV infection modified the effect that supplementation had on mortality. Vitamin A supplementation had no effect in infants who were polymerase chain reaction (PCR) negative for HIV at baseline. In infants who were PCR negative at baseline and PCR positive at 6 weeks, neonatal supplementation reduced mortality by 28% (P=.01), but maternal supplementation had no effect. In infants who were PCR negative at 6 weeks, all 3 vitamin A regimens were associated with 2-fold higher mortality (P< or =.05). CONCLUSIONS: Targeted vitamin A supplementation of HIV-positive children prolongs their survival. However, postpartum maternal and neonatal vitamin A supplementation may hasten progression to death in breast-fed children who are PCR negative at 6 weeks. These findings raise concern about universal maternal or neonatal vitamin A supplementation in HIV-endemic areas. Copyright © 2006 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

Background: In Zambia, half of children and adolescents living with HIV (CALWH) on antiretroviral therapy (ART) are virologically unsuppressed. Depressive symptoms are associated with ART nonadherence but have received insufficient attention as mediating factors in the relationship between HIV self-management and household-level adversities. We aimed to quantify theorized pathways from indicators of household adversity to ART adherence, partially mediated by depressive symptoms, among CALWH in 2 Zambian provinces., Setting: In July-September 2017, we enrolled 544 CALWH aged 5-17 years and their adult caregivers into a year-long prospective cohort study., Methods: At baseline, CALWH-caregiver dyads completed an interviewer-administered questionnaire, which included validated measures of recent (past 6 months) depressive symptomatology and self-reported past-month ART adherence (never versus sometimes or often missing medication doses). We used structural equation modeling with theta parameterization to identify statistically significant ( P < 0.05) pathways from household adversities (past-month food insecurity and caregiver self-reported health) to depression (modeled latently), ART adherence, and poor physical health in the past 2 weeks., Results: Most CALWH (mean age: 11 years, 59% female) exhibited depressive symptomatology (81%). In our structural equation model, food insecurity significantly predicted elevated depressive symptomatology ( ß = 0.128), which was associated inversely with daily ART adherence ( ß = -0.249) and positively with poor physical health ( ß = 0.359). Neither food insecurity nor poor caregiver health was directly associated with ART nonadherence or poor physical health., Conclusions: Using structural equation modeling, we found that depressive symptomatology fully mediated the relationship between food insecurity, ART nonadherence, and poor health among CALWH., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Advancing the health of adolescents, particularly their sexual and reproductive health, including HIV prevention and care, is a development imperative. A critical part for improving their wellbeing and economic development is the social status accorded to adolescent girls and young women (AGYW). However, AGYW in many countries including Zambia, encounter health challenges that stem from gender inequalities, lack of empowerment, inaccurate knowledge on sexuality, and poor access to sexual and reproductive health (SRH) services and information. Addressing the knowledge gaps through comprehensive sexuality education (CSE) and improving access to SRH services and appropriate information, should reduce school attrition from early and unintended pregnancies (EUP) and enhance realization of their full potential., Methods: The aim was to reduce EUP and improve SRH outcomes among AGYW in Zambia through provision of CSE linked to receptive SRH services. A 3-Arm randomized control study collected cross-sectional data at baseline, midline and Endline. Schools where CSE was being routinely provided were randomized into a non-intervention arm (arm1), an intervention arm in which information on available SRH services was provided in schools by health workers to complement CSE, (arm 2), and arm 3 in which pupils receiving CSE were also encouraged or supported to access pre-sensitized, receptive SRH services., Results: Following 3 years of intervention exposure (CSE-Health Facility linkages), findings showed a significant decline of in-school pregnancies amongst AGYW in both intervention arms, with arm two exhibiting a more significant decline, having recorded only 0.74% pregnancies at endline (p < 0.001), as well as arm 3, which recorded 1.34% pregnancies (p < 0.001). No significant decline was recorded in the CSE only control arm. Trends in decline of pregnancies started to show by midline, and persisted at endline (2020), and when difference in differences test was applied, the incident rate ratios (IRR) between the none and exposed arms were equally significant (p < 0.001)., Conclusion: Linking provision of CSE with accessible SRH services that are receptive to needs of adolescents and young people reduces EUP, which provides the opportunity for higher retention in school for adolescent girls., (© 2023. The Author(s).)

Objective: To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership's implementation., Methods: In September-October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance., Results: Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. To address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion., Conclusions: Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors., (© Rosen et al.)

Biomedical science is rapidly developing in terms of more transparency, openness and reproducibility of scientific publications. This is even more important for all studies that are based on results from basic semen examination. Recently two concordant documents have been published: the 6th edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen, and the International Standard ISO 23162:2021. With these tools, we propose that authors should be instructed to follow these laboratory methods in order to publish studies in peer-reviewed journals, preferable by using a checklist as suggested in an Appendix to this article., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Background: The high prevalence of HIV among adolescent girls and young women aged 15-24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers' perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia., Methods: We conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed., Results: Health workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics., Conclusions: These findings demonstrate the overlap in health workers' clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women., (© 2022. The Author(s).)

Background: Climate-induced disruptions like drought can destabilize household and community livelihoods, particularly in low- and middle-income countries. This qualitative study explores the impact of severe and prolonged droughts on gendered livelihood transitions, women's social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces., Methods: In September 2020, in-depth interviews (n = 20) and focus group discussions (n = 16) with 165 adult women and men in five drought-affected districts, as well as key informant interviews (n = 16) with civic leaders and healthcare providers, were conducted. A team-based thematic analysis approach, guided by the Framework Method, was used to code transcript text segments, facilitating identification and interpretation of salient thematic patterns., Results: Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women's breadwinning and caregiving responsibilities increased, especially in households where women's partners out-migrated in search of employment prospects. As household incomes declined, women and girls' vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or would resort to purchasing health commodities, including family planning, from private retail pharmacies when unavailable from government facilities. Most participants described changes in fertility intentions motivated by drought: women, in particular, expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient., Conclusions: Drought highlighted persistent and unaddressed vulnerabilities in women, increasing demand for health services while shrinking household resources to access those services. Policy solutions are proposed to mitigate drought-induced challenges meaningfully and sustainably, and foster climate resilience., (© 2021. The Author(s).)

Background: Children and youth are profoundly impacted groups in Zambia's HIV epidemic. To evaluate delivery of integrated psychosocial, economic strengthening, and clinical services to HIV-affected households through the Zambia Family (ZAMFAM) Project, a prospective cohort study compared socio-economic, psychosocial, and health outcomes among ZAMFAM beneficiaries to non-beneficiaries., Methods: In July-October 2017, 544 adolescents living with HIV (ALHIV) aged 5-17 years and their adult caregivers were recruited from Central (ZAMFAM implementation sites) and Eastern (non-intervention sites) Provinces. Structured interviews at baseline and one-year follow-up assessed household characteristics, socio-economic wellbeing, and health service utilization. Poisson regression with generalized estimating equations measured one-year changes in key health and socio-economic indicators, comparing ZAMFAM beneficiaries to non-beneficiaries., Results: Overall, 494 households completed two rounds of assessment (retention rate: 91%) Among ALHIV, improvements in current antiretroviral therapy use over time (Adjusted Prevalence Rate Ratio [aPRR] = 1.06, 95% Confidence Interval [95% CI]: 1.01-1.11) and reductions in non-household labor (aPRR = 0.44, 95% CI: 0.20-0.99) were significantly larger among ZAMFAM beneficiaries than non-beneficiaries. For caregivers, receiving ZAMFAM services was associated with significant reductions in HIV-related stigma (aPRR = 0.49, 95% CI: 0.28-0.88) and perceived negative community attitudes towards HIV (aPRR = 0.77, 95% CI: 0.62-0.96). Improvements in caregiver capacity to pay for unexpected (aPRR = 1.54, 95% CI: 1.17-2.04) and food-related expenses (aPRR = 1.48, 95% CI: 1.16-1.90), as well as shared decision-making authority in household spending (aPRR = 1.41, 95% CI: 1.04-1.93) and self-reported good or very good health status (aPRR = 1.46, 95% CI: 1.14-1.87), were also significantly larger among ZAMFAM beneficiaries., Conclusions: Significant improvements in caregivers' financial capacity were observed among households receiving ZAMFAM services, with few changes in health or wellbeing among ALHIV. Integrated service-delivery approaches like ZAMFAM may yield observable socio-economic improvements in the short-term. Strengthening community-based delivery of psychosocial and health support to ALHIV is encouraged., Competing Interests: The authors have declared that no competing interests exist.

Family planning represents a 'best buy' in global efforts to achieve sustainable development and attain improvements in sexual and reproductive health. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Drawing from the Zambian context, including a review of current policy solutions, we present a case for making investments in voluntary family planning (FP), underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia - and other low- and middle-income countries - can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Mbizvo MT et al.)

Family planning represents a 'best buy' in global efforts to achieve sustainable development and attain improvements in sexual and reproductive health. Ensuring access is amongst key transformative strategies that underpin health and sustainable development. It confers fertility choices on women and couples within a human rights framework. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. As such, there is a need to carefully consider the estimated costs and benefits for each proposed investment in health, education, social welfare, and security. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Increasing voluntary modern contraceptive use among women offers opportunities to reduce unintended pregnancy while effectively harnessing the demographic dividend in order to bolster socioeconomic outcomes for households and communities. Drawing from the Zambian context, we present a case for making investments in voluntary family planning (FP), underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia - and other low- and middle-income countries - can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population., Competing Interests: No competing interests were disclosed., (Copyright: © 2019 Mbizvo MT et al.)

Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries., Methods: We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach., Results: Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda., Conclusions: Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.

Developing the capacity to effectively carry out public health research is an integral part of health systems at both the national and global levels and strengthening research capacity is recognized as an approach to better health and development in low- and middle-income countries (LMICs). Especially fields such as sexual and reproductive health (SRH) would require inter-disciplinary teams of researchers equipped with a range of methodologies to achieve this. In November 2013, as part of the International Family Planning Conference in Addis Ababa, Ethiopia, a group of African researchers came together to discuss the gaps and strategies to improve sexual and reproductive health research and research capacity strengthening in Africa. This commentary summarizes the three broad areas where the issues and proposed solutions have concentrated around: 1) Addressing research gaps that are most relevant to policies and programmes in SRH, 2) Carrying out high quality and collaborative research, and 3) Translating research findings into SRH policies and programmes. Even though the focus of the discussions was Africa, the issues and proposed solutions can also be applied to other regions facing a high burden of disease with limited resources. The time is now and these can be achieved through synergistic commitment of African and global researchers, funders and organizations.

Background: In several recent papers it has been suggested that HIV prevalence and incidence are declining in Zimbabwe as a result of changing sexual behavior. We provide further support for these suggestions, based on an analysis of more extensive, age-stratified, HIV prevalence data from 1990 to 2009 for perinatal women in Harare, as well as data on incidence and mortality., Methodology/principal Findings: Pooled prevalence, incidence and mortality were fitted using a simple susceptible-infected (SI) model of HIV transmission; age-stratified prevalence data were fitted using double-logistic functions. We estimate that incidence peaked at 5.5% per year in 1991 declining to 1% per year in 2010. Prevalence peaked in 1998/9 [35.9% (CI95: 31.3-40.7)] and decreased by 67% to 11.9% (CI95: 10.1-13.8) in 2009. For women <20y, 20-24y, 25-29y, 30-34y and ≥35y, prevalence peaked at 25.4%, 34.2%, 47.1%, 44.0% and 33.5% in 1993, 1996, 1997, 1998 and 1999, respectively, declining thereafter in every age group. Among women <25y, prevalence peaked in 1994 at 28.8% declining thereafter by 69% to 8.9% (CI95: 6.8-11.5) in 2009., Conclusion/significance: HIV prevalence declined substantially among perinatal women in Harare after 1998 consequent upon a decline in incidence starting in the early 1990s. Our model suggests that this was primarily a result of changes in behavior which we attribute to a general increase in awareness of the dangers of AIDS and the ever more apparent increases in mortality., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Robert Terry and colleagues present working definitions of operational research, implementation research, and health systems research within the context of research to strengthen health systems.

Background: HIV prevention among young people in southern Africa is a public health priority. There is little rigorous evidence of the effectiveness of different intervention approaches. We describe findings of a cluster randomized trial of a community-based, multicomponent HIV, and reproductive health intervention aimed at changing social norms for adolescents in rural Zimbabwe., Methods: Thirty rural communities were randomized to early or deferred implementation of the intervention in 2003. Impact was assessed in a representative survey of 18-22-year-olds after 4 years. Participants self-completed a questionnaire and gave a dried blood spot sample for HIV and herpes simplex virus-2 (HSV-2) antibody testing. Young women had a urinary pregnancy test. Analyses were by intention-to-treat and were adjusted for clustering., Findings: Four thousand six hundred and eighty-four, 18-22-year-olds participated in the survey (97.1% of eligible candidates, 55.5% women). Just over 40% had been exposed to at least 10 intervention sessions. There were modest improvements in knowledge and attitudes among young men and women in intervention communities, but no impact on self-reported sexual behavior. There was no impact of the intervention on prevalence of HIV or HSV-2 or current pregnancy. Women in intervention communities were less likely to report ever having been pregnant., Interpretation: Despite an impact on knowledge, some attitudes, and reported pregnancy, there was no impact of this intervention on HIV or HSV-2 prevalence, further evidence that behavioral interventions alone are unlikely to be sufficient to reverse the HIV epidemic. The challenge remains to find effective HIV prevention approaches for young people in the face of continued and unacceptably high HIV incidence, particularly among young women.

Background: We assessed attitudes towards and acceptability of male hormonal contraception among volunteers participating in a clinical trial of a prototype regimen, consisting of progestin and testosterone injections., Methods: After completing screening, eligible men were randomly assigned to the no-treatment group (n = 40) or to receive injections of norethisterone enanthate and testosterone undecanoate or placebo at different intervals (n = 50) according to a blocked randomization list. They underwent self-administered questionnaires., Results: The average age of the participants was approximately 28 years; most were involved in a stable relationship and had no children. Ninety-two percentage of the respondents thought that men and women should share responsibility for contraception and 75% said they would try a hormonal contraceptive if available. At the end of the treatment phase, 66% of the participants said that they would use such a method, and most rated its acceptability very highly; none reported it to be unacceptable. The injections themselves were indicated as the biggest disadvantage. No significant changes in sexual function or mood states were detected among the men who underwent hormone injections., Conclusions: The contraceptive tested in this study was well accepted by the participants over the course of 1 year.

Although a decade has now passed since the launching of the Safe Motherhood Initiative, maternal mortality continues to be the health indicator showing the greatest disparity between developed and developing countries. Recently revised WHO and UNICEF figures indicate that an estimated 90% of the 585,000 worldwide maternal deaths that occur each year take place in sub-Saharan Africa and Asia. In terms of the lifetime risk of maternal death, this disparity remains striking: 1 in 12 women in parts of sub-Saharan Africa, compared with 1 in 4,000 women in Northern Europe. In addition, for every woman who dies, an estimated 16-17 will suffer from pregnancy-related complications. Research suggests that, in addition to biomedical interventions and the strengthening of health care services, improving awareness of obstetric complications among members of a pregnant woman's immediate and wider social network is an important step in improving her chances of survival when such complications occur. Many of the interventions implemented so far have focused exclusively on improving women's knowledge and practices as they relate to maternal health issues. Nevertheless, it is now increasingly being recognised that the actions required to achieve improvements in reproductive health outcomes in general, and maternal health in particular, should involve communities in the process and encourage men's active participation. Despite this, very few studies on risk perceptions or interventions to raise community awareness of obstetric risk factors, their complications and their consequences have targeted men. The present article argues for the development and testing of risk awareness interventions, which, in addition to women, target men in their familial and social roles within communities and as workers within health care services as a means of improving maternal health outcomes.

There is concern that male fertility is declining, but this is difficult to study because few men volunteer for studies of semen quality, and recruitment bias may over-represent the subfertile. The Human Reproduction Programme of the World Health Organization developed a protocol for multicentre studies of fertility involving a questionnaire for pregnant women to obtain time to pregnancy (TTP): the number of menstrual cycles taken to conceive. Male characteristics and semen quality will be determined in a subset of the partners. Our aim was to validate the TTP questionnaire, and to examine potential recruitment bias and feasibility of conducting large-scale surveillance of fertility. The questionnaire was administered to 120 pregnant women (16-32 weeks). Validation included internal reliability by consistency of responses, test-re-test reliability by repeat administration (20 women) and accuracy by comparison of gestational age from first antenatal ultrasound and menstrual dates. Internal reliability was high. Agreement between categorical responses on re-testing was very good (k > 0.8). In both the re-test and gestational age analysis, differences in TTP of 1 cycle were found (standard deviation <0.25 cycles). In this small pilot study there was no evidence of recruitment bias. Response rates indicate the feasibility of surveillance of fertility in large maternity centres.

Objectives: To compare the rate of self reported sexually transmitted diseases (STDs) among HIV infected men with men who remained HIV negative during follow up of a Harare male factory cohort., Methods: Male factory workers were offered enrolment and behavioural data were collected at entry then every 6 months, along with HIV testing. Self report of STDs was used to calculate incidence per 100 person years. Cox proportional hazards models examined independent risk factors for STDs, with hazard ratios (HRs)., Results: At entry 20% of men were HIV infected and 11% reported STDs in the previous year. A total of 2777 (82%) of 3383 men enrolled were followed at least once. Compared with men who remained HIV negative, seroconverters had the highest incidence of STDs (16.8 per 100 person years; IRR = 3.3, 95% CI = 2.5-4.3); men enrolled HIV positive also reported higher STD incidence (14.5 per 100 person years, IRR = 2.8; 95% CI 2.3-5.5). Among HIV positive men, the only independent risk factor for report of urethral discharge was history of multiple partners (HR = 10, 95% CI 1.4-73.2)., Conclusion: HIV positive men reported threefold higher incidence of STDs than HIV negative men, many related to high risk sexual behaviour.

Objectives: Lesions on the vaginal and cervical mucosa may facilitate transmission of HIV and other sexually transmitted diseases (STDs). We evaluated the relationship between intravaginal practices and the presence of colposcopic lesions in Zimbabwean women., Methods: Users and nonusers of intravaginal practices were seen at enrollment, and at 1 and 6 months. Interviewing, counseling, and pelvic and colposcopic examinations were performed at each study visit. Specimens were collected at enrollment and 6 months., Results: Colposcopic lesions were found at least once in 83% of the participants (n = 162), and in 66% of all exams (n = 430). Most lesions were classified as related to infection with human Papillomavirus (HPV) (58%) or another pathogen (20%), but 11% of lesions could have been caused by intravaginal practices (signal lesions). Intravaginal practices were not associated with an increased incidence in signal lesions (95 and 124 lesions per 100 person-years of follow-up for users and nonusers respectively; p = .290), nor with the presence of signal lesions in multivariate baseline (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.37-4.72; p = .666) and six month transition models (OR, 1.67; 95% CI, 0.59-4.70; p = .333)., Conclusions: No associations between intravaginal practices and colposcopic lesions were found in this study. However, the potential effect of intravaginal practices on the cervical and vaginal mucosa, and on subsequent HIV and STD transmission, warrants further study. The usefulness of colposcopy as a research tool in areas with high prevalences of HIV and HPV is questioned.

One hundred sixty-nine Zimbabwean women were studied to determine whether the use of intravaginal practices (cleaning with the fingers, wiping the vagina, and inserting traditional substances) are associated with disturbances of vaginal flora and acquisition of sexually transmitted diseases (STDs). Subjects were interviewed and received counseling and a pelvic examination at enrollment, 1 month, and 6 months, and vaginal specimens were collected at enrollment and at 6 months. Users were more likely than nonusers to have vaginal flora disturbances but were not more likely to acquire an STD (relative risk [RR], 2.15; P=.188). Certain vaginal flora disturbances were associated with increased STD incidence and HIV prevalence. The absence of lactobacilli from the vaginal flora was associated with being positive for human immunodeficiency virus in baseline (odds ratio [OR], 0.24; P=.001) and 6-month transition multivariate models (OR, 0.39; P=.025). The presence of clue cells at baseline was associated with a higher incidence of STDs (RR, 1. 94; P=.025).

We assessed the sensitivity and specificity of a newly developed DNA PCR kit (Roche Diagnostic Corporation, Indianapolis, Ind.) that incorporates primers for all the group M viruses for the detection of human immunodeficiency virus (HIV) type 1 (HIV-1) infection in Zimbabwe. A total of 202 whole-blood samples from adults whose HIV status was known were studied. This included 100 HIV-1-positive and 102 HIV-1-negative samples selected on the basis of concordant results obtained with two enzyme-linked immunosorbent assay kits. The prototype Roche DNA PCR assay had a 100% sensitivity for the detection of HIV-1 DNA and a specificity of 100%. We conclude that the new Roche DNA PCR kit is accurate for the detection of HIV DNA in Zimbabwean samples, in which HIV-1 subtype C dominates.

Objective: To compare HIV incidence estimates from cross-sectional age-specific prevalence data with concurrent cohort estimates and to examine the sensitivity of the estimates to changes in age-categorization and survivorship assumptions., Methods: Two previously described methods of estimating HIV incidence from cross-sectional prevalence data - the cumulative incidence and survival (CIS) and constant prevalence (CP) methods - are applied using data from a study of male factory workers in Harare, Zimbabwe. The methods are applied under two alternative groupings of the HIV prevalence data and under alternative survivorship assumptions: (a) Weibull distribution providing the best fit to the HIV prevalence data using the CIS method; (b) Weibull distribution matching data from an HIV natural history cohort study in Uganda; and (c) survivorship pattern as in (b) with survival periods reducing with increasing age at infection. Age-specific, age-standardized and cumulative HIV incidence estimates are calculated. The results are compared with concurrent longitudinal estimates from 3 years of follow-up of the Harare cohort (1993-1995)., Results: Age-standardized HIV incidence was estimated at 2.02 per 100 man years (95% CI, 1.57-2.47) in the cohort study. There was evidence of recent variability in HIV incidence in these data. Estimates from the cross-sectional methods ranged from 1.98 to 2.74 per 100 man years and were sensitive to changes in age-categorization of the HIV prevalence data and changes in survivorship assumptions. The cross-sectional estimates were higher at central ages and lower at older ages than the cohort estimates. The age-specific estimates from the CIS method were less sensitive to changes in age grouping than those from the CP method., Conclusions: HIV incidence remains high in Harare. Incidence estimates broadly consistent with cohort estimates can be obtained from single-round cross-sectional HIV prevalence data in established epidemics - even when the underlying assumption of stable endemic prevalence is not fully met. Estimates based on cross-sectional surveys should therefore be explored when reliable longitudinal estimates cannot be obtained. More data on post-HIV infection survivorship distributions in sub-Saharan Africa would facilitate the improvement of estimates of incidence based on cross-sectional surveys.

Transmission of human immunodeficiency virus (HIV) and mortality was studied among infants of infected women in Zimbabwe. Of 367 infants born to HIV-infected women, 72 (19.6%) died compared with 20 (5.4%) of 372 infants of uninfected women (P < .01). Infection by HIV DNA polymerase chain reaction among infants who survived >7 days and died within 2 years could be assessed in 87% (58/67) of infants of infected women and 83% (5/6) of infants of uninfected women; transmission occurred in 40 of 58 infants. Among 27 infected infants tested at birth, 19 (70%), 5 (19%), and 3 (11%) were apparently infected via in utero, intrapartum or early postpartum, and late postpartum transmission, respectively. The majority of HIV-infected infants who died in the first 2 years of life were likely to have acquired in utero infection.

Between March 1993 and March 1995, volunteers at 40 Harare factories were interviewed regarding sociodemographic characteristics and behavior; HIV serostatus was also determined. Among 2,691 men enrolled, HIV prevalence was 19.4%. Prevalence rose 2-fold with each year of age in young men (< 23 years). In a multivariate logistic model that included sociodemographic and behavioral variables, compared with those between 25 and 44 years, both younger men (OR = 0.51) and older men (OR = 0.49) were less likely to be HIV positive. In addition, marriage (OR = 2.01), history of sexually transmitted disease (STD) (genital ulcer, OR = 4.93, urethral discharge OR = 1.75), multiple partners (OR = 1.58), cash payment for sex (OR = 2.55) and condom use (OR = 1.35) were all independent risk factors for HIV infection. Home ownership conferred lower risk. Self-reported condom use was seen as a marker of correct personal risk assessment men who used condoms reported more risk behavior and had a higher prevalence of HIV, either because condom use was not consistent or because infection occurred prior to adoption of condoms. This study confirms established risk factors in a general population sample not selected for high risk of HIV infection. It suggests rapid acquisition of infection among young men and the importance of marriage (and separation of spouses) as correlates of HIV infection.

Reproduction is a dual commitment, but so often in much of the world, it is seen as wholly the woman's responsibility. She bears the burden not only of pregnancy and childbirth but also the threats from excessive child bearing, some responsibility for contraception, infertility investigation and often undiagnosed sexually transmitted diseases (STDs) including AIDS. Failure to target men in reproductive health interventions has weakened the impact of reproductive health care programmes. The paper proposes that sophisticated and dynamic strategies in Africa and elsewhere which target women's reproductive health and research (such as control of STDs including AIDS, family planning, infertility investigation) require complementary linkage to the study and education of men. Men's perceptions, as well as determinants of sexual behavioural change and the socioeconomic context in which STDs, including AIDS, become rife, should be reviewed. There is a need to study and foster change to reduce or prevent poor reproductive health outcomes; to identify behaviours which could be adversely affecting women's reproductive health. Issues of gender, identity and tolerance as expressed through sexuality and procreation need to be amplified in the context of present risks in reproductive health. Researchers and providers often ignore the social significance of men. This paper reviews the impact of male dominance, as manifested through reproductive health and sexual decisions, against the background of present reproductive health problems. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes. This should be followed up by well-developed causal models of the determinants of positive reproductive health-promoting behaviours. Behaviour specific influences in sexual partnership include the degree of interpersonal support towards prevention, for example, of STDs, unwanted pregnancy or maternal deaths. Perceived efficacy and situational variables influencing male compliance in, say, condom use, form part of the wider study that addresses men. Thus preventive reproductive health initiatives and information should move from the female alone to both sexes. Women need men as partners in reproductive health who understand the risks they might be exposed to and strategies for their prevention.

Objective: To determine if the motility stimulants, caffeine (7 mM), pentoxifylline (3 mM), 2-deoxyadenosine (3 mM), and a combination of the three would induce hyperactivated (HA) motility., Design: Controlled laboratory study of stimulants using cryopreserved semen from 10 donors at three time points., Setting: The study was performed in the Andrology Laboratory at Prince Henry's Institute of Medical Research Clayton, Victoria, Australia., Interventions: Stimulants in doses maximally effective for stimulation of motility were incubated with suspensions of previously cryopreserved sperm., Main Outcome Measures: Motility characteristics (curvilinear velocity [VCL], linearity [LIN], and maximum amplitude of lateral head displacement [ALHmax]) were derived using the single cell track facility of the CellSoft computer-automated semen analyzer (Cryo Resources Ltd., Montgomery, NY). Videotapes were visually inspected, and 125 sperm cell trajectories exhibiting characteristic HA behavior were identified. The HA motility thresholds (5th or 95th centiles) were as follows: VCL > 74 microns/s, LIN < 74%, and ALHmax > 4.7 microns. Cells with motility characteristics outside these limits were regarded as HA. The significance of the effect of the stimulants on the proportion of sperm exhibiting HA was examined by Poisson regression analysis., Results: Sperm washing (removal of the cells from the cryoprotectant) and swim-up caused significant changes in the VCL and straight line velocity and a twofold (5.6% to 11.9%) increase in the proportion of HA cells. In the presence of motility stimulants, the proportion of HA cells was significantly increased threefold (11.9% to 32.5%) above that seen in the control washed sperm. Hyperactivated motility declined after 1 to 2 hours, but 2-deoxyadenosine demonstrated a prolonged effect., Conclusion: These motility stimulants that affect adenosine 3':5' monophosphate in human sperm stimulate cyclic hyperactivation.

A multimedia communication campaign was conducted between 1988 and 1989 to promote family planning among men in Zimbabwe. The campaign consisted of a 52-episode semiweekly radio soap opera, about 60 motivational talks, and two pamphlets about contraceptive methods. Changes over time were measured by comparing a subset of a follow-up survey conducted from October to December 1989 to a baseline survey conducted from April to June 1988. Men exposed to the campaign were also compared to men who were not exposed. The follow-up survey revealed that the campaign reached 52 percent of men aged 18 to 55. Among married Shona-speaking men, use of modern contraceptive methods increased from about 56 percent to 59 percent during the campaign. Condom use increased from about 5 percent to 10 percent. Awareness and current use of modern contraceptives was also higher among men exposed to the campaign, primarily because of their greater awareness of condoms. Men exposed to the campaign were significantly more likely than other men to make the decision to use family planning and to say that both spouses should decide how many children to have.

This report describes, for a sample of Zimbabwean men, sources of family planning information, media exposure, media preferences, and whether they would like to learn more about family planning methods. The data are from the 1988 Zimbabwe Male Fertility Survey, a representative sample of 711 currently married men aged 20 and over. The analysis is restricted to the 512 men whose wives were aged 49 and under at the time of the survey. The radio and personal communications, followed by posters and newspapers, are the most frequently reported sources of family planning information. The radio is considered to be the best medium for learning about family planning, followed by community-based distributors. Nearly 85 percent of respondents indicated that they would like to learn more about family planning. Information from men should be included in information, education, and communication programs in order to enhance male involvement in the family planning process.

The purpose of this report is to describe knowledge, attitudes, and practices in family planning among male Zimbabweans. Understanding the role of men in inhibiting or promoting contraceptive adoption could affect the design of family planning promotion programs and program success in Zimbabwe and other African countries. Data from the 1988 Male Fertility Survey, a representative sample of 711 currently married men aged 20 and over, showed that men have a major role in the decision to use family planning methods and in determining the number of children a couple should have. Male knowledge of various family planning methods was high, as was approval and ever-use of family planning. Attitudes toward family planning information, obtaining methods, couple communication, and family size were also investigated. It was concluded that men should be included in information, education, and communication programs, without delay. Program efforts should move beyond emphasis on child spacing to stress family size limitation in order to increase contraceptive prevalence, resulting in a commensurate decline in the level of fertility.

Since human follicular fluid (FF) is known to enhance the acrosome reaction and capacitation, we investigated whether hyperactivated motility is stimulated by FF. Follicular fluid-treated sperm exhibited a threefold increase in hyperactivation compared with the controls. The use of fetal cord serum in the medium, instead of bovine serum albumin, supported the same high levels of hyperactivation, although the peak occurred at 3 hours rather than 5 hours of capacitation. When sperm were treated with a steroid-rich fraction of the FF, hyperactivation was stimulated to the same degree as with whole FF. In contrast, no stimulation occurred when sperm were treated with a FF fraction stripped of steroids. The FF enhancement of hyperactivation in vitro could augment the fertilizing capacity of subfertile sperm samples, providing also a glimpse of possible in vivo events as sperm traverse the FF-laden cumulus oophorus.

If hormone levels affect sperm motility during capacitation, then the serum added to samples prepared for artificial insemination could affect sperm fertilizability. We investigated various sperm functional movement characteristics (percent motile, progressive velocity, linearity, beat cross frequency, lateral head displacement, longevity, and hyperactivation) in specimens incubated with women's sera, as well as exogenous hormone preparations of estradiol (E2) and progesterone (P). Early follicular phase serum (low E2 and low P) maintained motility and longevity. Sperm in E2-treated medium exhibited higher progressive velocity, linear motility, and longevity. In contrast, the percent motility decreased as sperm exhibited hyperactivated motility with P.