Social marketing sexually transmitted disease and HIV prevention: a consumer-centered approach to achieving behaviour change.

This paper proposes that international sexually transmitted disease (STD)/HIV prevention efforts might be enhanced by the application of social marketing principles. It first outlines the conceptual basis of social marketing approaches to health behaviour change generally and then explores key issues and opportunities for using these principles to improve current STD/HIV prevention efforts.

PIP: Social marketing is a research-driven, consumer-centered process used in the field of public health to change individuals' behavior. Social marketing differs from other health education strategies only in its approach, which is based upon commercial marketing techniques. In social marketing campaigns, social products such as condom use are viewed as commercial products and promoted using the same principles applied in the commercial sector. With consistent and long-term government commitment, social marketing programs have been highly effective. When used properly, social marketing-based public health interventions can help to prevent and control STDs and HIV. Health consumer behavior and focus, targeting and audience segmentation, social market research, the social marketing mix, and implications for social marketing STD/HIV prevention are discussed. Decreasing sexual partner change and making sex safe, improving access to effective STD treatment, and condom social marketing are then discussed as elements of social marketing to reduce sexual risk, followed by an examination of important policy considerations.

Ounce of prevention worth a million lives.

PIP: The results from trials of a new generation of anti-HIV drugs are encouraging. Researchers have reported that the new protease inhibitors, taken together with other AIDS drugs such as AZT, ddC, and 3TC, can reduce the amount of HIV in infected people to undetectable levels. Some scientists even cautiously discuss eliminating HIV from the body. People are therefore naturally excited about these new treatment breakthroughs and the possibility of a cure on the horizon. However, it must be understood that the treatment which is currently available against AIDS is no cure and that prevention is and will remain the most powerful weapon against HIV. The three drugs which comprise the new regimen must be taken several times per day with more than a liter of water, some on an empty stomach and others with a high-fat meal. Compliance to the regimen is therefore difficult to maintain. Moreover, the mixture of drugs costs at least US$10,000 per patient per year, it remains to be seen how long the drugs can control HIV, and they don't work for everyone. Should people begin to believe that scientists have found a cure for AIDS, prevention efforts may even be undermined. Cost-effective STD/HIV prevention activities must continue to be integrated into reproductive health and family planning programs.^ieng

Prevention of sexual transmission of HIV in sub-Saharan Africa: lessons learned.

PIP: More than 80% of cases of HIV infection in Africa are attributed to heterosexual transmission, and most prevention efforts have focused upon checking the sexual spread of HIV. A range of interventions have been implemented over the past 10-15 years in different countries throughout the continent. The nature of the activities depends upon the stage of the epidemic, the target population, the funding level, the level of policy support, donor interests, and the capabilities of implementing agencies in the public and private sectors. Despite reports of some encouraging results, the epidemic remains powerful, dynamic, and spreading. Slowing the HIV/AIDS epidemic in Africa will probably require comprehensive, integrated, and multisectoral programs. Most programs to date, however, intervene almost exclusively at the individual level. The authors describe the evolution of intervention programs to prevent the sexual transmission of HIV in sub-Saharan Africa, discuss lessons learned from programs, and identify gaps in the existing knowledge. Sections review interventions to prevent the sexual transmission of HIV, STD treatment, promoting condoms and making them more available, and behavior change interventions.^ieng

Expanding the partnership. The private sector's role in HIV / AIDS prevention.

PIP: The public sector supports most HIV/AIDS prevention and care activities in developing countries, with significant funding provided by the US Agency for International Development, the Overseas Development Authority, the European Community, and international banking institutions such as the World Bank. Local nongovernmental organizations (NGOs) and international private voluntary organizations (PVOs) implement many of the grassroots prevention and care efforts in developing countries, but often require support from donor agencies. While the private commercial sector has played a minor role in supporting HIV/AIDS prevention and care efforts, a number of local and multinational companies are beginning to recognize the importance of protecting their workers from HIV infection. These companies are motivated by a sense of moral obligation and/or view HIV/AIDS prevention as a cost-effective investment. Mainly affecting the most economically productive age groups, the HIV/AIDS epidemic will have a significant impact upon private industry. Workplace-based prevention programs and policies, private sector resources for HIV/AIDS prevention and care, how HIV/AIDS programs can benefit from the private sector's experience in commercial service delivery, research and development, and corporate direct cash and in-kind contributions to government and NGO HIV/AIDS prevention activities are discussed. The AIDS Control and Prevention (AIDSCAP) Project's Businesses Managing AIDS Project helps owners and managers understand the potential impact of HIV/AIDS upon their businesses and the benefits of HIV/AIDS prevention.^ieng

Slowing AIDS: lessons from a decade of prevention efforts.

PIP: Now in the third decade of the AIDS pandemic, much has been learned about the virology and epidemiology of HIV and AIDS, as well as the biological and behavioral factors which enhance its transmission, but neither vaccine nor cure has been developed. Contracting and transmitting HIV can, however, be prevented and is currently the most effective way to control the spread of AIDS. 75% of HIV infections worldwide are the result of sexual intercourse and relations without the use of a condom. Programs designed to reduce the sexual transmission of HIV will therefore have the greatest impact in curbing the progression of the pandemic. Biologically susceptible to infection and more likely to have untreated sexually transmitted diseases (STD) which increase their risk of acquiring HIV, women are particularly vulnerable to HIV/AIDS. As such, the care and prevention of STDs has become a major element of the overall approach to controlling HIV. In so far as behavior is concerned, much has also been learned from research about why people engage in behavior which puts them at risk of infection and what may be done to change such behavior. It is clear that knowledge of the basic facts of AIDS is insufficient to induce behavioral change. Prevention programs instead need to communicate the benefits of low-risk behavior and provide people with the skills they need to practice safer sex. Behavioral change must then be sustained. Success stories and future challenges are considered.^ieng

Evaluation of a targeted AIDS prevention intervention to increase condom use among prostitutes in Ghana.

OBJECTIVE: To assess the short- and long-term impact of a 6-month pilot intervention program on condom use among prostitutes in Accra, Ghana. DESIGN: The 4-year prospective study follows-up cohorts enrolled in the intervention in 1987 and 1988, comparing condom use in 1991 with that among a comparison group not enrolled in the intervention. SETTING: The community-based intervention was initiated in Accra, Ghana in 1987. PARTICIPANTS: Self-identified female prostitutes who volunteered participation. INTERVENTION: The educational intervention used local health workers to train and support selected prostitutes to be health educators and condom distributors to their peers. OUTCOME MEASURES: Self-reported condom use with clients. RESULTS: Reported condom use increased dramatically between 1987 and 1988 during the first 6 months of the intervention. In 1991, after 3 years of program relapse, 107 (43%) of the 248 women who had enrolled in 1987 or 1988 were still in prostitution and located for interview. Their level of condom use in 1991 was higher than pre-enrollment but similar to use among prostitutes never enrolled. Sixty-four per cent of those followed-up reported always using condoms with clients in 1991. These 'always users' were more likely to have maintained informal contact with project staff, know that HIV can be transmitted by healthy clients, and report that clients frequently initiate condom use. CONCLUSIONS: Findings support the development of long-range educational strategies that recognize the career longevity of prostitutes, available channels for informal program diffusion, individual changes in condom use over time, and the role of clients in condom negotiation.

PIP: Findings of a prospective study of condom use among prostitutes in Ghana provided support for acquired immunodeficiency syndrome (AIDS) prevention educational interventions with this high risk populating and evidence of informal program diffusion. 382 self-identified prostitutes voluntarily entered the study in three waves (a pilot group of 72 recruited in June 1987, another 176 prostitutes who were admitted at their request in January 1988, and 106 who entered in September 1991). From this group, selected prostitutes were trained to educate their peers about AIDS risk factors through meetings and printed materials and to distribute free condoms. Self-reported condom use in 1991 was correlated with contact with these peer educators. During the 6-month pilot study, the proportion of prostitutes who always used condom increased from 6% at baseline to 71%. 48% of prostitutes entering the study in January 1988 were already always using condoms, suggesting a diffusion effect. In 1991, consistent condom use was reported by 56% of women from the pilot group available for follow-up and 66% of those interviewed from the 1988 wave; however, these rates were not appreciably higher than the 55% rate reported at baseline by the 1991 wave of recruits. (This convergence is assumed to reflect both suspension of the educational program in 1988-91 and increased social acceptance of condom use given the spread of AIDS.) Of the 107 women from the pilot and expanded groups available for interview in 1991, 24% identified peer outreach workers as their source of AIDS information. Women who had contact with staff were 2.63 times more likely than non-exposed women to report consistent condom use. The interaction model revealed that women who maintained contact with project staff were 3.17 times more likely to be consistent users, those who knew that healthy appearing men could transmit AIDS were 2.68 times more likely to fall into this use category, and prostitutes who had clients who initiated condom use more than half the time were 4.49 times more likely than other women to be consistent users, even when staff contact and AIDS knowledge were controlled. Given the career longevity of some prostitutes, sustained program activity is encouraged.

How intervention projects affect sexual behavior.

PIP: HIV is largely transmitted through sexual contact. Engaging in sexual activities and contact with little to no risk of HIV transmission therefore reduces the spread of HIV. AIDSTECH has worked in 45 countries, focusing upon strategies for changing sexual behavior with the goal of checking the spread of HIV. Focus is given to targeted intervention programs designed to reduce the sexual transmission of HIV among people at greatest risk of infection. Programs involve peer education, clinic-based projects, and reaching men at work and in social settings. Condom promotion and distribution, designing effective AIDS education materials, and evaluating the effectiveness of intervention projects are integral to program efforts. Gaining government support for such interventions can be crucial to success at both the national and local levels. AIDSTECH's programs must be replicated, expanded, and sustained in target communities throughout the developing world in order to achieve some measure of success against the HIV/AIDS pandemic.^ieng

Condom issues in AIDS prevention in Africa.

PIP: In vitro studies have demonstrated that an intact latex condom provides an effective barrier against several sexually transmitted pathogens, including herpes simplex virus type 2, hepatitis B virus, cytomegalovirus, HIV, Neisseria gonorrhea, Chlamydia trachomatis, and mycoplasma. This paper discusses some of the major advances and critical issues which should be incorporated in condom program design and implementation. The authors drew extensively from their experience with Family Health International's AIDSTECH Project with 21 targeted HIV prevention programs in 14 African countries. The programs are designed primarily to reach high-risk behavior groups among whom the virus is most prevalent. The authors observe from their work that a number of social, economic, political, and cultural obstacles impede greater condom use in Africa; private sector initiatives which recruit members of target populations to be key personnel in project implementation show promise for reaching high-risk behavior groups; condom logistics systems remain a weak link in condom distribution programs; rising costs and inadequate sources of latex condoms are problematic; and alternatives to the male latex condom could be commercially available by 1992. Sections discuss barriers to condom use, new approaches in condom distribution, condom quality assurance, condom costs and economics, and technological advances in condoms.^ieng

Preventing IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion.

Most of the small increased risk in pelvic inflammatory disease (PID) associated with the intrauterine contraceptive device (IUCD) appears to be caused by bacterial contamination of the endometrial cavity at the time of insertion. This randomized clinical trial of 1813 women in Nairobi, Kenya, assessed the effectiveness of 200 mg of doxycycline given orally at the time of insertion in reducing the occurrence of PID. The rate of this infection in the doxycycline-treated group was 31% lower than that in the placebo-treated group (1.3 and 1.9%, respectively; RR 0.69; 95% CI 0.32 to 1.5). The rate of an unplanned IUCD-related visit to the clinic was also 31% lower in the doxycycline-treated group (RR 0.69; 95% CI 0.52 to 0.91). Although the significance level (P = 0.17) for the reduction is PID does not meet the conventional standard of 0.05, the results may be suggestive of an effect. Moreover, the reduction in IUCD-related visits (P = 0.004) not only represents an important decrease in morbidity but also substantiates the reduction found for PID. Further studies are needed to corroborate these results. Consideration should be given to the prophylactic use of doxycycline at the time of IUCD insertion as an approach to preventing PID and other IUCD-related morbidity.

PIP: This double-blind, randomized clinical trial was conducted to investigate whether the use of prophylactic doxycycline at intrauterine contraceptive device (IUCD) insertion can reduce the incidence of pelvic inflammatory disease (PID) in women. 1813 women in Nairobi, Kenya, were given 200 mg of doxycycline, taken orally at the time of IUCD insertion. Analysis of the data collected show that the rate of PID infection in the doxycycline-treated group was 31% lower than that in the placebo-treated group. The rate of an unplanned IUCD-related visit to the clinic was also 31% lower in the doxycycline-treated group. Although the significance level (P = 0.17) for the reduction in PID does not meet the conventional standard of 0.05, the results may be suggestive of an effect. In addition, the reduction in IUCD-related visits (P = 0.004) not only represents an important decrease in morbidity, but also substantiates the reduction found for PID. To conclude, the prophylactic use of doxycycline at the time of IUCD insertion appears effective, well tolerated, and cost-effective. Further studies are needed to corroborate these results and consideration should be given to the prophylactic use of doxycycline at the time of IUCD insertion as an approach in preventing PID and other IUCD-related morbidity.

Do the benefits of breastfeeding outweigh the risk of postnatal transmission of HIV via breastmilk?

Conflicting recommendations have been offered about whether HIV+ mothers should breastfeed. Since there is a strong precedent for US infant feeding practices to be imitated in developing countries, a model was constructed to estimate infant mortality if the CDC admonition for HIV+ mothers not to breastfeed were upheld in less developed settings. Estimates are given for infant mortality in the presence and absence of breastfeeding across several baseline levels of infant mortality and across several theoretical rates of transmission through breastfeeding. The infant mortality associated with HIV infection acquired through breastfeeding is estimated to be lower than the mortality associated with the diseases of infancy that would result if breastmilk were withheld. The difference in these estimates is greater in areas with high baseline levels of infant mortality.

PIP: Conflicting advice is available on breast feeding for HIV-positive mothers to developing countries. WHO recommends that mothers regardless of HIV status should continue breast feeding where alternatives are not safe. In the US, CDC advises against breast feeding for HTLV-III/LAV-infected women to avoid transmission to an as yet unaffected newborn. The British have a similar recommendation. Industrialized countries tend to set the standard for developing countries, even though CDC has not directed its policy to developing countries. This study examined the effects of breast feeding by HIV-infected mothers on infant/child mortality compared with bottle feeding. Countries are selected with varying levels of infant mortality (5%, 10%, and 15%). The risk of infection/100,000 uninfected infants is hypothetically modeled. Calculations are made 1) for the number of expected deaths among breast-fed infants due to HIV-related infections from breast milk and to other diseases, and the number of deaths for other diseases is uninfected babies; 2) expected deaths among bottle-fed infants; and 3) total deaths for all babies. It is assume that HIV transmission through breast milk is 20%, that 95% of HIV-infected babies will die before 1 year, and that there are 4 relative risks of death (3 the lowest; 4; 5; and 6 the highest risk) due to diseases of childhood for bottle-fed babies. The confirmed expectation was that reduction in breast feeding will contribute to greater infant mortality. Breast feeding as a method of HIV transmission is still open to question, particularly when mothers are asymptomatic seropositive. The results show that in countries with a 10% infant mortality rate, and the lowest relative risk of 3, 30,000/100,000 uninfected bottle-fed babies are expected to die, however, if breast fed by HIV-infected mothers with a 5% transmission rate, mortality would be 14,000/100,000. Only at a 20% infant mortality rate do expected HIV deaths among breast-fed babies approach the breast-fed babies approach the rate for bottle-fed babies. The likely transmission rate is 1% or 11,000 deaths. Breast milk transmission rates of 1% would yield rate is 1% or 11,000 deaths. Breast milk transmission rates of 1% would yield an estimated 950 additional infant deaths, at 5% 4750, at 10% 9500, and 20% 19,000. These numbers contrast with a 10% infant mortality among bottle-fed babies and 20,000 deaths.

Tubal ligation at cesarean delivery in five Asian centers: a comparison with tubal ligation soon after vaginal delivery.

Increasingly more tubal sterilizations are being performed at the time of cesarean section in the United States and probably also in developing countries. This descriptive study provides us with hitherto unavailable information on the impact of this combined procedure on the women undergoing it. Five Asian centers were included for study. In these centers, 618 women had concurrent tubal ligation at cesarean section in 1973 and 1974. During this period, 3399 women had tubal ligation soon after term vaginal deliveries. The much higher morbidity and mortality in the former group were judged to be attributable to the indications leading to, or the complications of, cesarean section and not to the concurrent tubal ligation. Women undergoing the combined procedure of tubal ligation and cesarean section were more likely to have characteristics associated with later regretting the sterilization.

The percutaneous electrocoagulation vasectomy technique--a comparative trial with the standard incision technique at Marie Stopes House, London.

One-hundred-and-one men requesting vasectomy in 1985 for the purpose of limiting family size were admitted to a study of standard incision and monopolar diathermy, and a new percutaneous electrocoagulation vasectomy procedure. Semen specimens were tested at 10 and 12 weeks after surgery. Men were telephoned at 2, 12 and 24 weeks post-surgery to elicit complications and complaints. Half of the men having the standard incision procedure and about one-third of the men undergoing the percutaneous procedure complained of discomfort during the surgery. At the two-week telephone contact, 23% of those having the standard incision and 66% of those having the percutaneous procedure reported complications. There were few complications or complaints reported at the long-term follow-up contacts with either method; although twice as many men in the percutaneous group were not declared sterile by the end of the study period. Failure rates were 2.0% for the standard incision procedure and 7.8% for the percutaneous approach.

Four-year follow-up of electrocoagulation and tubal ring sterilizations in Costa Rica.

An earlier analysis of 299 laparoscopic sterilizations comparing electrocoagulation and tubal ring occlusion techniques found no significant differences in rates of surgical complications. The risk of potentially serious complications, such as bowel/bladder burns, was considered higher with electrocoagulation be the preferred technique. Examination of the same women through 48 months poststerilization between the two techniques with respect to the incidence of gynecologic surgery performed subsequent to sterilization. Gynecologic abnormalities were similar for women in both groups. The rate of pregnancy was higher for tubal rings than for electrocoagulation (2.1 compared to 0.7 at 48 months) but this difference was not statistically significant.

PIP: An earlier analysis of 299 laparoscopic sterilizations comparing electrocoagulation and tubal ring occlusion techniques found no significant differences in rates of surgical complications. The risk of potentially serious complications, such as bowel/bladder burns, was considered higher with electrocoagulation suggesting that tubal rings might be the preferred technique. Examination of the same women 48 months posterilization showed no signficant difference between the 2 techniques with respect to the incidence of gynecologic surgery performed subsequent to sterilization. Gynecologic abnormalities were similar for women in both groups. The rate of pregnancy was higher for tubal rings than for electrocoagulaton (2.1 compared to 0.7 at 48 months) but this difference was not statistically significant. 151 women (50.5%) underwent sterilization by electrocoagulation; 148 women (49.5%) were sterilized using the tubal ring occlusion technique. All procedures were single incision laparoscopies.

The prevalence of Neisseria gonorrhoea and Chlamydia trachomatis in intra-uterine contraceptive acceptors in Kenya.

PIP: The 1725 women presenting at Kenyatta National Hospital in 1984-86 for IUD insertion were screened for cervical Chlamydia trachomatis and Neisseria gonorrhoea before the IUD insertion. 207 (12%) cases of chlamydia trachomatis and 61 (3.5%) cases of Neisseria gonorrhoea were detected. There was no association between the ages of the women and the prevalence of these 2 sexually transmitted pathogens; however, there was a significant relationship between the prevalence of N gonorrhoea and marital status. N gonorrhoea was detected in 6.2% of never-married and 5.2% of formerly married women compared with 2.3% of currently married subjects (p0.001). Although there was no significant relationship between parity and the rate of isolation of the 2 pathogens, infection tended to be lower in women with 5 or more children. Educational attainment was significantly associated with N gonorrhoea infection: 5.1% in women who had 0-7 years of schooling compared with 3.0% in those with 8 or more years of education (p0.05). 12 women with C trachomatis infection were also positive for N gonorrhoea. There was no significant relationship between C trachomatis infection and any of the demographic variables examined. Given the finding that the greatest risk of pelvic inflammatory disease occurs in the 1st month of IUD use, it can be speculated that pathogens are inserted into the uterine cavity at the time of IUD insertion. It is therefore recommended that clients--especially the unmarried, the formerly unmarried, and those with low levels of education--be screened and treated for N gonorrhoea and C trachomatis before an IUD is inserted.^ieng

Technical failures in female sterilization using the tubal ring: a case-control analysis.

To delineate characteristics of women predisposing to sterilization technical failures, we performed an analysis of 20 technical failures that occurred during tubal ring procedures and 80 control ring procedures matched on planned surgical approach and study site. None of the women had recently been pregnant (interval procedures). The odds ratios (ORs) were elevated for women wearing an IUD in the three months prior to sterilization (OR = 5.0, 90% confidence interval [CI] 2.2, 11.2) and for women with a history of spontaneous abortion (OR = 4.3, 90% CI 1.8, 9.8). A history of pelvic inflammatory disease (PID) and/or current evidence of PID was strongly associated with technical failure (X2 = 25.0, p less than 0.001). The combined effect of any two of these three factors increased the risk synergistically. We examined these factors prospectively and confirmed the elevated risks (relative risk [RR] = 5.0, 5.5 and 22.7 for recent IUD wearing, spontaneous abortion history and history/evidence of PID, respectively). The prospective analysis also found that previous abdominal surgery is associated with technical failure (RR = 6.7).

PIP: To delineate characteristics of women predisposing to sterilization technical failures, we performed an analysis of 20 technical failures that occurred during tubal ring procedures and 80 control ring procedures matched on planned surgical approach and study site. None of the women had recently been pregnant (interval procedures). The odds ratios (ORs) were elevated for women wearing an IUD in the 3 months prior to sterilization (OR=5.0, 90% confidence interval CI 2.2, 11.2) and for women with a history of spontaneous abortion (OR=4.3, CI 1.8, 9.8). A history of pelvic inflammatory disease (PID) and/or current evidence of PID was strongly associated with technical failure (X squared=25.0, p less than 0.001). The combined effect of any 2 of these 3 factors increased the risk synergistically. We examined these factors prospectively and confirmed the elevated risks (relative risk RR =5.0, 5.5 and 22.7 for recent IUD wearing, spontaneous abortion history and history/evidence of PID, respectively). The prospective analysis also found that previous abdominal surgery is associated with technical failure (RR=6.7).

Physician attitudes and family planning in Nigeria.

This study examines family planning attitudes and practices of 681 Nigerian physicians selected from cities in which large university teaching hospitals are located. About half of the physicians were practicing family planning; the method of choice was the IUD. Obstetrician/gynecologists and general practitioners were more likely to provide methods to their patients than were other types of physicians. The physicians were concerned about population growth and favored family planning, yet a substantial minority believed that family planning is foreign to the culture and that it promotes promiscuity. Physicians were reluctant to promote family planning on a wide scale; many disapproved of non-physicians providing oral contraceptives or IUDs.

PIP: This study examines family planning attitudes and practices of 681 Nigerian physicians selected from cities in which large university teaching hospitals are located. About 1/2 of the physicians were practicing family planning; the method of choice was the IUD. Obsterician/gynecologists and general practitioners were more likely to provide methods to their patients than were other types of physicians. The physicians were concerned about population growth and favored family planning, yet a substantial minority believed that family planning is foreign to the culture and that it promotes promiscuity. Physicians were reluctant to promote family planning on a wide scale; many disapproved of non-physicians providing oral contraceptives or IUDs. They desired an average family size of 4 children. The average number of children desired by Nigerians is 8. Only 6% of the general population is practicing contraception, and the majority reports using abstinence. While contraceptive use was high among physicians who did not want any more children, it was low for those who did want more. With the decline in breastfeeding and postpartum abstinence among Nigerian women, contraceptive use is becoming more important for spacing pregnancies. Use of sterilization was low among the respondents who did not want more children. While physicians said that they would recommend sterilization to their patients, few chose it for themselves. Many Nigerian women do not have access to a physician. In order to provide services to these women, nurse/midwives and community health workers should be trained as distributors of family planning. Community-based distribution programs have the potential to increase contraceptive prevalence dramatically.

A comparative study of Neo Sampoon, Ortho Vaginal Tablets and Emko Vaginal Tablets in Accra, Ghana.

Neo Sampoon is an effervescent contraceptive vaginal tablet manufactured in Japan that contains 60 mg of the spermicide menfegol. Ortho Vaginal Tablets (OVT) and Emko Vaginal Tablets (EVT), both containing 100 mg of the spermicide nonoxynol-9, were manufactured in the USA. The three products were compared in a randomized clinical trial conducted at the family planning clinics of the Korle-Bu Teaching Hospital and the Kotobaabi Polyclinic in Accra, Ghana. Three-hundred volunteers participated. At 12 months, the life-table pregnancy rates were 9.6, 11.3 and 12.5 per 100 women in the Neo Sampoon, OVT and EVT groups, respectively (p greater than 0.10). More EVT than Neo Sampoon or OVT users discontinued because of discomfort as well as for other product-related reasons (p less than 0.01). The most common reason for discontinuation was the temporary absence of sexual partner, with more than 40% of the women overall terminating for this reason. The 12-month life-table continuation rates per 100 women were higher for the Neo Sampoon group (62.4) than the OVT group (48.6) or the EVT group (38.5) (p less than 0.01). The effectiveness of the three products seems to be similar, but Neo Sampoon and OVT appear to be more acceptable than EVT in this Ghanaian population.

PIP: The effectiveness and acceptability of 3 vaginal tablets (VTs)--Neo Sampoon, Ortho (OVT) and Emko (EVT)--were compared in a clinical trial conducted at the family planning clinics of Korle-Bu Teaching Hospital and Kotobaabi Polyclinic in Accra, Ghana. Subjects included 300 sexually active women ages 18-40 years who were randomly allocated to 1 of the 3 contraceptive methods. The results suggest that, although the effectiveness of the 3 tablets is comparable, Neo Sampoon and OVT are more acceptable than EVT. EVT acceptors reported poorer product compliance, more method-related complaints, and a higher rate of discontinuation. The proportion of women reporting 1 or more method-related complaints (e.g., burning or stinging) during the 1-year study period was 8.9% among Neo Sampoon acceptors, 11.5% among women in the OVT group, and 32.6% among subjects in the EVT group. However, the prevalence of these complaints, and that of increased vaginal discharge, diminished with time in all 3 study groups. Within 12 months, there had been 33 discontinuations in the Neo Sampoon group, 47 among OVT acceptors, and 57 in the EVT group. Over 40% of these discontinuations were a result of temporary absence of the sexual partner, and another 19% reflected non-method-related reasons such as desiring a pregnancy. On the other hand, discontinuation for discomfort or product-related reasons was significantly higher among EVT acceptors compared to Neo Sampoon and OVT acceptors. There were 7 unplanned pregnancies in the Neo Sampoon group (12 month cumulative pregnancy rate 9.6/100), 8 in OVT group (11.3/100), and 9 among EVT acceptors (12.5/100). 9 (38%) of the 24 pregnancies occurred in the 1st month of tablet use and only 1 pregnancy occurred 6 months or more after admission, suggesting that lack of familiarity contributed to method failure. 12-month continuation rates were significantly higher among Neo Sampoon acceptors (62.4/100) than among OVT (48.6/100) or EVT (38.5/100) acceptors.

Abortion experience among obstetric patients at Korle-Bu Hospital, Accra, Ghana.

PIP: Hospital admissions for complications of abortion have been increasing in Africa, indicating a rise in the incidence of abortion. In all pregnant women ever admitted to Korle-Bu hospital in Accra, Ghana, the chance that the outcome of their last pregnancy was an induced abortion decreased as the number of previous pregnancies increased. Women with higher levels of education were more likely to have their 1st pregnancy terminated in an induced abortion. Younger women were more likely than older women at each level of education to have an induced abortion terminate a 1st pregnancy. The use of contraceptives during the last pregnancy interval increased with the level of education of the woman and the number of previous pregnancies. Contraceptive use was also highest among women whose last pregnancy outcome was an induced abortion. The mean pregnancy interval decreased with increasing number of previous pregnancies for both women who used and who did not use contraceptives during their last pregnancy interval. But the mean pregnancy interval was higher among women who used contraceptives. It appears that the abortion experience in this region of Africa is most common in lower parity young women with high levels of education who desire to delay a 1st birth or to space births. This is in contrast in Latin America and other developing countries in which abortion is used mainly by older, married, urban women to limit family size. Contraceptive use in this region of Africa is low, indicating the need for more family planning programs and increasing use of existing programs.^ieng