Who is at high risk? A comparison of the seroprevalence of human immunodeficiency virus in pregnant women and a high risk group

To compare the seroprevalence of HIV in Jamaican pregnant women with that in substance abusers, two groups of antenatal patients were studied, one (A) attending a public hospital clinic and the other (B) attending private clinics. The HIV seroprevalence in the antenatal patients was compared with that in the substance abusers, group C, in 1996 and five years later in 2001. HIV antibody was determined by enzyme immunoassay. The HIV seroprevalence in group A more than doubled (1.6-3.8) in five-years, 1996-2001. There were no seropositives in group B. In group C, the seroprevalence rose from 2.08 in 1996 to 5.76 in 2001. There was indication that group A might no longer be considered [quot ]low risk[quot ], as there was no significant difference from group C in HIV seroprevalence in 1996 and 2001. The trend seen in this study is worthy of further investigation

Who is at high risk? A comparison of the seroprevalence of human immunodeficiency virus in pregnant women and a high risk group.

To compare the seroprevalence of HIV in Jamaican pregnant women with that in substance abusers, two groups of antenatal patients were studied, one (A) attending a public hospital clinic and the other (B) attending private clinics. The HIV seroprevalence in the antenatal patients was compared with that in the substance abusers, group C, in 1996 and five years later in 2001. HIV antibody was determined by enzyme immunoassay. The HIV seroprevalence in group A more than doubled (1.6%-3.8%) in five-years, 1996-2001. There were no seropositives in group B. In group C, the seroprevalence rose from 2.08% in 1996 to 5.76% in 2001. There was indication that group A might no longer be considered "low risk", as there was no significant difference from group C in HIV seroprevalence in 1996 and 2001. The trend seen in this study is worthy of further investigation.

In vitro fertilization. The Jamaican experience

In June 2000, twenty-eight infertile couples were treated by in vitro fertilization and embryo transfer at our initial assisted reproduction programme carried out in conjunction with Midland Fertility Services, Aldridge, Birmingham, England. A pre-requisite for treatment was that on day 3 of the menstrual cycle the levels of follicle stimulating hormone (FSH) and oestradiol (E2) should be < 10 i mu/l and < 100 pg/ml respectively in the female partner. The ages of the women ranged from 26 to 42 years with a mean age of 35.5 years. Down regulation was carried out by using buserelin acetate 0.5 microgram subcutaneously from day 21 of the cycle for 21 days. This process was completed when the ovaries and pituitary gland were quiescent and the endometrial thickness < 4 mm in diameter. On completion of down regulation the gonadotrophin hormone, pergonal (dosage of 150-450 units) was used for ovarian hyperstimulation. A total of 294 oocytes (mean of 10.5, range 2-45) were retrieved of which 138 were fertilized (mean of 4.9, range of 0-28). Twenty-four patients each received a mean of two embryos. Five patients (20.8) had positive pregnancy tests. Three patients (0.1) developed ovarian hyperstimulation syndrome (OHSS), one had the severe, and two, the mild form of the syndrome. All three cases were treated successfully. The success at the initial IVF controlled ovarian hyperstimulation augers well for the future of infertile couples seeking treatment at the Fertility Management Unit, The University of the West Indies, Jamaica.

In vitro fertilization. The Jamaican experience.

In June 2000, twenty-eight infertile couples were treated by in vitro fertilization and embryo transfer at our initial assisted reproduction programme carried out in conjunction with Midland Fertility Services, Aldridge, Birmingham, England. A pre-requisite for treatment was that on day 3 of the menstrual cycle the levels of follicle stimulating hormone (FSH) and oestradiol (E2) should be < 10 i mu/l and < 100 pg/ml respectively in the female partner. The ages of the women ranged from 26 to 42 years with a mean age of 35.5 years. Down regulation was carried out by using buserelin acetate 0.5 microgram subcutaneously from day 21 of the cycle for 21 days. This process was completed when the ovaries and pituitary gland were quiescent and the endometrial thickness < 4 mm in diameter. On completion of down regulation the gonadotrophin hormone, pergonal (dosage of 150-450 units) was used for ovarian hyperstimulation. A total of 294 oocytes (mean of 10.5, range 2-45) were retrieved of which 138 were fertilized (mean of 4.9, range of 0-28). Twenty-four patients each received a mean of two embryos. Five patients (20.8%) had positive pregnancy tests. Three patients (0.1%) developed ovarian hyperstimulation syndrome (OHSS), one had the severe, and two, the mild form of the syndrome. All three cases were treated successfully. The success at the initial IVF controlled ovarian hyperstimulation augers well for the future of infertile couples seeking treatment at the Fertility Management Unit, The University of the West Indies, Jamaica.

Prevalence of viral and bacterial sexually transmitted pathogens in Jamaican pregnant women.

In this study we investigated the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, human immunodeficiency virus type I (HIV-I), human T cell lymphotropic virus type 1 (HTLV-1) and hepatitis B virus (HBV) infections in 200 pregnant women attending antenatal clinics at the University Hospital of the West Indies. 19% of the women had at least one pathogen: C. trachomatis was found in 16%, HTLV-1 in 2%, HIV-1, HBV and N. gonorrhoeae each in 0.5% C. trachomatis infection was more prevalent in women less than 20 years of age (31%) than in those 20 years and older (16%; OR = 0.43; chi 2 = 5.66; p < 0.05). The study demonstrates the need for identification of sexually transmitted pathogens in antenatal women for syndromic management of genital infections as part of the strategy for prevention and control of HIV/AIDS (acquired immunodeficiency syndrome) in Jamaica.

Prevalence of viral and bacterial sexually transmitted pathogens in Jamaican pregnant women

In this study we investigated the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, human immunodeficiency virus type I (HIV-I), human T cell lymphotropic virus type 1 (HTLV-1) and hepatitis B virus (HBV) infections in 200 pregnant women attending antenatal clinics at the University Hospital of the West Indies. 19of the women had at least one pathogen: C. trachomatis was found in 16, HTLV-1 in 2, HIV-1, HBV and N. gonorrhoeae each in 0.5C. trachomatis infection was more prevalent in women less than 20 years of age (31) than in those 20 years and older (16; OR = 0.43; chi 2 = 5.66; p < 0.05). The study demonstrates the need for identification of sexually transmitted pathogens in antenatal women for syndromic management of genital infections as part of the strategy for prevention and control of HIV/AIDS (acquired immunodeficiency syndrome) in Jamaica.

The Norplant experience at the University Hospital of the West Indies.

Sixty-eight patients had Norplant inserted between May 1992 and November 1993 as part of a pre-introductory study. The main side effect was weight change which occurred in 85.3% (58 patients); weight loss occurred in 25.0% (17 patients, one patient voiced a complaint) and weight gain occurred in 60.3% (41 patients, 10 of whom voiced a complaint). Menstrual problems were the next most frequent side effect occurring in 70.4% (48 patients); spotting occurring in 22% (15 patients, none of whom complained) and heavy bleeding in 7.3% (five patients, all of whom complained). Amenorrhoea occurred in 41.1% (28 patients). Other complaints were minor. No pregnancies have been recorded to date. There were no procedural complications and all patients were satisfied with the cosmetic appearance. To date there have been 36 removals, the majority for menstrual complications. Norplant is a safe, effective means of 'reversible sterilisation' which should be utilised in family planning programmes throughout the country.

Disparities in access to family planning services in Jamaica.

In order to improve the effectiveness and subtainability of the family planning programme, the National Family Planning Board has devised a strategy to shift users to longer-acting methods and increase the role of the private sector. To design interventions, a better understanding of existing services was thought to be necessary. This study examines the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. The study found that, because of the concentration of private sector providers-the main outlets for longer-acting methods-in urban areas, rural areas had poor access to these methods. Because rural areas are not attractive to private sector providers, the public sector should recognize the need to continue to serve these areas.

PIP: Jamaica's National Family Planning Board's strategy to ensure the sustainability of its family planning program and improve its effectiveness involves getting users of contraception to use longer-acting methods and increasing the role of the private sector in service delivery. Before this approach was implemented, however, a study was conducted to secure a better understanding of the nature and scope of existing family planning services in Jamaica. The study looked at the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. Private sector providers, the main sources of longer-acting methods, were found to be concentrated in urban areas. As such, longer-acting methods were hard to come by in rural areas. The public sector must recognize that private sector providers are not serving rural areas, and provide longer-acting methods to people who want them.

Prevalence of antibodies to hepatitis C virus and other markers in Jamaica.

Three population groups, 1500 blood donors, 513 antenatal women representing a normal population group and 250 sicklers representing a multiply transfused group were studied to determine the prevalence of hepatitis C viral (HCV) infection in Jamaica. The relationship to liver enzyme levels, hepatitis B infection, syphilis and HIV infection was also investigated. Sera were screened by enzyme-linked immunoassay (EIA) for anti-HCV C100-3 and subsequently tested by a supplementary second generation recombinant immunoblot assay (RIBA). In the blood donors, the prevalence of anti-HCV was low, 0.3%-0.4%, the same level as that reported by several European countries. In the multiply transfused sicklers, the prevalence was more than seven times higher. No HCV infection was detected in the antenatal group. There was little correlation between HCV infection and surrogate markers alanine aminotransferase (ALT) and antibody to hepatitis B core antigen (anti-HBc) and no correlation with sexually transmitted diseases.

The effect of user fees on the utilization of family planning services. A clinical study.

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinical records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods.

PIP: In order to foster the self-sustainability of its family planning (FP) program, Jamaica has introduced user fees for previously free FP services. In 1992, donations were solicited for injectables and sterilization. By January 1993, a fee of J $200 was set for sterilization, and fees for other services were introduced. A study was undertaken to 1) examine the effect of the new fee structure on clinic attendance; 2) determine the extent to which the fees might have encouraged a shift to other methods; and 3) establish a range of affordable prices for current users. Data were collected from clinic attendance records for January-April of 1990-1992 and compared to the same period in 1993. A 20% sample of clients (n = 1002) attending in January of each year was followed for 4 months to allow comparisons of method changes. Finally a questionnaire was administered to a 25% sample of daily users (n = 200) over 4 weeks in February 1993 to determine affordable fees. It was found that there was a 28% decline in attendance in 1993 over 1992 despite a temporary halt in sterilizations in early 1992. The number of new clients in 1993 increased but failed to reach the 1990 level. The number of old clients attending in 1993 was the lowest for the 4 years. In early 1992, there was a shortage of injectable contraceptives. Despite this, injectables were used 7% more in 1992 than in 1993 when a fee of J $100 was established. Almost a third of the sample of new clients accepted sterilization in 1993, and all of the women kept their appointments unlike previous experience (perhaps out of fear of a higher fee in the future). 1993 also saw the highest percentage of drop-outs of any year studied. Current prices charged by the clinic for oral contraceptives, injectables, and sterilization were acceptable to 85, 23, and 13% of the women, respectively. The substantial drop in clientele over a single year affected mainly clients using injectables. A reduction in the price of this method seems justified not only by the loss of clients but also because the fee for this method is higher than that for longterm or permanent methods. Costs could also be subsidized by other strategies, such as allowing higher income couples to pay a fee to secure an appointment instead of having to wait. Future price increases should be gradual, since increases of 10% a few times a year are less likely to result in patient loss.

Show, no show and sterilization.

The study investigates the factors involved in the decision of a sample of women to break appointments for sterilizations at the Fertility Management Unit of the University of the West Indies. A case control study involved 50 women who did not show up (no-shows) and an equal number who did show up (shows) over the same period. The no-shows had spent a shorter time in their current union than the shows, and some had no children for their partners at the time the appointments were made. Marriage was the single most important event that would encourage the no-shows to consider sterilization in the future. As long as poor women see child bearing as a precondition for financial assistance from spouses, they will hesitate to give up this capability.

PIP: As part of a research program to identify the barriers to increasing the acceptance of sterilization in the West Indies, a study was undertaken to determine why an estimated 16% of annual registrants for sterilization failed to keep their appointments (no-shows). From 300 no-shows, a random sample of 50 was interviewed and matched for year of registration, age, parity, marital and economic status, and geographic area with a control sample of 50 sterilized women. The most important reason for considering sterilization for all of the women was the desire to have no more children. The no-shows exhibited a lack of self-motivation, citing friends and medical personnel as motivators, and in no case did motivation come from the partner. The no-shows cited partner-related reasons and fear as causing them to break the appointments. Many women were ready for sterilization but were unable to discuss the topic with their partners. Among the sterilized women, 2 regretted the procedure. Among the no-shows, there had been 8 pregnancies, 3 of which were terminated, and 7 women were attempting to become pregnant. Recent research in the Caribbean suggests that improving women's status plays a more important role in reducing fertility than that played by family planning programs. As long as childbearing is seen as a precondition for receiving financial assistance from a man, it will continue.

Hysteroscopic assessment of abnormal uterine bleeding in users of the intrauterine contraceptive device.

Sixty users of the IUD who complained of abnormal menstrual blood loss were evaluated by hysteroscopy, and the findings were compared with a matched group who had this investigation for "missing strings". Submucous fibroids and endometritis were more frequent in the study group whereas malposition of the IUD was commoner in the controls (p < 0.05).

PIP: Hysteroscopic findings in 60 Jamaican IUD users who complained of excessive bleeding revealed a high incidence of submucous fibroids and inflammatory lesions. Study subjects, recruited from the family planning clinic at the University of the West Indies, were using the Lippes Loop C or D; the average duration of use was 3.6 years. 60 matched controls undergoing hysteroscopic evaluation of missing IUD strings served as controls. Uterine abnormalities were detected in 42 of the 60 cases compared with only 26 of 60 controls (p 0.05). Submucous fibroids were identified in 16 cases and only 6 controls; endometriosis was present in 18 cases and 14 controls, while 4 cases and 2 controls had "suspicious" endometrium. Malposition of the IUD or penetration of the uterine wall was present in 14 cases compared to 36 controls. Until the levonorgestrel-releasing IUD (associated with reduced menstrual blood loss) becomes available in Jamaica, use of hysteroscopy is recommended to evaluate excessive bleeding in IUD users.

Large loop excision of the transformation zone (LLETZ)--an alternative treatment for cervical intraepithelial neoplasia.

The technique of large loop excision of the transformation zone (LLETZ) as an alternative to destructive/ablative methods of treatment of cervical intraepithelial neoplasia (CIN) such as cryotherapy, laser vaporization and cone biopsy of uterine cervix is assessed. Forty-five patients underwent this procedure for either diagnostic or therapeutic reasons. It was well-tolerated, and minor bleeding occurred in 4.4% of patients. The quality of the histological specimen was excellent in all cases, only two showing evidence of charring artefacts. In 11 patients (24.4%), a more serious lesion was detected than that found at punch biopsy of the cervix. This method offers a cheaper and more effective alternative to laser vaporization and combines the benefits of the gold standard cone biopsy of the cervix with that of local ablative techniques.

Chlamydial infections in selected populations in Jamaica.

The importance of Chlamydia trachomatis as a cause of genital tract infection in Caribbean countries is largely unknown. Two hundred and sixteen cervical and urethral specimens were collected from patients with cervicitis and urethritis attending a Sexually Transmitted Diseases (STD) Clinic, a Gynaecology Clinic and a Family Planning Clinic in Kingston. Specimens were tested for chlamydiae by direct immunofluorescence and cell culture methods. They were also investigated for N. gonorrhoeae infections. Seventy-two of 138 patients (52.2%) at the STD Clinic were positive for chlamydiae; 28 of 50 (56.0%) from the Gynaecology Clinic and 11 of 28 (39.3%) from the Family Planning Clinic were positive. The prevalence of C. trachomatis (52.3%) was higher than that of N. gonorrhoeae (11.1%) in all groups. The results indicate that C. trachomatis is a common cause of genital tract infections in Jamaica.

Diagnostic hysteroscopy.

Diagnostic hysteroscopy was performed on 100 patients. The most frequent indication was abnormal uterine bleeding. In premenopausal women, submucous fibroids were the main findings and in post-menopausal women, 59 per cent had an atrophic endometrium. Precise localization of the missing intrauterine contraceptive devices was achieved in all cases. Hysteroscopy improved diagnostic accuracy and reduced the need for blind curettage.

Testicular function in rats following immobilization stress.

Stress is believed to influence male reproductive activity. Male rats were subjected to immobilization stress for 2 h/day for 30 days to assess the effects of stress on testicular function. Net mass of the testes, epididymes and the seminal vesicles, sperm morphology, number of epididymal sperms and percent progressive motility of the sperms were determined. Adrenal weights were significantly increased (P less than 0.05) in the stressed animals. There was no significant difference between the control and the stressed animals with respect to testicular and epididymal weight, level of sperm production, progressive motility, seminal vesicular weight and abnormal forms. Histological examination also revealed a similarity in the structure of seminiferous tubules, adequacy of cell types of developing germ cells, structure of Leydig cells and epididymal lumina in both the groups. This study demonstrated a lack of significant effect of immobilization stress on testicular function in rats.

A multicentered phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: II. The comparison of bleeding patterns. World Health Organization. Task Force on Long-Acting Systemic Agents for Fertility Regulation Special Programme of Research, Development and Research Training in Human Reproduction.

A multicentered phase III clinical trial was conducted in seven countries to compare two dosages of depot-medroxyprogesterone acetate (DMPA), 100mg and 150mg, given every 90 days. Contraceptive efficacy and side-effects of both regimens were reported previously. Their effect on vaginal bleeding patterns is the object of this paper. A total of 1216 women were randomly assigned to a dose group and 1156 of them provided a menstrual diary. The comparison of the bleeding patterns is made using a 90-day reference period approach and following the guidelines published by WHO. In addition, the longest bleeding/spotting episode and the longest bleeding/spotting-free interval are calculated over the entire diary length. The only difference found between the two dose groups is a higher incidence of amenorrhea with the 150mg regimen. Overall, there is a high degree of consistency between the reasons given by individual women for discontinuing the contraceptive method and their vaginal bleeding pattern during the 90 days preceding discontinuation. However the data revealed large between-centre differences, both in the incidence of specific patterns, and in the identification by women of bleeding problems as reasons for discontinuation. This last point suggests that the life-table analysis underestimates the true incidence of menstrual irregularities. Comments on the reference period analysis method are made.

A multicentred phase III comparative clinical trial of depot-medroxyprogesterone acetate given three-monthly at doses of 100 mg or 150 mg: 1. Contraceptive efficacy and side effects. World Health Organization Task Force on Long-Acting Systemic Agents for Fertility Regulation. Special Programme of Research, Development and Research Training in Human Reproduction.

Two dosages of depot-medroxyprogesterone acetate (DMPA), 100 mg and 150 mg given every 90 days, were compared in two groups of women with regard to effectiveness, reported complaints and reasons for discontinuation. A total of 1216 women were recruited into a seven-centre, multinational, randomized clinical trial. Follow-up was for a period of one year and resulted in a total of 5507 woman-months of experience of 100 mg DMPA and 5429 woman-months of experience of the 150 mg dose. The study showed little difference in efficacy and side effects between the two treatment groups. Two pregnancies occurred in women receiving 100 mg DMPA giving a Pearl Index of 0.44 per 100 woman-years. None occurred in the 150 mg group. There was no difference in the overall continuation rates between the two groups at one year, being 59.3% in the 100 mg group and 58.8% in the 150 mg group. Except for discontinuation of method use for amenorrhea, the rates of all medical and non-medical reasons given for discontinuation were comparable between the two treatment groups. Women's perception of lack of bleeding was reported as amenorrhea and resulted in discontinuation rates at 12 months for amenorrhea of 7.2% for women receiving 100 mg of DMPA and 12.5% for those receiving the 150 mg dose. Three centres, Alexandria, Karachi and Szeged, made the major contributions to this difference.