Category Archives: Women’s Health

How the Female Condom Can Help the Women of Chile

Huge strides have been made in the understanding of how behavior drives HIV-infection. Notably, much of the coverage of how social constructs (and contexts!) contribute to the epidemic revolves around prevention education in the scope of proper – male – condom use. No doubt, comprehensive interventions in this arena have been instrumental in curbing infections. But it’s worth noting the limitations of this approach given the changing face of the virus.

Chile, a country with a prevalence of 28,963 notified people living with HIV (and an estimation of about twice that actually living with the virus), like many countries, is seeing an increasingly feminized epidemic.

Unfortunately (and perhaps unsurprisingly), most prevention and education frameworks neglect to take into consideration why this is.

In many cases, and specifically in Chile’s, women are contracting the virus via their husbands in relationships presumed to be safe and monogamous, and in which the negotiation of condom use on the part of the woman immediately presumes she is adulterous.

More nuanced approaches to prevention need to be undertaken with the understanding of how relationship dynamics – and the social climate in terms of perceptions of HIV+ individuals – contribute to the spread of the virus.

The International Community of Women Living with HIV/AIDS Chile is doing just that.

ICW Chile primarily works with women who contracted HIV from their husbands, have been subsequently widowed due to the illness, and are now attempting to forge their own way. This is difficult in a place where the stigma of HIV weighs heavily enough for most women to expect job termination if they disclose their status. While treatment is readily accessible – the Ministry of Health provides ARTs for all those in need, an initiative not to be understated – the social ramifications prompt many women to remain silent.

An organization dedicated to education, awareness raising, commemorations, and training in areas of women’s sexual and reproductive health and empowerment (and, importantly, with a board made up entirely of HIV+ women), they are embarking on an undertaking addressing the need for women to be able to protect themselves – by providing them with female condoms.

Female condoms aren’t entirely absent in Chile – but they can hardly be considered accessible when only one organization in Santiago is selling them – at $6 a piece. Of importance to note, they are desired – one organization that represents 2,000 sex workers in Santiago has shared that of the approximately 70 women a week coming to them for contraceptives and protection, female condoms are consistently requested.

The reason? They are often able to negotiate male condoms with clients, but not with their partners or husbands, putting both parties at risk. Female condoms can be inserted before sex by the woman herself, which precludes a negotiation conversation that comes with the use of the male condom (and is often ultimately refused).

This is where ICW Chile comes in.

Female Condom

The ICW Chile has already forged some of the essential partnerships to get this initiative off the ground. Groups like Fundacion Margen (a sex workers’ rights and advocacy group), in addition to their own five sub-regional teams around the country are prepared to help with raising awareness for the campaign as well as actually distributing the female condoms. Two HIV/AIDS organizations and two transgender health groups are also supporting ICW Chile’s efforts, and the Santiago Chapter of the National Women’s Service (SERNAM) has also offered their assistance. Creating a robust community of like-minded organizations, with resources and ties to mobilize is no doubt important here – but without the product, these connections run the risk of withering.

Luckily, one gift that’s helping them get off the ground is from the Female Health Company, one of the two primary female condom manufacturers, which recently pledged to donate 1,000 female condoms to the campaign, an instrumental and desperately needed move.

But it’s not enough.

When you reflect on the numbers above, it’s clear that ICW Chile needs our help in procuring the goods – and we’re going to make it as easy as possible to assist!

The goal is to distribute 30,000-35,000 female condoms in the next six months, and reach out to 60,000 people educationally. Showing a dedicated interest to the Chilean government, by region, and indicating how many people would utilize the female condoms if they were accessible (financially as well as physically!), could help prompt a firmer commitment from the Ministry of Health to provide female condoms on the scale of male condoms.

They’ve set up an Indiegogo page that details what your gift can provide, what you’ll get in return, and some of the important facts we’ve highlighted here. (I’m donating in the name of my mom for Mother’s Day!) They’ve gotten some buzz already, and this is a bandwagon worth jumping on.

I urge you to check out their Twitter and Facebook pages as well, and share widely with your networks. We’ve all seen what social media networks and crowd-funded projects can achieve, and I can think of no better project right now needing our crucial support.

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Filed under Epidemiology and Population Health, Feminism, Health Behavior, Health Education, International, Public Health, Reproductive and Sexual Health, Women's Health

Planned Parenthood Drops the Pro-Choice/Pro-Life Labels

And here is their video explaining why.

Thoughts?

I generally agree that using labels in an incredible complex and nuanced decision like terminating a pregnancy is for the most part unhelpful. However, I never much liked “pro-life” for those opposed to abortion rights anyway, and preferred to use the term “anti-choice,” for the reasons that many have articulated – that a woman’s life must be considered above that of a fetus, that choosing to terminate a pregnancy based on one’s personal circumstances is in fact being pro-life and thinking of a potential child’s future, that a fetus is not yet an actual life, that a woman has a right to decide what goes on in her own body. As with all things, the weight and emotions of descriptors sometimes get too heavy, and I do hope that this will encourage more in-depth conversation around abortion rights.

Additionally, Guttmacher recently release a series of infogrpahics covering the racial/ethnic disparities in accessing abortion care, income disparities, how women pay for abortions, and a cross-sectional look at abortion in the United States. Check them out:

U.S. Women who Have Abortions

 

How do Women Pay for Abortions?

How do Women Pay for Abortions?

 

Racial and Ethnic Disparities

Racial and Ethnic Disparities

 

Abortion Concentrated Among the Poor

Abortion Concentrated Among the Poor

 

Barriers to Abortion Access

Barriers to Abortion Access

 

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Filed under Feminism, Public Health, Reproductive and Sexual Health, Women's Health

Retraumatization: The Increased Risk of HIV Transmission among Abuse and Assault Victims

While the transmission of HIV and the causes of HIV-related death are actually more complicated—and even more nuanced—than public discussion would let on, a few presumptions about it remain fairly accurate.

For women who are marginalized in their communities, who are victims of abuse or assault, and who are economically or socially dependent on a spouse, the risk of them contracting HIV or dying from multiple complications from AIDS is simply greater than that of women fortunate enough to not be subjected to these circumstances. Take these scenarios:

  • The power dynamic in an abusive relationship may prohibit women from being able to protect herself from a partner who refuses to wear a condom
  • Women in poverty and those who need to rely on a partner for financial support may have greater risk of comorbid infections than women of economic independence. They are less likely to have the health insurance and relationship with a healthcare provider that would support HIV testing and provide the essential—and expensive—HIV medications to ensure a healthy life and lower the risk of co-morbid infections
  • People without social support, living in fear of what an HIV-positive diagnosis means, or those who have reason to fear stigma around personal behavior when seeking treatment are less likely to know where to access treatment or seek it out because of that fear, stigma and lack of support

Common sense would seem to support these statements. But until recently, the pathways of infection were not always clear, and while the conclusions above seemed certainly reasonable, specific data to support them had been difficult to collect. Two recent studies led by a UCSF-researcher have changed that. One synthesized what is known about PTSD and exposure to trauma among HIV-positive women, and the other explored the root of this relationship.

The results were remarkable. HIV-positive women had between two and six times the rates of childhood and adult physical and sexual abuse, and PTSD. The snapshot of risk behaviors among HIV-positive women was sobering:

  Sample size Number (%) of participants with each characteristic
Sexual activity
Any sexual activity in the past 6 months 113 61 (54.0%)
 With a main partnerMedian number of main partners (if any) 61 43 (70.5%)1 (range 1–2)
 With casual partnersMedian number of casual partners (if any)a 61 23 (37.7%)1 (range 1–25)
Sex with any HIV negative or unknown serostatus partners (if sexually active) in the last 6 months 61 51 (83.6%)
 Disclosure of HIV status less than all of the time with these partners 51 29 (56.9%)
 Using condoms less than all of the time with these partners 51 31 (60.8%)
 Detectable viral load 51 30 (58.8%)
 Disclosure of HIV status less than all of the time, and using condoms less than all of the time, and a detectable viral load 51 16 (31.4%)
Substance use (any, recent)
Cigarettes 110 71 (64.5%)
Alcohol 111 50 (45.0%)
Marijuana 111 39 (35.1%)
Crack/cocaine, heroin, and/or methamphetamines 111 45 (40.5%)
IDUb 112 11 (9.8%)
 IDU who share needles 11 5 (45.5%)
 IDU who have a detectable viral load 11 6 (54.5%)

aOne participant had a very high number of sexual partners (N = 250) and was excluded from the analysis; b IDU injection drug use; ©2012 Machtinger, et al. (retrieved December 16, 2012.)

There were striking findings in terms of both HIV treatment failure and the impact of the above risk behavior in these women, bringing us the first real data hoping to explain this relationship. Those who suffered from recent trauma had more than four times the odds of anti-retroviral (ART) failure while on treatment than HIV-positive non-victims—and this was seemingly not due to self-reported poor adherence to the medication. One potential explanation offered by the study authors is that abuse and trauma interfere with an individual’s ability to stay on a consistent medication schedule, which is essential for control of the virus. Other studies have confirmed that abuse manifest as control, in which a male partner prevents his HIV-positive female partner from accessing services at a clinic out of fear that the stigma of HIV would be attached to him.

HIV-positive victims of recent trauma also all reported experiencing what the study calls “coerced sex,” and have over three times the odds of un-traumatized women of having sex with HIV-negative or status-unknown individuals. They had greater than four times the odds of inconsistent condom use, potentially exposing those casual partners to the virus. While high-risk sex behavior is always a factor in HIV-transmission, HIV-positive individuals who adhere consistently to HIV treatments are significantly less likely to infect HIV-negative partners during sex. So the lack of treatment adherence among traumatized HIV-positive women combined with the risky sex behavior is a great concern.

Interestingly, these figures were only significant among women who experienced recent trauma, indicating that the ongoing—not merely one occurrence—circumstances of abuse are the key to the relationship between HIV-infection and HIV-related illness and death. This can actually be seen as a snapshot of hope—if we are able to offer abuse, assault, and PTSD victims the appropriate support to heal from the experiences, we may be able to weaken the HIV/trauma relationship.

These studies draw a clear line between victims of assault and trauma and both the spread of HIV within their communities and the increased risk of HIV-related illness and death. But interestingly, the risk goes much deeper than these socioeconomic circumstances. The conversation around HIV transmission is generally split into one of two categories: social and behavioral—risky activity, injection drug use, the prejudicial judgment of sex workers; and medical and clinical—how the virus infiltrates the immune system, takes over cells, and how it is and isn’t suppressed with antiretroviral medications. What isn’t usually discussed is the possible combination of these two categories and how together they create a perfect storm for potential infection.

Recent studies have shown that those individuals suffering from PTSD had significantly higher rates of cytomegalovirus (CMV) in their body. A virus that is found in between 50%-80% of adults in the United States, CMV remains largely undetected—latent, suppressed, unproblematic—in healthy individuals. It’s also seen as a marker of immune health and function, and of the body’s ability to control potential infections. Given that 30% of American women with HIV/AIDS have PTSD (five times the national average), the potential relationship between their HIV-status and even further compromised immune function could lead to a myriad of comorbid infections and premature death. Other research has also shown that additional biological mechanisms may prevent ART-treatment from being as effective as possible, including high cortisol (stress hormone) levels. Not only do these victims have to fight against abuse and assault, they have been left without the essential social support to decrease risky behaviors that may expose others to the virus, and their own bodies are in revolt.

Collecting this kind of information is difficult. It requires consistent and positive communication between women and providers, unobstructed access to medical care and uninterrupted ART treatment, and of course, in this example, most importantly—removal from an abusive environment.

The combination of immunosuppression due to PTSD, the detectable rates of HIV in traumatized women whose viral loads are not suppressed by consistent anti-retroviral treatments, and the concurrent risk behaviors of abused HIV-positive women, all contribute to higher rates of HIV-infection in communities, as well as the potential for co-morbid infections and HIV-related death. Until these women are able to find the essential social and community support, free from abuse and trauma, and until their access to care and preventative measures are fully realized, the relationship between trauma and HIV will only deepen.

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Filed under Epidemiology and Population Health, Feminism, Health Behavior, Mental Health, Public Health, Rape and Sexual Assault, Reproductive and Sexual Health, Violence Against Women, Women's Health

The Staggering Incidence of Breast Cancer in the Bay Area

Check out this piece in Tuesday’s edition of my hometown paper, the San Francisco Chronicle, discussing research by the Public Health Institute on the bizarrely high incidence of breast cancer in Bay Area counties. It’s fascinating. Marin County has for years been considered a hotbed for this disease, without much explanation as to why, but now it seems that multiple Bay Area counties – with the exception of San Francisco County itself – are showing similar rates. No research was undertaken in this project to determine why, but getting a handle on which regions have the highest incidence rates is a good first step for further exploration.

This image shows the counties and regions in which invasive breast cancer is 10%-20% higher than in other parts of the state – two other regions were seen with similar incidence rates in Southern California:

Picture copyright of San Francisco Chronicle

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Juvenile Detention Centers Miss Key Health Indicators for Girls

I listened to a great NPR report this afternoon by Jenny Gold about juvenile detention centers and how they’re missing some key indicators of the health status of girls that enter into the system. As someone specializing in adolescent girls’ health, I was pretty fascinated – it detailed the personal experiences of a few girls being seen in a New Mexico facility and also tried to address ways it could be rectified. Detention centers can actually be helpful entry points for girls and young women to be connected to healthcare resources (we’re talking mental and physical health, so everything from counseling to substance abuse help to medical attention if they are victims of assault or violence or have seen physicians only irregularly).

One of the biggest issues facing these girls was confidential disclosure of their health status and any social, emotional, and physical issues they were facing. Developing rapport with a provider at a detention facility can be difficult in and of itself, but the girls reported having to answer personal questions in an open-door location, often with men and boys – staff or other teens – present; unsurprisingly, this made it difficult for many girls to feel that they could answer questions of a personal nature (sexual behavior, drug and alcohol use, history of assault, abuse or violence) honestly and openly. What we do know about these girls – 41% have vaginal injury consistent with sexual assault, 8% have positive skin tests for tuberculosis, and 30% need glasses but don’t have them – shows that getting all of this information early on is essential for appropriate and timely care.

One proposed solution to this – getting as much information as possible from these girls about their health status and the best ways to then help them, treat them, and connect them with resources – was to have them fill out a survey themselves. Currently, girls are asked 35 questions by an intake nurse when they arrive, that cover things like current medications, alcohol or drug use in the last 24 hours, and whether they have a history of self-destructive behavior. The proposed survey in the New Mexico facility is 132 questions, and according to one facility employee the time that would take is just not feasible given the traffic and business of the facility. Researchers and providers implemented a pilot study of the survey for 30 girls at the detention facility.

Of course, I can’t comment on the actual level of frantic activity in the specific facility at hand, but I can say that having a questionnaire that catches health issues which can be immediately and effectively addressed can prevent a host of issues from getting worse as time goes on without treatment – potential injuries from abuse or assault, needing STI screenings for victims of rape or girls who are sexually active without access to contraceptives or regular gynecological care, and of course mental health resources and immediate connection with social workers or therapists for those girls in need. Either having the girls fill out the survey via computer themselves or having a nurse help them would also be enormously helpful in the long run. This can also be a great way to track the care progress of these girls over the years, as many go in and out of detention centers. For girls who have experienced assault or abuse or multiple infections and injuries, this can be an easy way to follow-up with them without having to go through essentially baseline assessments of their well-being every time they enter a facility.

Some of the sobering stats about the girls from this particular New Mexico facility from this report: Of the 30 girls who participated in the piloting of implementing this survey, 12 needed immediate medical care, and 23 were coded as needing medical care within 24 hours, based on the survey’s questions. Intakes without this survey missed essential things, like burns on one girl’s torso and chest.

Check out the whole report here. I have no doubt that detention centers are in dire need of additional resources and likely way more staff than they have, for more than just this particular issue of adolescent girls’ health, but if the issue is there being one nurse for multiple intakes, having the girls fill out the survey on a computer themselves – when they’re more likely to be honest than in discussion with a nurse anyway, seems like the best solution to these kind of initial entry screenings. Especially since poor physical health is an indicator of recidivism, increasing the likelihood of girls ending up back in a facility.

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Filed under Child Development and Child Health, Health Behavior, Health Education, Mental Health, Women's Health

Integrating Family Planning and HIV Services Benefits All

Some pretty great research is cropping up at the 2012 International AIDS Conference, and it’s hard to pick just one finding to reference, but I do love infographics and I do love family planning – so I found something that combines the two! Population Action International, a truly fantastic research and advocacy organization focused on women’s reproductive health access and care, and they make a great point about the advantages and importance of providing both family planning and HIV services at the same time and in the same place. They point out that mother-to-child HIV transmission can be reduced, stigma may decrease, and both time and money are save. Take a look:

Combining HIV and family planning services (courtesy of Population Action International).

Another issue at hand is that of the relationship between a provider and a patient or client. Family planning clinics have a better chance of establishing long-term relationships with women – particularly if women have multiple children – given that they also sometimes aid in pre- and post-natal care or help connect women to those services, which increases the likelihood of women who test HIV+ to getting the treatment they need. Again, all in one place!

Follow along at #AIDS2012 on Twitter to stay abreast of everything going on in D.C.

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Filed under Health Education, International, Public Health, Reproductive and Sexual Health, Women's Health

Maternal Health and the Status of Women

Both globally and domestically, maternal health and the standing of women are inextricably linked. If women do not have the means and access to give birth safely, with trained and educated midwives, physicians and nurses, with appropriate prenatal education and care, it is often indicative of the standing of women in their communities and countries overall. Women’s inequality is also linked to the soaring population growth in developing countries, which will pose a range of new challenges for the next few generations.

Some may point to the United States as an anomaly, citing women’s increasing economic and financial independence, education, and leadership roles in America, while in terms of maternal health rankings, we remain pathetically far down the line for our resources (49 other countries are safer places to give birth than the U.S. – despite us spending more money on healthcare than anywhere else). Of course, the recent and incessant attacks on allowing women to access credible, accurate, up-to-date and comprehensive sexual and reproductive health education and services makes this statistic not entirely…surprising, shall we say.

So, I found the incredibly detailed and visually impressive infographic by the National Post, pulled from spectacular data and research done by Save the Children to be particularly fascinating. What they did was combine information on the health, economic, and education status of women to create overall rankings of the best and worst countries for women, splitting the countries into categories of more developed, less developed, and least developed, and the countries were ranked in relation to the other countries in their category (the divisions were based on the 2008 United Nations Population Division’s World Population Prospects, which most recently no longer classified based on development standing). While these divisions and the rankings can certainly be contentious and may incite some disagreement (nothing unusual there, these kind of rankings usually are), I thought the results were interesting. Some highlights – Norway is first, Somalia is last. The United States was 19th, and Canada was 17th (Estonia fell in between us and the Great White North) in the most developed. Israel is first in the less developed category, and Bhutan is first in the least developed category. The full report with data from Save the Children is also available, if you want to learn more about the information combined to make this image. Take a look:

A Woman’s Place – Courtesy of the National Post

One thing that I thought was particularly great was that the researchers combined women’s health and children’s heath data to create rankings specific to being a mother, when that category is sometimes only assessed based on access to reproductive care.The specific rankings of maternal health highlights largely mimics the overall standing of women, as seen here – Norway is number one, again, and Niger falls into last place:

Mother’s Index, Courtesy of Save the Children

I think these images and graphs are particularly moving given one of the top health stories coming out of the New York Times today, which showed that a recent Johns Hopkins study indicated meeting the contraception needs of women in developing countries could reduce maternal mortality (and thereby increase the standing of women in many of the nations doing poorly in the above ranking) globally by a third. When looking at the countries in the infographic that have low rates of using modern contraception and the correlation between that and their ranking in terms of status of women, it’s not surprising what the JH researchers found. Many of the countries farther down in the rankings have rates below 50%, and for those countries filling the bottom 25 slots, none of them even reach a rate that is a third of the population in terms of contraceptive use – which of course in most cases has to do with availability, not choice. Wonderfully, the Gates Foundation yesterday announced that they would be donating $1 billion to increase the access to contraceptives in developing countries.

Also of note, and in relation to maternal and newborn health, is a new study recently published by Mailman researchers that showed PEPFAR funded programs in sub-Saharan Africa increased access to healthcare facilities for women (particularly important for this region, as 50% of maternal deaths occur there), thereby increasing the number of births occurring in these facilities – reducing the avoidable (and sometimes inevitable) complications from labor and delivery, decreasing the chance of infection and increasing treatment if contracted. This has clear implications for children as well (and why I think this study relates to the National Post infographic and the NY Times article), since newborns are also able to be assessed by trained healthcare workers and potentially life-threatening conditions averted – including HIV, if the newborns have HIV+ mothers and need early anti-retroviral treatment and a relationship with a healthcare worker and system. And it goes without saying that if a new mother is struggling with post-delivery healthcare issues, including abscesses and fistulas, or was dealing with a high-risk pre-labor condition like preeclampsia, the child will have an increasingly difficult early life, perhaps even a motherless one.

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Filed under Child Development and Child Health, Health Education, International, Politics, Public Health, Reproductive and Sexual Health, Women's Health