Newsletter December 2013

ICRH Global Newsletter

13th of December, 2013

Ghent University establishes the ‘Marleen Temmerman Fund’
With the establishment of this Fund, Ghent University wants to honor professor Temmerman and to continuously support the activities of the International Centre for Reproductive Health (ICRH).
ICRH employs some 30 staff members in Ghent and has projects all over the world, but it has extremely limited core funding and therefore has to rely mainly on project funding and donations. The Marleen Temmerman Fund will help to structure and attract the donations stream of income. For 2014, three projects were selected that will benefit from the donations that will be made through the fund:
-Home visits for new mothers in Kenya, Mozambique, Burkina Faso and Malawi
-An Internship Programme for African researchers
-Research into Sexual Violence in Mombasa (Kenya)
More information and online donations: www.fondsmarleentemmerman.ugent.be

PROJECTS

New FWO project on HIV prevention among young women in sub-Saharan Africa
The Flemish Scientific Research Fund (FWO) has approved funding for a new project on HIV prevention among young women in sub-Saharan Africa.
It is well established that young women in sub-Saharan Africa are at very high risk of HIV infection. Biological and behavioural risk factors, in combination with a complex sexual age-mixing pattern, have been proposed to explain this gender discrepancy. Age-mixing patterns characterized by the frequent occurrence of large age differences between sexual partners are thought to be the result of socio-economic inequalities in society. Young women may be participating in sexual relationships with older men in order to gain socio-economic benefits.
The FWO project, involving collaborators from The World Bank, Columbia University, the South African Centre for Epidemiological Modelling and Analysis (SACEMA) and Hasselt University, will investigate the age-mixing pattern and associated trends in socio-economic status and sexual risk behaviour in two settings in Malawi. Further, computer simulation models will be used to explore how changes in the age-mixing pattern affect individual HIV risk and alter the course of the epidemic, taking into account the biology, sociology and behavioural science behind the epidemiology of HIV in young women in sub- Saharan Africa.
For more information, please contact Wim Delva, Wim.Delva@ugent.be and Roxanne Beauclair, Roxanne.Beauclair@gmail.com

DIFFER Project Management Team meeting

The DIFFER Consortium has gathered for its third PMT meeting in Mysore, India, for a three-day meeting (3-5 December).
All partners were present and discussed the activities and the implementation of the site interventions as well as other topics related to the project. The PMT was hosted by Ashodaya Samithi, DIFFER partner organization in India. Besides its working programme, the Consortium had the opportunity to visit Ashodaya facilities and meet some of its members. This PMT meeting follows a one-week Capacity Building training which allowed the research teams and sex workers from Kenya, Mozambique and South Africa to work together on the project and on community empowerment. The next DIFFER PMT meeting is planned to take place in London at the end of 2014.

Demonstration project for the WHO antenatal care (ANC) model in Mozambique
ICRH Mozambique is implementing with the Mozambican Ministry of Health and WHO a demonstration project for the WHO ANC model.
Antenatal care (ANC) reduces maternal and perinatal morbidity and mortality directly through the detection and treatment of pregnancy-related illnesses, and indirectly through the detection of women at increased risk of delivery complications. The demonstration project in Mozambique aims to ensure the implementation of the WHO ANC model that recommends the delivery of four antenatal and one postpartum visit for women with no evidence of complications. The intervention was tailored, based on formative research findings, to be readily applicable to local prenatal care services and acceptable to local pregnant women and health providers.

The intervention includes four components: the provision of kits with all necessary medicines and laboratory supplies for ANC (medical and non-medical equipment), a storage system, a tracking system, and training sessions for health care providers. Ten clinics were selected and will start receiving the intervention in a random order.
Support visit to the research assistant to validate quality of data collected,
Health Centre of Chibuto, November 2013

EVENTS

International conference on sexual and reproductive health in Nicaragua
On 18 and 19 September, the results of the CERCA project and of the project ‘Enhancing quality health delivery in primary health services in transition’ were presented during an international conference in Nicaragua. In close collaboration with the local Nicaraguan partners, Peter Decat and Sara De Meyer presented the main aspects of both projects. The project design and implementation of the CERCA project (Community-Embedded Reproductive Health Care for adolescents) were explained. Additionally preliminary results were described, such as the correlation between positive attitudes towards gender equality and safe sexual behavior of adolescents. Related to the project on quality primary health care in Nicaragua, barriers of good care were discussed with a focus on the unpredictability of services (waiting times, access to health providers and availability of medicines). The conclusions will be presented in a scientific article. Besides ICRH-staff, scientists and politicians from Nicaragua and other Latin American countries - such as El Salvador and Honduras - described their work related to the conference´s topics. The conference was organized by CIES - Centro de Investigación y Estudios de la Salud).

ICRH - PEOPLE

Alexia Sabbe
After having done five years of research on gender based violence at ICHR, Alexia left Ghent University to explore new horizons.

Alexia started at ICRH in 2008, after having worked a few years as a development officer for the Belgian Technical Cooperation in Rwanda. Her research, sponsored by a VLIR-UOS PhD scholarship, focused on the impact of context on the occurrence of forced marriage in Morocco, and among Moroccan immigrants in Belgium. More specifically, Alexia examined to what degree the cultural and religious perceptions have been transferred in migratory circumstances. In addition, the impact of different context, policies, law enforcement, etc. was investigated. Overall, an in-depth understanding of the phenomenon of forced marriage will provide policy makers and program managers with factual support and background knowledge for potential interventions. The project came to an end in September 2013, and the PhD thesis that will result from this is expected to be submitted soon.

Simukai Shamu and Françoise Hamers
On 25 November 2013, Simukai Shamu and Françoise Hamers successfully defended their PhD theses at Ghent University

Simukai Shamu investigated the link between disclosure of HIV status and partner violence during pregnancy in Zimbabwe. He found that HIV-positive women have a higher exposure to partner violence than HIV negative women when they inform their partners about their status. Overall, the link between HIV status and violence is very complex, but among others the level of ender inequality appears to play an important role. Health workers, who could play a preventive role, in general lack the knowledge, means and/or support to identify partner violence and to react on it. Simukai’s doctorate is a joint PhD between Ghent University and the University of the Western Cape, where he defended his thesis a couple of months ago.
The full thesis, entitled ‘The dynamics of intimate partner violence (IPV) during pregnancy and linkages with HIV infection and disclosure in Zimbabwe’ can be downloaded at http://icrhb.org/publication/icrh-monographs-phd-defence-simukai-shamu

Françoise Hamers analysed the data of the European HIV/AIDS surveillance system and found that the prevalence of HIV in the European WHO region results from several distinguished but simultaneous and interconnected HIV epidemics. In Western-Europa, the emergence of combination antiretroviral therapy (cART) in 1996 has lead to a weakening attention for prevention and a revival of high risk behaviour among man having sex with man, resulting in an increase in new infections. Heterosexual migrants from sub-Sahara Africa have considerably contributed to the HIV epidemic in Europe, but the number of new infections in this population shows a downward trend since 2005, which could be related to decreasing HIV incidence in Africa. The number of infections through intravenous drug use has decreased gradually since the 1990s. Françoise Hamers’ thesis stresses the need for sensitization and information on the benefits of early testing and treatment. Health workers should be better trained in recognizing HIV infections.
The full thesis, entitled ‘HIV/AIDS in Europe: The link between surveillance and prevention’ can be downloaded at http://icrhb.org/publication/icrh-monographs-phd-fran%C3%A7oise-hamers-hivaids-europe-link-between-surveillance-and

PUBLICATIONS

Determinants of child and forced marriage in Morocco
An exploration of stakeholder perspectives on factors that contribute to the occurrence of child and forced marriage in Morocco.
In Morocco, the social and legal framework surrounding sexual and reproductive health has
transformed greatly in the past decade, especially with the introduction of the new Family
Law or Moudawana. Yet, despite raising the minimum age of marriage for girls and
stipulating equal rights in the family, child and forced marriage is widespread. A qualitative approach was used to explore perspectives of a broad range of professionals on factors that contribute to the occurrence of child and forced marriage in Morocco.
Four major themes arose from the data, indicating that the following elements contribute to
child and forced marriage: (1) the legal and social divergence in conceptualizing forced and
child marriage; (2) the impact of legislation; (3) the role of education; and (4) the economic
factor. Emphasis was especially placed on the new Family Code or Moudawana as having the
greatest influence on advancement of women's rights in the sphere of marriage. However,
participants pointed out that embedded patriarchal attitudes and behaviours limit its
effectiveness. The authors concluded that, from the viewpoint of professionals, policy measures and the law have the greatest potential to bring child and forced marriage to a halt. However, the implementation of new legal tools is facing barriers and resistance. Additionally, the legal and policy framework should go hand in hand with both education and increased economic opportunities. Education and awareness raising of all ages is considered essential, seeing that parents and the extended family play a huge role in marrying off girls and young women.
Alexia Sabbe, Halima Oulami, Wahiba Zekraoui, Halima Hikmat, Marleen Temmerman, Els Leye. Determinants of child and forced marriage in Morocco: stakeholder perspectives on health,
policies and human rights. BMC International Health and Human Rights 2013, 13:43 doi:10.1186/1472-698X-13-43
The article can be downloaded at http://www.biomedcentral.com/1472-698X/13/43

Pregnancy danger signs and counselling
A study on counselling and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania.
The aims of this cross-sectional study were to (i) assess healthcare workers' counselling practices concerning danger signs during antenatal consultations in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania; to (ii) assess pregnant women's awareness of these danger signs; and (iii) to identify factors affecting counselling practices and women's awareness.
In each country, 12 facilities were randomly selected. WHO guidelines were used as standard for good counselling. Providers' counselling practice was assessed on seven danger signs through direct observation study. Exit interviews were used to assess women's awareness of the same seven danger signs.
About one in three women was not informed of any danger sign. For most danger signs, fewer than half of the women were counselled. Vaginal bleeding and severe abdominal pain were the signs most counselled on (between 52% and 66%). At study facilities in Burkina Faso, 58% of the pregnant women were not able to mention a danger sign, in Ghana this was 22% and in Tanzania 30%. Fever, vaginal bleeding and severe abdominal pain were the danger signs most frequently mentioned. The type of health worker (depending on the training they received) was significantly associated with counselling practices. Depending on the study site, characteristics significantly associated with awareness of signs were women's age, gestational age, gravidity and educational level.
The authors conclude that counselling practice is poor and not very efficient. A new approach of informing pregnant women on danger signs is needed. However, as effects of antenatal care education remain largely unknown, it is very well possible that improved counselling will not affect maternal and newborn mortality and morbidity.
Duysburgh E, Ye M, Williams A, Massawe S, Sié A, Williams J, Mpembeni R, Loukanova S, Temmerman M. Counselling on and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania. Trop Med Int Health. 2013 Oct 10.
This paper was selected as ‘the editor’s choice’ of Tropical Medicine & International Health and was made available for download at http://onlinelibrary.wiley.com/doi/10.1111/tmi.12214/full

Adolescent intimate partner violence
A systematic review of interventions for preventing adolescent intimate partner violence.
Intimate partner violence (IPV) is a pervasive global health issue affecting adolescents. From a review of randomized controlled trials of interventions to reduce physical, sexual, and psychological violence perpetration and victimization among adolescents, eight articles reporting on six randomized controlled trials were retrieved. Four interventions contained both school and community components. The researchers found positive intervention effects on IPV perpetration (three studies) and IPV victimization (one study). Compared with the studies with no effects on IPV, the effective interventions were of longer duration, and were implemented in more than one setting. There were quality issues in all six trials.
The authors conclude that interventions targeting perpetration and victimization of IPV among adolescents can be effective. Those interventions are more likely to be based in multiple settings, and focus on key people in the adolescents' environment. Future trials should assess perpetration and victimization of IPV among male and female adolescents with and without prior experiences with IPV, taking gender differences into account
De Koker P, Mathews C, Zuch M, Bastien S, Mason-Jones AJ.A Systematic Review of Interventions for Preventing Adolescent Intimate Partner Violence. J Adolesc Health. 2013 Oct 11. pii: S1054-139X(13)00460-6. doi: 10.1016/j.jadohealth.2013.08.008

HIV and age differences in relations
Relationships with young men and age-mates are considered ‘risky’ by women in Cape Town
Researchers have noted that young women in relationships with older men are typically at an elevated risk for acquisition of HIV in sub-Saharan Africa. To date, most qualitative studies have tended to focus on why women are motivated to participate in these relationships, offering little insight into perceived risks of these relationships. To this end, the authors conducted in-depth interviews with 23 women recruited from three urban communities in Cape Town, South Africa. Thematic content analysis was used to explore women’s perceived risks of age-disparate and non-age-disparate relationships, the benefits of dating older men, and risk perceptions that influence decisions around beginning or ending a relationship. Most women thought that dating an older man does not bring any adverse consequences, although a few thought that older men were less likely to use condoms and more likely to cheat on them. Many women were less inclined to date same-age or younger men, because they were viewed as being disrespectful and abusive. The authors demonstrate a need for more awareness raising about the risks of age-disparate relationships and call for more research on the association between intimate partner violence (IPV) and age gaps between sexual partners. In addition, there is an urgent need to implement holistic approaches to relationship health, in order to curb IPV, improve gender equity and make non-age-disparate relationships more attractive.
Beauclair R, Delva W. Is younger really safer? A qualitative study of perceived risks and benefits of age-disparate relationships among women in Cape Town, South Africa. PLoS ONE. 2013; 8(11): e81748. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0081748

Sexual and reproductive health of migrants: Does the EU care?
A literature review on migrant’s sexual and reproductive health in the EU.
The European Union (EU) refers to health as a human right in many internal and external communications, policies and agreements, defending its universality.
In parallel, specific health needs of migrants originating from outside the EU have been acknowledged. Yet, their right to health and in particular sexual and reproductive health (SRH) is currently not ensured throughout the EU. This paper reflects on the results of a comprehensive literature review on migrants’ SRH in the EU applying the Critical Interpretive Synthesis review method. The authors highlight the discrepancy between a proclaimed rights-based approach to health and actual obstacles to migrants’ attainment of good SRH. Uncertainties on entitlements of diverse migrant groups are fuelled by unclear legal provisions, creating significant barriers to access health systems in general and SRH services in particular. Furthermore, the rare strategies addressing migrants’ health fail to address sexual health and are generally limited to perinatal care and HIV screening. Thus, future European public health policy-making should not only strongly encourage its Member States to ensure equal access to health care for migrants as for EU citizens, but also promote migrants’ SRH effectively through a holistic and inclusive approach in SRH policies, prevention and care.
Ines Keygnaert, Aurore Guieu, Gorik Ooms, Nicole Vettenburg, Marleen Temmerman, Kristien Roelens, Sexual and reproductive health of migrants: Does the EU care? Health Policy (2013), ttp://dx.doi.org/10.1016/j.healthpol.2013.10.007

Prevention of HIV mother-to-child transmission
Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries.
Although substantiated by little evidence, concerns about zidovudine-related anaemia in pregnancy have influenced antiretroviral (ARV) regimen choice for preventing mother-to-child transmission of HIV-1, especially in settings where anaemia is common.
Eligible HIV-infected pregnant women in Burkina Faso, Kenya and South Africa were followed from 28 weeks of pregnancy until 12--24 months after delivery (n = 1070). Women with a CD4 count of 200-500cells/mm3 and gestational age 28-36 weeks were randomly assigned to zidovudine-containing triple-ARV prophylaxis continued during breastfeeding up to 6-months, or to zidovudine during pregnancy plus single-dose nevirapine (sd-NVP) at labour. Additionally, two cohorts were established, women with CD4 counts: <200 cells/mm3 initiated antiretroviral therapy, and >500 cells/mm3 received zidovudine during pregnancy plus sd-NVP at labour. Mild (haemoglobin 8.0-10.9 g/dl) and severe anaemia (haemoglobin < 8.0 g/dl) occurrence were assessed across study arms, using Kaplan-Meier and multivariable Cox proportional hazards models.
At enrolment (corresponded to a median 32 weeks gestation), median haemoglobin was 10.3 g/dl (IQR = 9.2-11.1). Severe anaemia occurred subsequently in 194 (18.1 %) women, mostly in those with low baseline haemoglobin, lowest socio-economic category, advanced HIV disease, prolonged breastfeeding (>=6 months) and shorter ARV exposure. Severe anaemia incidence was similar in the randomized arms (equivalence P-value = 0.32). After 1-2 months of ARV's, severe anaemia was significantly reduced in all groups, though remained highest in the low CD4 cohort.
The authors conclude that severe anaemia occurs at a similar rate in women receiving longer triple zidovudine-containing regimens or shorter prophylaxis. Pregnant women with pre-existing anaemia and advanced HIV disease require close monitoring.
Sartorius BK, Chersich MF, Mwaura M, Meda N, Temmerman M, Newell ML, Farley TM, Luchters S. Maternal anaemia and duration of zidovudine in antiretroviral regimens for preventing mother-to-child transmission: a randomized trial in three African countries. BMC Infect Dis. 2013 Nov 6;13(1):522.