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CSU 30/2009: ABSTINENCE ONLY PROGRAMS FOR HIV PREVENTION/VITAMIN A FOR MEASLES TREATMENT/ VITAMIN A ADMINISTRATION FOR NEONATES

Thursday, 21st of May 2009

Dear All,
 
 CSU 30/2009: ABSTINENCE ONLY PROGRAMS FOR HIV  PREVENTION/VITAMIN A FOR MEASLES TREATMENT / VITAMIN A  ADMINISTRATION FOR NEONATES
 
 ABSTINENCE ONLY PROGRAMS
 
 In this Cochrane review, Underhill and colleagues review the evidence
 on impact of abstinence only programs for HIV prevention in developed
 countries. Their findings give little comfort to the advocates of
 abstinence only programs. ' Compared to various controls, the
 evaluated programs consistently did not affect incidence of
 unprotected vaginal sex, frequency of vaginal sex, number of partners,
 sexual initiation, or condom use.'
 
 Is it time to move from assumption based planning for HIV prevention
 to evidence based planning?
 
 POLICY ON VITAMIN A ADMINISTRATION
 
 Two literature reviews on vitamin A look at the evidence base for
 current recommendations on vitamin A administration. The first
 concludes that 'There was a significant reduction in childhood
 mortality and respiratory morbidity and mortality in children that
 received the two doses of 200,000 IU vitamin A. This finding supports
 the WHO recommendation that two doses of 200,000 IU be given to every
 child with severe measles.'
 
 The second concludes 'There is no convincing evidence of a reduced
 risk of mortality and possibly morbidity or of increased early adverse
 effects after neonatal supplementation with vitamin A.'
 
 
 Good reading.
 
 BD
 
 Full text of the review is at
 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005421/frame.html
 
 
 To subscribe or unsubscribe to this list, pls contact Evelyn Chege,
 echege@unicef.org
 
 
 
 Abstinence-only programs for HIV infection prevention in high-income
 countries
 
 Kristen Underhill2, Don Operario1, Paul Montgomery3
 
 1Department of Social Policy and Social Work, University of Oxford,
 Oxford, UK. 2Yale Law School, New Haven, CT, USA. 3The Centre for
 Evidence-Based Intervention, University of Oxford, Oxford, UK
 
 Contact address: Don Operario, Department of Social Policy and Social
 Work, University of Oxford, Oxford, UK.
 don.operario@applied-social-studies.oxford.ac.uk. (Editorial group:
 Cochrane HIV/AIDS Group.)
 
 Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this
 issue: Unchanged)
 Copyright © 2009 The Cochrane Collaboration. Published by John Wiley &
 Sons, Ltd.
 DOI: 10.1002/14651858.CD005421.pub2
 This version first published online: 17 October 2007 in Issue 4, 2007.
 Last assessed as up-to-date: 21 August 2007. (Help document - Dates
 and Statuses explained).
 
 This record should be cited as: Underhill K, Operario D, Montgomery P.
 Abstinence-only programs for HIV infection prevention in high-income
 countries. Cochrane Database of Systematic Reviews 2007, Issue 4. Art.
 No.: CD005421. DOI: 10.1002/14651858.CD005421.pub2.
 ________________________________________
 
 Abstract
 Background
 Abstinence-only interventions promote sexual abstinence as the only
 means of preventing sexual acquisition of HIV; they do not promote
 safer-sex strategies (e.g., condom use). Although abstinence-only
 programs are widespread, there has been no internationally focused
 review of their effectiveness for HIV prevention in high-income
 countries.
 
 Objectives
 To assess the effects of abstinence-only programs for HIV prevention
 in high-income countries.
 
 Search strategy
 We searched 30 electronic databases (e.g., CENTRAL, PubMed, EMBASE,
 AIDSLINE, PsycINFO) ending February 2007. Cross-referencing,
 handsearching, and contacting experts yielded additional citations
 through April 2007.
 
 Selection criteria
 We included randomized and quasi-randomized controlled trials
 evaluating abstinence-only interventions in high-income countries
 (defined by the World Bank). Interventions were any efforts to
 encourage sexual abstinence for HIV prevention; programs that also
 promoted safer-sex strategies were excluded. Results were biological
 and behavioral outcomes.
 
 Data collection and analysis
 Three reviewers independently appraised 20,070 records and 326
 full-text papers for inclusion and methodological quality; 13
 evaluations were included. Due to heterogeneity and data
 unavailability, we presented the results of individual studies instead
 of conducting a meta-analysis.
 
 Main results
 Studies involved 15,940 United States youth; participants were
 ethnically diverse. Seven programs were school-based, two were
 community-based, and one was delivered in family homes. Median final
 follow-up occurred 17 months after baseline.
 
 Results showed no indications that abstinence-only programs can reduce
 HIV risk as indicated by self-reported biological and behavioral
 outcomes. Compared to various controls, the evaluated programs
 consistently did not affect incidence of unprotected vaginal sex,
 frequency of vaginal sex, number of partners, sexual initiation, or
 condom use.
 
 One study found a significantly protective effect for incidence of
 recent vaginal sex (n=839), but this was limited to short-term
 follow-up, countered by measurement error, and offset by six studies
 with non-significant results (n=2615).
 
 One study found significantly harmful effects for STI incidence
 (n=2711), pregnancy incidence (n=1548), and frequency of vaginal sex
 (n=338); these effects were also offset by studies with
 non-significant findings.
 
 Methodological strengths included large samples, efforts to improve
 self-report, and analyses controlling for baseline values. Weaknesses
 included underutilization of relevant outcomes, underreporting of key
 data, self-report bias, and analyses neglecting attrition and
 clustered randomization.
 
 Authors' conclusions
 Evidence does not indicate that abstinence-only interventions
 effectively decrease or exacerbate HIV risk among participants in
 high-income countries; trials suggest that the programs are
 ineffective, but generalizability may be limited to US youth. Should
 funding continue, additional resources could support rigorous
 evaluations with behavioral or biological outcomes. More trials
 comparing abstinence-only and abstinence-plus interventions are
 needed.
 ________________________________________
 
 Plain language summary
 
 Abstinence-only programs for preventing HIV infection in high-income
 countries (as defined by the World Bank)
 
 Abstinence-only programs are widespread and well-funded, particularly
 in the United States and countries supported by the US President's
 Emergency Plan for AIDS Relief. On the premise that sexual abstinence
 is the best and only way to prevent HIV, abstinence-only interventions
 aim to prevent, stop, or decrease sexual activity. These programs
 differ from abstinence-plus designs: abstinence-plus programs promote
 safer-sex strategies (e.g., condom use) along with sexual abstinence,
 but abstinence-only programs do not, and instead often highlight the
 limitations of condom use. An up-to-date review suggests that
 abstinence-only programs do not affect HIV risk in low-income
 countries; this review examined the evidence in high-income countries.
 
 This review included thirteen randomized controlled trials comparing
 abstinence-only programs to various control groups (e.g., "usual
 care," no intervention). Although we conducted an extensive
 international search for trials, all included studies enrolled youth
 in the US (total baseline enrollment=15,940 participants). Programs
 were conducted in schools, community centers, and family homes; all
 were delivered in family units or groups of young people. We could not
 conduct a meta-analysis because of missing data and variation in
 program designs. However, findings from the individual trials were
 remarkably consistent.
 
 Overall, the trials did not indicate that abstinence-only programs can
 reduce HIV risk as indicated by behavioral outcomes (e.g., unprotected
 vaginal sex) or biological outcomes (e.g., sexually transmitted
 infection). Instead, the programs consistently had no effect on
 participants' incidence of unprotected vaginal sex, frequency of
 vaginal sex, number of sex partners, sexual initiation, or condom use.
 
 One trial favored an abstinence-only program over usual care for
 incidence of vaginal sex (n=839), but this was limited to two-month
 follow-up and was offset by measurement error and six other studies
 with non-significant effects (n=2615).
 
 One evaluation found several significant adverse (harmful) program
 effects: abstinence-only program participants were more likely than
 usual-care controls to report sexually transmitted infections
 (n=2711), pregnancy (n=1548), and increased frequency of vaginal sex
 (n=338). These effects were offset by high attrition and other studies
 showing non-significant effects.
 
 We concluded that abstinence-only programs do not appear to reduce or
 exacerbate HIV risk among participants in high-income countries,
 although this evidence might not apply beyond US youth. Trial
 limitations included underreporting of relevant outcomes, reliance on
 program participants to report their behaviors accurately, and
 methodological weaknesses in the trials.
 
 
 VITAMIN A FOR MEASLES TREATMENT
 
 Vitamin A given to children with measles - Does dose make a difference?
 
 D'Souza R.M., D'Souza R., Australian National University, Canberra
 
 AGE DAY 1 DAY 2
 
 UNDER 6 MONTHS 50,000 IU 50,000 IU
 6-11 MONTHS 100,000 IU 100,000 IU
 12+ MONTHS 200,000 IU 200,000 IU
 
 The World Health Organization (WHO) in 1987 recommended a single dose
 of 200,000 IU of vitamin A, at the time of initial measles diagnosis,
 to non-xerophthalmic children who live in areas where measles case
 fatality rates were a problem [see table above]. In 1997, this
 recommendation was changed to 200,000 IU of vitamin A for two days for
 all children older than one year of age with measles in populations
 where vitamin A deficiency may be present. This review aims to
 determine whether vitamin A given to children after measles has been
 diagnosed is beneficial in preventing morbidity and mortality Methods
 The search strategy used was developed for the Acute Respiratory
 Infections Group, which included The Cochrane Library, Issue 1, 1999.
 Twenty-eight studies were assessed independently by two reviewers
 using the Jadad method for assessing the quality of trials. In the
 meta-analysis administration of vitamin A was compared with placebo.
 Summary estimates of effect (using relative risk or weighted mean
 difference) were calculated across studies for morbidity (incidence of
 pneumonia, diarrhoea, croup) and mortality. Five of the 28 studies met
 the selection criteria and were included in the review. A sixth study
 was found later. Trialists were contacted for missing data. Data was
 extracted from each trial for analysis by intention to treat. Results
 Mortality reduction was seen in studies that used the double dose.
 There were two studies that repeated the dose of 200,000 IU on day two
 and a third study that gave it on Day 1,2 and 8. When these three
 studies were pooled there was an overall 60% reduction in mortality,
 RR=0.40 (95% CI 0.19, 0.87). The reduction in mortality was more
 pronounced in children under the age of two years ie 79%; RR=0.21 (95%
 CI=0.07, 0.66). The studies that used the double dose had a 64%
 reduction in pneumonia specific mortality RR=0.36 (95% CI 0.14, 0.92)
 and 46% reduction in the incidence of croup, RR=0.54 (95% CI, 0.34,
 0.88). When the studies were stratified by formulation, water soluble
 preparations of vitamin A had a more significant effect on overall
 mortality reduction than oil-based preparations (77% reduction in
 mortality) RR 0.23 (0.06, 0.89).
 
 Conclusion This review has demonstrated that there was a significant
 reduction in childhood mortality and respiratory morbidity and
 mortality in children that received the two doses of 200,000 IU
 vitamin A. This finding supports the WHO recommendation that two doses
 of 200,000 IU be given to every child with severe measles.
 
 
 
 
 VITAMIN A ADMINISTRATION FOR NEONATES
 
 
 Most countries which give prophylactic vitamin A routinely do so with
 an initial dose of 100,000 IU at six months of age.
 
 In this article from the BMJ, Gogia and colleagues review the
 published evidence on neonatal administration of vitamin A. From their
 conclusions: 'There is no convincing evidence of a reduced risk of
 mortality and possibly morbidity or of increased early adverse effects
 after neonatal supplementation with vitamin A. There is thus no
 justification for initiating such supplementation as a public health
 intervention in developing countries for reducing infant mortality and
 morbidity '
 
 
 'Neonatal vitamin A supplementation for prevention of mortality and
 morbidity in infancy: systematic review of randomised controlled
 trials'
 
 Siddhartha Gogia, attending consultant, Harshpal Singh Sachdev, senior
 consultant
 
 1 Department of Paediatrics and Clinical Epidemiology, Sitaram Bhartia
 Institute of Science and Research, B-16 Qutab Institutional Area, New
 Delhi 110016, India
 
 Correspondence to: H S Sachdev, E-6/12 Vasant Vihar, New Delhi 110057,
 India hpssachdev@gmail.com
 
 Objective To evaluate the effect of neonatal vitamin A supplementation
 on infant mortality, morbidity and early adverse effects.
 Design Systematic review, meta-analysis, and meta-regression of
 randomised controlled trials.
 
 Data sources Electronic databases and hand search of reviews;
 abstracts and proceedings of conferences.
 
 Review methods Randomised or quasi-randomised or cluster randomised,
 placebo controlled trials evaluating the effect of prophylactic,
 neonatal (<1 month) supplementation with synthetic vitamin A on
 mortality or morbidity within infancy (<1 year), and early adverse
 effects (7 days).
 
 Results The six included trials were from developing countries. There
 was no convincing evidence of a reduced risk of mortality during
 infancy (relative risk 0.92, 95% confidence interval 0.75 to 1.12,
 P=0.393 random effect; I2=54.1%) or of an increase in early adverse
 effects including bulging fontanelle (1.16, 0.81 to 1.65, P=0.418;
 I2=65.3%). No variable emerged as a significant predictor of
 mortality, but data for important risk groups (high maternal night
 blindness prevalence and low birth weights) were restricted. Limited
 data (from one to four trials) did not indicate a reduced risk of
 mortality during the neonatal period (0.90, 0.75 to 1.08, P=0.270;
 I2=0%), cause specific mortality, common morbidities (diarrhoea and
 others), and admission to hospital. There was, however, evidence of an
 increased risk of acute respiratory infection and a reduced risk of
 clinic visits.
 
 Conclusions There is no convincing evidence of a reduced risk of
 mortality and possibly morbidity or of increased early adverse effects
 after neonatal supplementation with vitamin A. There is thus no
 justification for initiating such supplementation as a public health
 intervention in developing countries for reducing infant mortality and
 morbidity.
 
 © Gogia et al 2009
 This is an open-access article distributed under the terms of the
 Creative Commons Attribution Non-commercial License, which permits
 unrestricted use, distribution, and reproduction in any medium,
 provided the original work is properly cited.