What Works for Women and Girls

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as a result of the potential to prejudice treatment options for mothers and transmit nevirapineresistance to their infants (Kiptoo et al., 2008).Starting ARVs Early in Pregnancy Can Improve Pregnant Women’s Health andReduce Vertical TransmissionIn November 2009, the WHO released new recommendations for the use of ARVs in pregnantwomen. These guidelines recommend lifelong antiretroviral drug regimens for womenwho need ARVs to protect their own health (based on severe or advanced clinical disease orwith the CD4 count at or below 350 cells/mm3, regardless of symptoms) and short-term prophylacticregimens to decrease the risk of HIV transmission to the baby during pregnancy, laborand delivery and throughout the breastfeeding period (based on CD4 cell counts above 350 orfor women who do not require ARVs for their own health). Short-term prophylactic regimensdelivered to the baby during delivery and the breastfeeding period (should the mother chooseto breastfeed) are also recommended and will be discussed in the Delivery and Postpartumsections of this document. Of note, the recommendation for initiating ARV treatment forpregnant women has been raised from a CD4 count of
own health needs has never been evaluated. The new WHO guidelines represent the currentconsensus on best international practice for the use of ARVs in pregnant women in developingcountry settings for both the maintenance of the woman’s own health and the preventionof mother-to-child transmission of HIV (WHO, 2009b). Development of these guidelinesproceeded according to the WHO GRADE procedure and included costing analyses of thedifferent options under review (WHO, 2009b). Of course, many important questions remainunder consideration, including the long-term effects on the health of women who initiate ARVtherapy as prophylaxis to prevent mother-to-child transmission and then stop treatment (Panelon Antiretroviral Guidelines for Adults and Adolescents, 2009). A study funded by NIH thatstarted in January 2010 with results expected in 2015 should answer this vital question. ThePROMISE Study (Promoting Maternal-Infant Survival Everywhere) is a multi-national clinicaltrial in 18 countries that is being conducted by the International Maternal Pediatric AdolescentAIDS Clinical Trials Group. It will examine the long-term effects on the health of women whoinitiate ARV therapy as prophylaxis to prevent vertical transmission and then stop treatmentin addition to comparing the effectiveness of different drug combinations for the treatment ofPMTCT (NIAID Web Bulletin, January 21, 2010).WHO recommends pregnant women who access HAART with CD4 counts above 350(i.e., for PMTCT prophylaxis) should continue “through the end of the breastfeeding period”(WHO, 2009b: 14); implying that women can stop HAART at the end of breastfeeding if theirCD4 count remains above 350. Until the results from the PROMISE study are available, thequestion about what this might mean for the woman’s future treatment options remains.Treatment Regimens for Preventing Vertical Transmission Vary GloballyIt should be noted that the development of ARV regimens to treat pregnant women and preventvertical transmission is evolving and implementation varies around the world. For instance,in Europe, the initiation of ARV therapy in pregnant women proceeds according to the sameCD4 count measurements as are used to initiate therapy within the general population, withthe goal of full suppression of HIV by the third trimester of pregnancy (European AIDSClinical Society, 2009). By contrast, in the United States, ARV therapy is now recommendedfor all pregnant women, regardless of their CD4 counts (Panel on Antiretroviral Guidelines forAdults and Adolescents, 2009).It is important to note that the evidence base in this section does not yet reflect implementationof the November 2009 WHO guidelines. At the time of this writing, the final WHOguidelines, slated for publication in June 2010, remain pending (WHO, 2009b). The evidencepresented in this section should thus be considered in light of the new WHO guidelines andpending research in the field.WHAT WORKS FOR WOMEN AND GIRLS235
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WHAT WORKSFOR WOMEN AND GIRLSEviden
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Authors:Jill Gay, MAKaren Hardee, P
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Jose Esparza, MD, Ph.D.Senior Advis
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Shyam Kottilil, MD, Ph.D.Staff Clin
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Larry Slutsker, MD, MPHChief, Malar
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Table of ContentsList of Abbreviati
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List of Abbreviations3TCACTAHIANCAP
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PEPPHAPHRPIDPLHAPMTCTPPEPPTPRPTPRBP
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MethodologyMeasuring “what works
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2. Hormonal contraception is safe f
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outcomes has been more difficult to
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2. Promoting contraceptives and fam
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International Political Commitments
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established national action plans o
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Organization of the DocumentThis do
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Table 1.1Countries included in What
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understanding the epidemic in any g
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girls in school, for example. The c
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Within each intervention, studies a
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Chapter 3.Prevention for WomenA. Ma
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Special Risks for WomenStill, despi
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AIDS cases reported from 1982 to 20
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experience observed in clinical tri
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Female Condoms Are the Only Female-
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condom if it gives them more pleasu
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Correct use of the female condom ha
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A two month prospective study from
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A study of trends from Demographic
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8. Peer education for women can inc
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3B. Prevention for Women: Partner R
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matic focus on partner reduction, y
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of HIV acquisition, but were either
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four visits, each participant was i
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What Works—Prevention for Women:
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vention immediately following the b
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Chapter 4.Prevention for Key Affect
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2010). Transgender men and women al
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confidentiality—violate human rig
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there were major socio-demographic
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and post-intervention were used to
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tent condom use and 1.5 times more
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to their peers, distribute condoms
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Gaps in Programming—Female Sex Wo
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of a sexual relationship with a pri
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than were naltrexone or placebo. HI
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attributed to …swift introduction
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Promising Strategies:5. Sex-segrega
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9. Programming to prevent initiatio
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D’Ivoire, Cuba, Estonia, Indonesi
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Gaps in Programming—Women Prisone
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EVIDENCEPromising Strategies:1. Vol
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In fact, as of September 2008, 66 o
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Transgender women and men are often
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2009). “The invisibility and marg
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especially young women, have their
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negotiation skills and other critic
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to be reached with sex and HIV educ
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What Works—Prevention for Young P
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44% and 100% of participants (Kirby
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tudes, self-efficacy, intentions, a
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as young people in this area had li
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ical validity of the findings that
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study reported having received info
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nancy. Almost 87% of men and 89% of
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last sex, having ever used a condom
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Gap noted, for example, in South Af
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Disaggregated Data Is NeededEffecti
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were also effective in increasing u
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Chapter 6.HIV Testing and Counselin
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Equitable Access to Testing and Cou
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they would come for HIV testing, re
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their jobs (Human Rights Watch, 200
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What Works—HIV Testing and Counse
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women. Of all married HIV-positive
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A study in Ethiopia found that inco
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At a provincial hospital in Mombasa
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Between June and December 2007, mob
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Promising Strategies:6. Encouraging
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10. Counseling may reduce risk beha
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women learned violence prevention s
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Chapter 7.TreatmentA. Provision and
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Treatment Has Been Successfully Adm
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HIV Prevention Is Needed as well as
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Gaps in Programming—Provision and
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These practices and tools are usefu
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Non-judgmental, non-stigmatizing in
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percent among ART-experienced patie
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(Donnell et al., 2010). (Abstract)
Page 186 and 187: The sexual health of women is an im
Page 188 and 189: [ for women living with HIV]: impro
Page 190 and 191: Available GuidelinesA number of sex
Page 192 and 193: advantages of dual method use, alon
Page 194 and 195: contraception: 57% used hormonal co
Page 196 and 197: different; and progression to WHO c
Page 198 and 199: HIV-related behavioral or biologic
Page 200 and 201: use was positively associated with
Page 202 and 203: Gaps in Programming—Meeting the S
Page 204 and 205: Interactions between ARVs and oral
Page 207 and 208: Chapter 9.Safe Motherhood and Preve
Page 209 and 210: Pillar 1: Preventing Primary HIV In
Page 211 and 212: mission of HIV. HIV testing and cou
Page 213 and 214: EVIDENCE1. Preventing unintended pr
Page 215 and 216: Gaps in Programming—Reducing Unin
Page 217 and 218: 9B. Safe Motherhood and Preventiono
Page 219 and 220: EVIDENCEPromising Strategies:1. Dis
Page 221 and 222: Gaps in Programming—Pre-Conceptio
Page 223 and 224: 9C-1. Safe Motherhood and Preventio
Page 225 and 226: tion (Kershaw et al., 2006). “…
Page 227 and 228: outine tests. Fifty percent of the
Page 229 and 230: An evaluation of UNICEF-funded PMTC
Page 231 and 232: and syphilis (by rapid plasma regai
Page 233 and 234: 2. Additional efforts are needed to
Page 235: for their own disease” (ITPC, 200
Page 239 and 240: dine and lamivudine during pregnanc
Page 241 and 242: chose elective cesarean section to
Page 243 and 244: their current pregnancy or a past p
Page 245 and 246: Promising Strategies:5. Integrating
Page 247 and 248: Gaps in Programming—Treatment1. I
Page 249 and 250: cesarean, and 221 were non-elective
Page 251 and 252: 3. Efforts are needed to ensure tha
Page 253 and 254: “There is no doubt that there are
Page 255 and 256: formula feeding increases the risk
Page 257 and 258: of age. For breastfed infants, the
Page 259 and 260: weeks of gestation and continued un
Page 261 and 262: A study in Côte d’Ivoire with 54
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Page 265 and 266: 3 times higher for infants who were
Page 267 and 268: counseling tools are needed. Studie
Page 269 and 270: Chapter 10.Preventing, Detecting an
Page 271 and 272: latent infection. Some immunocompro
Page 273 and 274: concurrent active TB and HIV infect
Page 275 and 276: mortality of HIV-positive people re
Page 277 and 278: in a 65% decline in mortality and t
Page 279 and 280: 1. Efforts are needed to reduce TB-
Page 281 and 282: al., 2004 cited in Slutsker and Mar
Page 283 and 284: stillbirths by 33%. Three cluster-r
Page 285 and 286: Gaps in Programming—Malaria1. Fur
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dose global coverage was just 27% i
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Chapter 11.Strengthening the Enabli
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combining microfinance and training
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pants meeting once per week for thr
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the men believed that they should n
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in the intervention village were si
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positive impacts. The quasi-experim
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Samoa, Serbia and Montenegro, Thail
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factor associated with sexual assau
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What Works—Strengthening the Enab
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worked with women’s groups, radio
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of school in addressing gender-base
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11C. Strengthening the Enabling Env
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also widely used worldwide and part
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ecognize women’s property rights
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Promising Strategies:2. Community o
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11D. Strengthening the Enabling Env
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more likely to report having used a
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likely than illiterate women to kno
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of the women surveyed were HIV-posi
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countries extending the fee aboliti
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families and separated from their c
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used the resource “Understanding
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6. Support groups for people living
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11G. Strengthening the Enabling Env
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EVIDENCEPromising Strategies:1. Inv
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Chapter 12.Care and SupportA. Women
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ical care provided by family member
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dealing with their sorrow, grief, a
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What Works—Care and Support: Wome
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2. Peer support groups can be highl
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discriminated unjustly against them
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6. Home-based antiretroviral therap
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12B. Care and Support: Orphans and
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(Thurman et al., 2007). As of 2008,
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care and services were provided, wh
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for treatment can be safely monitor
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A study done in Kenya (year not giv
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ather than a narrowly defined HIV/A
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7. Further interventions to provide
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ning providers, antenatal care and
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What Works—Structuring Health Ser
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counts available at primary health
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Pregnant women reported feeling out
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Before implementation of the PMTCT
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accessing PMTCT. An evaluation of 3
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A mathematical model based on TB tr
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1. Improved integration is needed b
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15. Additional efforts are needed t
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Community-based Care is holistic ca
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Microfinance is often defined as fi
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Sexuality is a central aspect of be
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References 1Aaron, E. and S. Crinit
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Akabaysh, H. and G. Psacharopoulos.
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Barker, P., C. McCanno, N. Mehta, C
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Berer, M. 2008b. “Male Circumcisi
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Druce, N. and A. Nolan. 2007. “Se
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“What Works compiles a wealth of
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