PURPOSE: To evaluate a case of a normal estrogenic woman with amenorrhea and polycystic ovarian syndrome who fails to get menses after progesterone withdrawal but who menstruates with oral contraceptives. METHODS: The following sera assays were obtained: total testosterone (T), free T, weakly bound T, dehydroepiandrosterone sulfate, 17 hydroxyprogesterone, estradiol, free thyroxin, thyroid stimulating hormone, prolactin, evening cortisol, LH and FSH. RESULTS: The total testosterone was markedly elevated but the free testosterone was normal and the free and weakly bound testosterone was the high end of normal. The LH/FSH ratio was markedly increased consistent with the ultrasound findings of polycystic ovarian syndrome. Vaginal cytology showed a mixed high estrogen/high androgen effect and the endometrial thickness was only 5 mm. Twice she failed to have menses following progesterone withdrawal. CONCLUSIONS: One hypothesized mechanism is that the high testosterone levels even though mostly in the bound form inhibited estrogen from causing adequate endometrial development.

BACKGROUND: Unwanted pregnancy is associated with increased risk of maternal mortality and morbidity. Knowledge of the causes and its impact on maternal health and utilization of health services is crucial to develop preventive strategies. OBJECTIVE: To assess possible factors of unwanted pregnancy and its impact on maternal health and utilization of health services. METHODS: This is a prospective study (February 1, 2002-January 31, 2004) conducted on patients with diagnosis of abortion and admitted to gynecological ward of a zonal hospital. RESULTS: Totally 907 patients were admitted with a diagnosis of abortion which accounted for 12.6% of all hospital and 60.6% of gynecological admissions. Majority (69.8%) had unwanted pregnancy. Interference was reported in 81.4% of unwanted pregnancy. More than 95% of patients with wanted and 74.9% of unwanted pregnancies reported to the hospital within 3 days of vaginal bleeding (P < 0.0001). High incidence of complication was reported on patients with unwanted pregnancy. There were three maternal deaths and all were related to unwanted pregnancy. The mean hospital stay was 1.42 days in wanted and 2.06 days in unwanted pregnancies. Forced sex and failure of contraception were among the reasons for unwanted pregnancy. CONCLUSION: Unwanted pregnancy is associated with increased risk of maternal morbidity and mortality. Besides, it poses a burden to the utilization of health services. The development and prompt implementation of a strategy, that enables to safely manage unwanted pregnancy in recommended.

Acute measles virus infection can result in a transient decrease in plasma human immunodeficiency virus type 1 (HIV-1) RNA loads. We report the kinetics of plasma HIV-1 RNA loads in 2 Zambian children with confirmed and probable measles, and show that the decline in viral load is of similar magnitude to the first-phase decay rate after initiation of antiretroviral therapy.

This report shows how countries with low prevalence of male circumcision but high prevalence of HIV have made progress to scale up male circumcision services.

Although the development of an effective HIV-1 vaccine has proved very challenging for more than two decades, it remains the best hope to control the HIV pandemic. Since Brazil has particular epidemiological features, as well as adequate policies and infrastructure, the country has been an interesting site for HIV vaccine trials. Since 1995, eight trials were performed in Brazil enrolling over 2000 subjects. Peptide vaccine candidates were initially designed to elicit neutralising antibodies as an attempt to provide sterilising immunity against HIV-1. This strategy, however, has proved extremely difficult, and candidates were poorly immunogenic. Therefore, the next vaccine candidates focused mainly on the induction of cell mediated immune responses that would limit AIDS progression and transmission by suppressing viremia. Such candidates were naked DNA or viral vectors in either prophylactic or therapeutic approaches. Even though several candidates were immunogenic, protective immune responses against HIV-1 remain to be achieved. However, several studies with non-human primates and human elite controllers demonstrate that effective immune responses against HIV-1 may be elicited, supporting the belief that an HIV-1 vaccine is possible. Much has been learned, and now the development of an effective HIV-1 vaccine requires resetting priorities with focus on basic research, considering the merits of neutralising antibodies and CMI, as well as the role of innate immunity on HIV-1 protection. In this new perspective, large-scale trials should be replaced by smaller preliminary efficacy studies.

Encouraging seropositive people to voluntarily disclose their serostatus has been promoted as a key component of HIV prevention. Among other reasons, HIV disclosure to one's main partner is believed to be an incentive for serodiscordant couples to practice safe sex. The present article investigated this issue by conducting a cross-sectional survey of a large sample of HIV-infected women attending HIV care centers in Cameroon (N=1014). Overall, 86.3% of these women had disclosed their serostatus to their main partner. With respect to sexual activity with their main partner during the previous three months, 35.0% had practiced abstinence and 47.4% only safe sex, whereas 17.6% had engaged in unsafe sex at least once. HIV disclosure to one's main partner was related to safe sexual practices in multivariate analysis. Some of the factors associated with disclosure and safe sex were illustrative of the positive roles of improved access to care and women's empowerment. On the contrary, beliefs overestimating the effectiveness of antiretroviral therapies were quite widespread among respondents and predictive of both concealment of HIV status and unsafe sex.

BACKGROUND: Small families adopting family planning are usually considered happy families. They are expected to lead a better qualitative life. Quality-of-life (QOL) is routinely assessed for knowing patients' health status. Recently, the QOL concept has become increasingly popular for evaluating the impact of public health interventions. Hitherto, QOL is usually assessed by means of program achievements or indicators, which may sometimes be misleading. Hence, the new culture of QOL assessment by means of user perspectives is now becoming popular. Research Questions: 1) Is the quality-of-life of family planning (FP) adopters better than that of non-FP adopters? 2) Are the user perspectives helpful in QOL assessment? MATERIALS AND METHODS: A cross-sectional descriptive study was carried out among 50 FP adopting families and 50 non-FP adopting families from the village of Vutoor and the city of Karimnagar in Andhra Pradesh. SAMPLING METHODS: Random sampling, Proportions and Chi square test. RESULTS: Program perspectives revealed a better standard of living for FP adopters because they have amenities like housing, television, and vehicles and less mortality and morbidity (P < 0.001). However, they lack positive feelings towards life, general adaptation, personal relationships, and leisure opportunities. Finally, self-assessment by FP adopters themselves revealed no significant increase in their qualitative life after family planning (P = 0.05). CONCLUSIONS: While assessing the impact of a health program on quality-of-life, multiple methods of assessments including user perspectives are better than program indicators alone.

OBJECTIVE: To study the effect of mifepristone for priming and induction of second-trimester abortion in conjunction with a high-concentration oxytocin drip. STUDY DESIGN: Prospective, randomized, placebo-controlled, pilot study. Thirty patients with 14-25 weeks' gestational age abortion received either 600 mg of mifepristone or placebo in 3 identical capsules followed, 48 hours later, by a high-concentration oxytocin drip (HCOD). RESULTS: The mifepristone group showed significantly higher success rates as compared to the placebo group (92.3% vs. 52.9%, p<0.05). The time interval to abortion (from beginning of HCOD) was also significantly shorter in the mifepristone group as compared to the placebo group (11.3 +/- 6.0 hours vs. 17.6 +/- 6.5 hours, p <0.05). Probability of success as calculated by the Kaplan-Meier method was found to be highly significant (log rank test p = 0.001). CONCLUSION: Our results suggest that mifepristone is very effective for priming and induction of second-trimester abortion and shortens significantly the time interval to evacuation following HCOD.

A cross-sectional study was undertaken among drug-naive HIV patients at the University Hospital in Ouagadougou shortly before and after the introduction of large-scale antiretroviral therapy (ART) in Burkina Faso. Baseline clinical and virological data as well as protease (PR) and 5' reverse transcriptase (RT) sequences from 104 HIV infected patients were analyzed. Genotypic classification revealed the following subtypes and recombinant forms: CRF06_cpx, n = 46 (44.2%); CRF02_AG, n = 39 (37.5%); subtype A, n = 4 (3.8%); CRF09_cpx, n = 2 (1.9%); and unclassified, n = 13 (12.5%). Bootstrap analysis of CRF02_AG and CRF06_cpx viruses showed that >80% had a similar structure to their respective prototypes. The prevalence of primary drug resistance mutations was 12.5%, all mutations arising in the RT sequences in accordance with the dominance of this drug class in Burkina Faso. The mutations were distributed as follows: NRTI (10.6%): M41L (n = 2), D67N (n = 2), K70K/E (n = 2), L210W (n = 1), T215S/Y (n = 2), and K219K/Q (n = 2); NNRTI (6.1%): K103K/N (n = 2), Y181C (n = 2), G190G/A (n = 1), and P236P/L (n = 1). Subtype specific secondary polymorphisms such as K20I and M36I in the PR were observed in almost all patients. Drug resistance mutations occurred at similar frequencies (12.8% and 10.8%, respectively) among patients infected with CRF02_AG and CRF06_cpx. Some subtype specific polymorphisms were observed within important HLA epitopes, including B35, B7, and A2 in the RT, and A*6802 in the PR sequences. The observed resistance mutations are most likely to have been transmitted based on the timing of the study but prior undocumented use of ART cannot be excluded.

PURPOSE: Role of risk factors in cervical carcinogenesis and strategies for control of the disease have been assessed from the accumulated cytological data, derived from 35 years of hospital-based screening in Lucknow, North India. MATERIALS AND METHODS: A total of 36,484 women have been cytologically screened during a span of 35 years (April 1971 - June 2005) in the Gynaecology out patient department (OPD) of Queen Mary's Hospital. RESULTS: The frequency of Squamous Intraepithelial Lesion (SIL) and carcinoma was found to be 7.2% and 0.6%, respectively, in the present study. The study revealed high age and parity as a predominant factor in cervical carcinogenesis, while viral sexually transmitted disease (STDs) -human papilloma virus (HPV) and Herpes simplex virus (HSV) were also largely associated with SIL cases. The study emphasized great value of clinically downstaging the cervical cancer by detecting cervical cancer in the early stage. The study also revealed a significant difference in the frequency of SIL in symptomatic and asymptomatic women. CONCLUSION: Based on the analyzed data, it was felt that single lifetime screening, which appears to be the most feasible and affordable mode for control of carcinoma cervix in developing countries like India, should be carried out in all women of high parity irrespective of age (with three or more children) and in older women above the age of 40 years irrespective of parity.

BACKGROUND: Surgical patients and healthcare workers in sub-Saharan Africa are at an increased risk of contracting HIV. Sierra Leone is one of the poorest countries in the world and has a documented HIV prevalence rate of 2%. Because surgeons and other healthcare staff in sub-Saharan Africa are at risk for HIV exposure from their patients, an assessment of protective supplies and equipment was considered essential. METHODS: A Society of International Humanitarian Surgeons team in cooperation with the Sierra Leonean Ministry of Health and Sanitation undertook a survey of HIV-protective supplies and equipment at government hospitals in Sierra Leone. The presence of eye protection, sterile gloves, aprons, functioning suction machines, and sharps containers was recorded and compared with a local mission hospital and a local private hospital. RESULTS: Only 20% of government hospitals in Sierra Leone have adequate stores of sterile gloves or eye protection. Suction pumps and aprons are available in only 30-40% of facilities, respectively, and only half have functioning sterilizers and sharps containers. The mission and private hospitals were fully stocked. CONCLUSIONS: Although surgical healthcare workers are at risk for exposure to HIV, resources for their protection at government hospitals in Sierra Leone are severely lacking. The Society of International Humanitarian Surgeons is developing a program to provide protective supplies and equipment to hospitals in Sierra Leone, but additional efforts by other organizations working to decrease the spread of HIV are essential.

This report uses currently available data to take stock of the health of girls and women around the world and to draw attention to the consequences and costs of failing to address health issues at appropriate points in their lives. The report is structured around a life course divided into stages that have particular relevance for health -- early childhood (from birth to nine years), adolescence (from 10 to 19 years), adulthood (from 20 to 59 years, and including the reproductive ages of 15-44 years) and older age (from 60 years onwards). While many of the factors that affect the health of the girl child, the female adolescent, the adult and the older woman do not fit neatly or exclusively into these stages, the approach fosters a deeper understanding of how interventions in childhood, through adolescence, during the reproductive years and beyond affect health later in life and across the generations. The data in this report are largely drawn from WHO databases and publications, and from publications of other United Nations agencies. Readers should consult these sources for further information on data compilation and methods of analysis. Main sources are referenced in the text. While bringing together a wealth of evidence, the report does not set out to be comprehensive; indeed, it points to significant gaps in knowledge relating to women's health. While in some cases the report compares women with men, for the most part it draws attention to the differences in health and health care that girls and women face in different settings. The report highlights the interplay of biological and social determinants of women's health and draws attention to the role of gender inequality in increasing exposure and vulnerability to risk, limiting access to health care and information, and influencing health outcomes. The report notes the importance of women's multiple contributions to society in both their productive and reproductive roles, and both as consumers and -just as importantly -as providers of health care. In recognition of this, the report calls for primary health care reforms to be implemented in ways that ensure that health systems better meet the needs of girls and women. (Excerpt)

BACKGROUND: The extent to which immunologic and clinical biomarkers influence human immunodeficiency virus type 1 (HIV-1) infection outcomes remains incompletely characterized, particularly for non-B subtypes. On the basis of data supporting in vitro HIV-1 protein-specific CD8 T lymphocyte responses as correlates of immune control in cross-sectional studies, we assessed the relationship of these responses, along with established HIV-1 biomarkers, with rates of CD4 cell count decrease in individuals infected with HIV-1 subtype C. METHODS: Bivariate and multivariate mixed-effects models were used to assess the relationship of baseline CD4 cell count, plasma viral load, human leukocyte antigen (HLA) class I alleles, and HIV-1 protein-specific CD8 T cell responses with the rate of CD4 cell count decrease in a longitudinal population-based cohort of 300 therapy-naive, chronically infected adults with baseline CD4 cell counts >200 cells/mm(3) and plasma viral loads >500 copies/mL over a median of 25 months of follow-up. RESULTS: In bivariate analyses, baseline CD4 cell count, plasma viral load, and possession of a protective HLA allele correlated significantly with the rate of CD4 cell count decrease. No relationship was observed between HIV-1 protein-specific CD8 T cell responses and CD4 cell count decrease. Results from multivariate models incorporating baseline CD4 cell counts (201-350 vs >350 cells/mm(3)), plasma viral load (< or =100,000 vs >100,000 copies/mL), and HLA (protective vs not protective) yielded the ability to discriminate CD4 cell count decreases over a 10-fold range. The fastest decrease was observed among individuals with CD4 cell counts >350 cells/mm(3) and plasma viral loads >100,000 copies/mL with no protective HLA alleles (-59 cells/mm(3) per year), whereas the slowest decrease was observed among individuals with CD4 cell counts 201-350 cells/mm(3), plasma viral loads < or =100,000 copies/mL, and a protective HLA allele (-6 cells/mm(3) per year). CONCLUSIONS: The combination of plasma viral load and HLA class I type, but not in vitro HIV-1 protein-specific CD8 T cell responses, differentiates rates of CD4 cell count decrease in patients with chronic subtype-C infection better than either marker alone.

BACKGROUND: The ocular manifestations of HIV may lead to visual impairment or blindness. In India, patients typically initiate antiretroviral treatment (ART) with low CD4 cell counts when the risk of ocular complications may be high. The objective of this study was to determine the prevalence and types of HIV-associated ocular conditions in patients referred for ART in India. METHODS: This cross-sectional study was undertaken at a large public sector ART centre in Mumbai, India. Data collection including a standardised symptom screen, and an ophthalmic examination were performed on all consecutive patients satisfying the criteria for enrollment into the ART clinic irrespective of the presence or absence of ophthalmic/visual symptoms. RESULTS: Enrolled patients (n = 149) had a median CD4 cell count of 180 cell/microL (inter-quartile range [IQR], 106-253 cells/microL). The prevalence of HIV-associated ocular disease was 17.5% (95% CI, 11.2-23.6%) in all participants and 23.8% (95% CI: 14.5-33.1) in those with CD4 cell counts <200 cells/microL (n = 84). Only 7.7% of patients with HIV-associated ocular disease reported any eye symptoms in the standardised symptom screen. Objective visual impairment was detected in 20% of those with HIV-associated ocular disease compared to 6% in those without ocular manifestations (p = 0.02). Vitreoretinal disease was the most common manifestation, of which cytomegalovirus retinitis (CMVR) was the most frequent retinal infection (overall prevalence 8.7%, 95% CI: 4.1-13.3%). In a multivariable analysis, HIV-associated ocular disease was independently associated with a CD4 count <100 cells/microL (odds ratio [OR], 6.3, 95% CI: 1.5-25.9) and WHO clinical stages 3 and 4 (OR 9.4, 95% CI: 2.4-37.2). However, symptoms were not independently predictive of ocular disease. Sensitivity of ocular symptom screening was 7.7%, with a positive predictive value of 18% in this population. CONCLUSION: Over a fifth of unselected patients who are eligible for ART in this setting have HIV-related ocular disease of which CMVR is the most common form. Such patients may be at risk of developing ocular immune reconstitution phenomena during ART. Screening for ocular symptoms is not a reliable method to identify those with ocular morbidity and this highlights the need for routine ophthalmic screening prior to commencement of ART.

As part of prevention of HIV mother-to-child transmission (PMTCT) strategies, HIV-positive women are asked to choose between two options regarding infant feeding: replacement feeding or exclusive breastfeeding with early weaning. Health services must offer women counseling, guidance, and support to enable them to make an informed choice. This article aims to shed light on the content of counseling and its adaptation to local situations, including women's perceptions, in three resource-poor countries with different infant feeding patterns (Burkina Faso, Cambodia, and Cameroon). The qualitative study included observations in health facilities and interviews with HIV-positive mothers and health workers. The results show that counseling practices vary, including prescriptive counseling proposing only one option to all women, an option based on the mother's economic level assessed by health care providers, and the choice between options. While health workers consider economic aspects first, women mostly consider social aspects related to the risk of being stigmatized as a "bad mother'" or as HIV-positive. Overall trends identify some limits to counseling effectiveness when considering women's perceptions and needs, such as: the content of information provided by health care providers, duration and timing of counseling, discrepancies between information provided during counseling and from the health system, and ranking of preventive options by health workers. Women's agency for feeding choices is related to local practices and local authorities' abilities to provide more or less comprehensive counseling based on the organization of the health and aid system. Local practices also depend on institutions' interpretations of international recommendations based on public health considerations regarding standard of care and women's and the health system's respective responsibilities. Beyond structural constraints that hinder the adoption of preventive infant feeding patterns, addressing these issues may help improve counseling practices.

Oral contraceptive (OC) treatment has an inhibiting effect on protein synthesis in tendon and muscle connective tissue. We aimed to investigate whether OC influence myofibrillar protein turnover in young women. OC-users (24+/-2 years; Lindynette((R))n=7, Cilest((R))n=4) and non-OC-users (controls, 24+/-4 years n=12) performed one-legged kicking exercise. The next day, the myofibrillar protein fractional synthesis rate (FSR) was measured using stable isotopic tracers ((13)C-proline) while the subjects were fed standardized nutrient drinks. Simultaneously, a marker for myofibrillar protein breakdown, 3-methyl-histidine (3-MH), was measured in the interstitial fluid of the vastus lateralis. Measurements were performed in both legs. In general, myofibrillar protein FSR was lower in OC-users (two-way analysis of variance, P<0.05), although the difference seemed to depend on the OC type. Interstitial 3-MH in the skeletal muscle was not different between groups and did not vary by OC type. Exercise did not change myofibrillar protein FSR or 3-MH concentrations. Serum androstenedione and bioavailability of testosterone were lower in OC-users. In conclusion, the results indicate that the use of OC has an inhibiting effect on myofibrillar protein synthesis and the magnitude of the effect may depend on the type of OC. In contrast, there was no effect of OC on myofibrillar protein breakdown in the fed state.

In Peru, there is a lack of information on molecular analysis in pediatric human immunodeficiency virus (HIV) infection. At present, the mother-to-child transmission rate is estimated at approximately 2-4%. The objective of this study was to assess the molecular epidemiology of HIV-1 in infected children. Children with suspected or confirmed pulmonary tuberculosis were evaluated at two public hospitals between 2002 and 2007. Whole blood samples were obtained from 90 HIV-positive children, who were confirmed to be positive by enzyme-linked immunosorbent assay and Western blot. The specimens were subjected to envelope heteroduplex mobility assay (env HMA) followed by gag and pol gene region sequence analysis. Subtype B was found in 88 (98%) of 90 children and 2 (2%) children were subtype BF recombinants. This is the first report of recombinant HIV strains in HIV-infected children in Peru. Understanding the origin, diversity, and spread of HIV strains worldwide will be necessary for the development of an effective vaccine that targets pediatric populations throughout the world.

This letter to the editor discusses medical abortions and the rates of serious infection that may follow. It asks that careful consideration of the benefits and risks of universal antibiotic administration be considered in different economic, social, medical, and legal environments.

The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women. In the Ditrame Plus PMTCT program in Abidjan, Cote d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up. Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners. In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.

This paper examines the principle of beneficence in the light of moral and epistemological concerns that have crystallized in the South African context around clinical care. Three examples from the South African experience affecting the development of bioethics are examined: medical colonialism, the death in detention of Steve Biko, and the HIV/AIDS epidemic. Michael Gelfand's book [(1948). The sick African: a clinical study. Cape Town: Stewart Printing Company.] on African medical conditions captures the ambiguous nature of colonial medicine that linked genuine medical treatment with the civilizing mission. Biko's death was a key historical event that deeply implicated the medical profession under apartheid. The present HIV/AIDS epidemic presents the gravest social and political crisis for South African society. All three experiences influence the meaning and relevance of beneficence as a bioethics principle in the South African context. This paper argues for a South African bioethics informed by a critical humanism that takes account of the colonial past, and that does not model itself on an "original wound" or negation, but on positive care-giving practices.