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FHI has recently participated in three research projects that are
changing contraceptive service provision and recommendations.
- Vasectomy: Interim results from a seven-country vasectomy
study by FHI and New York-based EngenderHealth have shown that
ligation and excision vasectomy is more effective when it includes
fascial interposition (a technique in which the fascial sheath
covering the vas is pulled over one of the cut ends and the end is
sewn shut).1Analysis of data from some 800 men in the
study is nearly complete, and final results are expected by the end
of 2003.
In the meantime, EngenderHealth is integrating fascial
interposition into its training materials. The third edition of its
training resource No-Scalpel
Vasectomy: An Illustrated Guide for Surgeons, published in
March 2003, contains an expanded description of the steps for
performing ligation and excision plus fascial interposition.2
Also in March 2003, the organization held a training exercise in New
Delhi, India, during which 10 key trainers from India, Nepal,
Bangladesh, Cambodia, the Philippines, and Kenya standardized their
fascial interposition techniques and were oriented to
EngenderHealth's revised vasectomy-training curriculum. "Fascial
interposition is no longer an option for our trainers," says
John Pile, senior manager of family planning services at
EngenderHealth. "It is a necessity."
Based on a recent study of the time and number of ejaculations
before reaching azoospermia (the absence of sperm in the ejaculate)
after ligation and excision vasectomy,3 the illustrated
guide and new curriculum also recommend a follow-up visit 12 weeks
(three months) after vasectomy. This is considered a more reliable
way to confirm success than giving clients the option of returning
after 20 ejaculations. The guide and curriculum also highlight the
importance of providers counseling their clients about the small
possibility of vasectomy failure.
-
Pregnancy Checklist: Using guidelines prepared by the U.S.
Agency for International Development (USAID), FHI has developed a
six-question checklist
(on FHI's website) that health care providers can use to help rule
out pregnancy in nonmenstruating clients who request contraceptives.
This simple and low-cost job aid, which is available in English,
French, and Spanish, has been shown in a Kenyan study to be more
than 99 percent effective at identifying nonpregnant women.4
The checklist has also been translated into Creole, Hindi, Khmer,
Kiswahili, and Nepali. An extensive dissemination campaign has
targeted USAID missions and cooperating agencies, and the checklist
is being disseminated nationally in Kenya, Mali, and Nepal and in
selected settings in Cambodia, Guatemala, India, Jordan, Senegal,
and Zimbabwe.
-
Nonoxynol-9: After studies by FHI, the Joint United
Nations Programme on HIV/AIDS (UNAIDS), and others revealed that the
spermicide nonoxynol-9 (N-9) does not protect against HIV,
gonorrhea, and chlamydial infection,5 international
organizations moved quickly to begin putting these findings into
practice. In October 2001, experts convened by the World Health
Organization (WHO) and the U.S.-based CONRAD Program concluded that
while N-9 remains a contraceptive option for women at low risk of
HIV infection, it may increase the risk of HIV infection among women
already at high risk for HIV.6 A note advising such women
to avoid using N-9 alone or products containing N-9 was added to
WHO's Selected Practice Recommendations for Contraceptive Use.7
In March 2003, WHO also published interim
recommendations on the use of N-9 spermicides in an on-line
update to its medical eligibility criteria for contraceptive use.
In January 2003, the U.S. Food and Drug Administration proposed new
warnings for the labels of over-the-counter vaginal contraceptives
containing N-9, stating that their use does not protect against
infection with HIV or other sexually transmitted pathogens. The label
would also advise consumers that using such contraceptives can increase
vaginal irritation, which is thought to be the reason why N-9 may
actually increase the possibility of acquiring HIV.8
— Kerry L. Wright and Kathleen Henry Shears
References
- Chen-Mok M, Bangdiwala SI, Dominik R, et al. Termination of a
randomized controlled trial of two vasectomy techniques. Control
Clin Trials 2003;24(1):78-84.
- EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for
Surgeons. Third Edition. New York, NY: EngenderHealth, 2003.
- Barone MA, Nazerali H, Cortes M, et al. A prospective study of
time and number of ejaculations to azoospermia after vasectomy by
ligation and excision. J Urol 2003;170(3):892-96.
- Stanback J, Qureshi Z, Sekadde-Kigondu C, et al. Checklist for
ruling out pregnancy among family-planning clients in primary care
[letter]. Lancet 1999;354(9178):566-67.
- Van Damme L, Ramjee G, Alary M, et al. Effectiveness of COL-1492,
a nonoyxnol-9 vaginal gel, on HIV-1 transmission in female sex
workers: a randomized controlled trial. Lancet
2002;360(9338):971-77; Roddy RE, Zekeng L, Ryan KA, et al. Effect of
nonoxynol-9 gel on urogenital gonorrhea and chlamydia infection: a
randomized controlled trial. JAMA 2002;287(9):1117-22; Roddy
RE, Zekeng L, Ryan KA, et al. A controlled trial of nonoxynol 9 film
to reduce male-to-female transmission of sexually transmitted
diseases. N Engl J Med 1998;339(8):504-10.
- World Health Organization, CONRAD Program. Safety of
Nonoxynol-9 When Used for Contraception: Report from WHO/CONRAD
Technical Consultation, October 2001. Geneva, Switzerland: World
Health Organization and CONRAD Program, 2002. Available online.
- World Health Organization. Selected Practice Recommendations
for Contraceptive Use, Question 20. Geneva, Switzerland: World
Health Organization, 2002: Available online.
- Over-the-counter vaginal contraceptive drug products containing
nonoxynol 9: required labeling (proposed rule). Federal Regist
2003;68(11):2254-62. Available online.
For more information, visit Family Health International's Website at www.fhi.org
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