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To compare national human immunodeficiency virus (HIV) policies influencing access to HIV testing and treatment services in six sub-Saharan African countries.We reviewed HIV policies as part of a multi-country study on adult mortality in sub-Saharan Africa. A policy extraction tool was developed and used to review national HIV policy documents and guidelines published in Kenya, Malawi, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe between 2003 and 2013. Key informant interviews helped to fill gaps in findings. National policies were categorized according to whether they explicitly or implicitly adhered to 54 policy indicators, identified through literature and expert reviews. We also compared the national policies with World Health Organization (WHO) guidance.There was wide variation in policies between countries; each country was progressive in some areas and not in others. Malawi was particularly advanced in promoting rapid initiation of antiretroviral therapy. However, no country had a consistently enabling policy context expected to increase access to care and prevent attrition. Countries went beyond WHO guidance in certain areas and key informants reported that practice often surpassed policy.Evaluating the impact of policy differences on access to care and health outcomes among people living with HIV is challenging. Certain policies will exert more influence than others and official policies are not always implemented. Future research should assess the extent of policy implementation and link these findings with HIV outcomes.Comparer les politiques nationales de lutte contre le virus de l'immunodéficience humaine (VIH) qui influencent l'accès aux services de dépistage et de traitement du VIH dans six pays d'Afrique subsaharienne.Nous avons examiné les politiques de lutte contre le VIH dans le cadre d'une étude multi-pays sur la mortalité des adultes en Afrique subsaharienne. Un outil d'extraction de données a été mis au point et utilisé afin d'examiner les documents et les directives des politiques nationales de lutte contre le VIH publiés en Afrique du Sud, au Kenya, au Malawi, en Ouganda, en République-Unie de Tanzanie et au Zimbabwe entre 2003 et 2013. Des entretiens avec des informateurs clés ont permis de combler les carences de ces résultats. Les politiques nationales ont été classées suivant leur degré de correspondance, explicite ou implicite, avec 54 indicateurs relatifs aux politiques, déterminés d'après des analyses documentaires et des examens d'experts. Nous avons également comparé les politiques nationales avec les recommandations de l'Organisation mondiale de la Santé (OMS).Nous avons observé de grandes différences entre les politiques de ces pays ; chaque pays était avancé dans certains domaines et pas dans d'autres. Le Malawi l'était particulièrement en matière de promotion du démarrage rapide du traitement antirétroviral. Cependant, aucun pays n'avait un contexte politique pouvant systématiquement permettre d'augmenter l'accès aux soins et d'éviter l'arrêt du traitement. Dans certains domaines, les pays allaient plus loin que les recommandations de l'OMS et les informateurs ont indiqué que la pratique dépassait souvent le cadre des politiques.Évaluer l'impact des différentes politiques sur l'accès aux soins et les résultats en termes de santé des personnes qui vivent avec le VIH n'est pas chose simple. Certaines politiques exercent une influence plus forte que d'autres et les politiques officielles ne sont pas toujours mises en œuvre. Des recherches ultérieures devraient évaluer le degré de mise en œuvre des politiques et mettre en lien leurs conclusions avec les résultats de la lutte contre le VIH.Comparar las políticas nacionales relativas al virus de la inmunodeficiencia humana (VIH) que influencian el acceso a las pruebas del VIH y a los tratamientos en seis países sub-saharianos.Se revisaron las políticas relativas al VIH como parte de un estudio multinacional sobre la mortalidad de adultos en África Subsahariana. Se desarrolló una herramienta de extracción de políticas y se utilizó para revisar los documentos y guías de las políticas nacionales relativas al VIH publicadas en Kenia, Malawi, República Unida de Tanzania, Sudáfrica, Uganda y Zimbabue entre 2003 y 2013. Se hicieron entrevistas a informantes claves que ayudaron a llenar los vacíos en los resultados. Las políticas nacionales se clasificaron según si se adhirieron explícita o implícitamente a 54 indicadores de políticas, identificados mediante bibliografía y opiniones de expertos. Asimismo, se compararon las políticas nacionales con las directrices de la Organización Mundial de la Salud (OMS).Se descubrió que había una amplia variedad entre las políticas de los países. Cada país estaba más avanzado en algunas áreas que en otras. Malawi estaba especialmente avanzado en la promoción de empezar rápidamente la terapia antirretroviral. Sin embargo, ningún país tenía un contexto de introducción de políticas consistente que incrementara el acceso a la atención primaria y evitara la deserción. Algunos países iban más allá de las orientaciones de la OMS en algunas áreas e informantes clave informaron de que la práctica a menudo superaba la política.Evaluar el impacto de las diferencias en las políticas relativas en el acceso a la atención primaria y los resultados en la salud entre aquellas personas con VIH es un reto. Algunas políticas ejercerán más influencia que otras y las políticas oficiales no siempre se aplican. Las investigaciones futuras deberían evaluar el grado de aplicación de las políticas y vincular estos resultados con los resultados del VIH.الغرض : مقارنة السياسات الوطنية لمكافحة فيروس العوز المناعي البشري(HIV) والتي تؤثر على القدرة على الاستفادة من خدمات الاختبار والعلاج من فيروس العوز المناعي البشري في ستة بلدان أفريقية واقعة جنوبي الصحراء. الطريقة : لقد راجعنا سياسات مكافحة فيروس العوز المناعي البشري كجزء من دراسة شملت العديد من البلدان حول معدلات وفيات البالغين في البلدان الأفريقية الواقعة جنوبي الصحراء. تم إعداد واستخدام أداة استخلاص السياسة لمراجعة الوثائق والمبادئ التوجيهية لسياسة مكافحة فيروس العوز المناعي البشري الوطنية التي نشرت في كينيا وملاوي وجنوب أفريقيا وأوغندا وجمهورية تنزانيا المتحدة وزمبابوي في الفترة ما بين عام 2003 و2013. ولقد ساعدت مقابلات المبلّغين الرئيسين على سد الثغرات في النتائج. صُنِّفت السياسات الوطنية وفقًا لما إذا كانت التزمت صراحةً أو ضمنيًا بـ 54 من مؤشرات السياسة، التي تم تحديدها من خلال المؤلفات الطبية ومراجعات الخبراء. وقمنا أيضًا بمقارنة السياسات الوطنية مع توجيهات منظمة الصحة العالمية (WHO). النتائج : كان هناك تفاوت كبير في السياسات بين البلدان؛ حيث تميز كل بلد بالتقدم في بعض الجوانب دون غيرها. كانت ملاوي متقدمة على وجه الخصوص في تعزيز فكرة الإسراع في بدء العلاج باستخدام مضادات الفيروسات القهقرية. ومع ذلك، لم يكن لدى أي بلد سياق لتطبيق سياسة تتيح تطوير القدرات بصورة ثابتة، بحيث يُنتظر منه تيسير سبل الاستفادة من الرعاية والحد من الاستنزاف. قامت البلدان بتجاوز توجيهات منظمة الصحة العالمية في مناطق معينة وذكر المبلّغون الرئيسون أن الممارسة غالبًا ما كانت تتجاوز السياسة. الاستنتاج : من العسير تقييم تأثير اختلافات السياسة في فرص الحصول على الرعاية والنتائج الصحية بين الأشخاص المصابين بفيروس العوز المناعي البشري. فسوف تحقق بعض السياسات المعينة المزيد من التأثير دون سواها، كما لا يتم دائمًا تنفيذ السياسات الرسمية. ينبغي على الأبحاث المستقبلية تقييم مدى تنفيذ السياسات وربط هذه النتائج بحصائل الإصابة بفيروس العوز المناعي البشري.旨在对比在撒哈拉沙漠以南的六个非洲国家中能够影响艾滋病病毒测试和治疗服务的国家艾滋病病毒 (HIV) 政策。.在撒哈拉沙漠以南的非洲国家中进行有关成人死亡率的多国研究期间,我们评审了艾滋病病毒政策。 当时开发了一种政策提取工具并将其用于评审津巴布韦、肯尼亚、马拉维、南非、坦桑尼亚联合共和国以及乌干达在 2003 年和 2013 年期间出版的国家艾滋病病毒政策文件和指南。关键知情人访谈帮助我们弥补了调查结果中的不足之处。 我们依据国家政策是否以明确或隐含的方式遵循 54 项政策指标来对其进行分类,并且通过文献和专家评审加以确认。 同时,我们还对比了国家政策和世界卫生组织 (WHO) 指南。.各国的政策差异很大;每个国家都在一些方面达到先进水平,而在另一些方面却没有达到先进水平。 马拉维在推动抗逆转录病毒疗法的快速启动方面尤为先进。 然而,没有一个国家能够终保持一贯有利的政策环境,难以按预期提高护理普及率和预防消耗。 各国在某些方面超出了世界卫生组织指南的范围,并且据关键知情人报告,实际情况往往超越政策范围。.评估政策差异对艾滋病病毒患者的护理普及率和医疗效果的影响具有挑战性。 某些政策会比其他政策产生更大的影响,并且官方政策并不总是能够得到落实。 今后的研究应评估政策实施的程度,并将这些调查结果与艾滋病病毒的医疗效果联系起来。.Сравнить политику в отношении вируса иммунодефицита человека (ВИЧ) в шести странах Африки к югу от Сахары. Оценивается доступность анализа на ВИЧ и услуг по лечению.Политики в отношении ВИЧ были рассмотрены в рамках многонационального исследования смертности взрослого населения в странах Африки к югу от Сахары. Для анализа политик был разработан специальный инструмент, который использовался для проверки официальных документов и рекомендаций, связанных с государственной политикой в отношении ВИЧ, опубликованных в Кении, Малави, Южной Африке, Уганде, Объединенной Республике Танзания и Зимбабве в период между 2003 и 2013 гг. Неясные моменты уточнялись благодаря ключевым информаторам. Национальные политики распределялись по категориям в зависимости от того, придерживались ли они явным или косвенным образом 54 показателей, выявленных в ходе оценки публикаций и отчетов специалистов. Было также проведено сравнение национальных политик с рекомендациями Всемирной организации здравоохранения (ВОЗ).Политики в разных странах отличались друг от друга; в каждой из стран отмечался прогресс в одних областях и отставание в других. В частности, Малави значительно выделялась продвижением раннего начала антиретровирусной терапии. Тем не менее ни в одной стране не была реализована эффективная политика, которая облегчала бы доступ к медицинской помощи и препятствовала бы оттоку персонала. В некоторых областях страны пошли дальше рекомендаций ВОЗ и основные информаторы сообщили, что практика часто опережала политику.Оценить, насколько отличия в государственной политике влияют на доступ к лечению и результаты мероприятий по охране здоровья для лиц, живущих с ВИЧ, довольно сложно. Некоторые из политик имеют сравнительно больший эффект, и официальная политика не всегда выполняется. В будущих исследованиях необходимо оценить степень выполнения политик и связать полученные данные с результатами лечения ВИЧ.
To identify points of dropout on the pathway from offering HIV testing to maintenance on antiretroviral therapy (ART), following the introduction of the Option B+ policy for pregnant women in Malawi (lifelong ART for HIV-positive mothers and 6 weeks nevirapine for the infants), a retrospective cohort study within a demographic surveillance system in northern Malawi. Women living in the demographic surveillance system who initiated antenatal care (ANC) between July 2011 (date of policy change) and January 2013, were eligible for inclusion. Women who consented were interviewed at home about their health facility attendance and care since pregnancy, including antenatal clinic (ANC) visits, delivery and postpartum care. Women9s reports, patient-held health records and clinic health records were manually linked to ascertain service use. Among 395 women, 86% had tested for HIV before the pregnancy, 90% tested or re-tested at the ANC visit, and <1% had never tested. Among 53 mothers known to be HIV-positive before attending ANC, 15 (28%) were already on ART prior to pregnancy. Ten women tested HIV-positive for the first time during pregnancy. Of the 47 HIV-positive mothers not already on ART, 26/47 (55%) started treatment during pregnancy. All but five women who started ART were still on treatment at the time of study interview. HIV testing was almost universal and most women who initiated ART were retained in care. However, nearly half of eligible pregnant women not on ART at the start of ANC had not taken up the invitation to initiate (lifelong) ART by the time of delivery, leaving their infants potentially HIV-exposed.
Estimates of the potential impacts of contraceptive use on averting unintended pregnancies, total and unsafe abortions, maternal deaths, and newborn, infant, and child deaths provide evidence of the value of investments in family planning programs and thus are critically important for policy makers, donors, and advocates alike. Several research teams have independently developed mathematical models that estimate the number of adverse health outcomes averted due to contraceptive use. However, each modeling approach was designed for different purposes, and as such the methodological assumptions, data inputs, and mathematical algorithms initially used in each model differed; consequently, the models did not produce comparable estimates for the same outcome indicators. To address this, a series of expert group meetings took place in which 5 models—Adding it Up, Impact 2, ImpactNow, Reality Check, and FamPlan/Lives Saved Tool (LiST)—were reviewed and harmonized where possible. The group identified the main reasons for the inconsistencies in the estimates generated by the models for each of the adverse health outcome indicators. The group then worked together to align the methodologies for estimating numbers of unintended pregnancies, abortions, and maternal deaths averted due to contraceptive use, and reviewed the challenges with estimating the impact of contraceptive use on newborn, infant, and child deaths, including the lack of a conceptually clear pathway and rigorous evidence. The assumption that most influenced harmonization was the comparison pregnancy rate used by the models to estimate the counterfactual scenario—that is, if women who are currently using contraception were not using a method, how many would become pregnant? All the models now base this on the number of unintended pregnancies among women with unmet contraceptive need, bringing the estimates for unintended pregnancies, total and unsafe abortion, and maternal deaths much closer together. The agreed approaches have already been adopted by the Family Planning 2020 (FP2020) initiative and Track20, a project that supports FP2020. The experts will continue to update their models collaboratively to ensure that the most current estimation methodologies and data available are used. Valid and reliable methodologies for estimating these impacts from family planning are critically important, not only for advocacy to sustain resource allocation commitments but also to enable measurement and tracking of global development indicators. Conflicting estimates can be counterproductive to generating support for family planning programs, and this harmonization process has created a more unified voice for quantifying the benefits of family planning.
Abstract This paper presents an analysis of trends in sexual activity by marital status and age, and their associations with contraceptive use. Understanding levels of, and trends in, sexual activity is important for assessing the needs for family planning services and for analysing commonly used family planning indicators. Data were taken from 220 Demographic and Health Surveys (DHSs) and 62 Multiple Indicator Cluster Surveys (MICSs) to provide insights into sexual activity by marital status and age in a total of 94 countries in different regions of the world. The results show the sensitivity of the indicator with respect to the definition of currently sexually active, based on the timing of last sexual intercourse (during the last 4 weeks, 3 months, or 1 year). Substantial diversity in sexual activity by marital status and age was demonstrated across countries. The proportion of married women reporting recent sexual activity (sexual intercourse during the last 4 weeks) ranged from 50% to 90%. The proportion of unmarried women reporting recent sexual activity did not exceed 50% in any of the 94 countries with available data, but showed substantial regional differences: it appeared to be rare in Asia and extremely varied within Africa, Europe and Latin America and the Caribbean. Among married women, sexual activity did not vary much by age group, while for unmarried women, there was an inverted U-pattern by age, with the youngest age group (15–19 years old) having the lowest proportion sexually active. The proportion of women who reported currently using contraception and reported not being sexually active varied by the contraceptive method used and was overall much greater among unmarried women. The evidence presented in this paper can be used to improve family planning policies and programmes to serve the diverse needs, for example regarding method choice and service provision, of unmarried women.
Abstract The Anthropocene can be read as being the era when the demand humanity makes on the biosphere’s goods and services—humanity’s ‘ecological footprint’—vastly exceeds its ability to supply it on a sustainable basis. Because the ‘ecological’ gap is met by a diminution of the biosphere, the inequality is increasing. We deploy estimates of the ecological gap, global GDP and its growth rates in recent years, and the rate at which natural capital has declined, to study three questions: (1) at what rate must efficiency at which Nature’s services are converted into GDP rise if the UN’s Sustainable Development Goals for year 2030 are to be sustainable; (2) what would a sustainable figure for world population be if global living standard is to be maintained at an acceptably high level? (3) What living standard could we aspire to if world population was to attain the UN’s near lower-end projection for 2100 of 9 billion? While we take a global perspective, the reasoning we deploy may also be applied on a smaller scale. The base year we adopt for our computations is the pre-pandemic 2019.
We consider two aspects of the human enterprise that profoundly affect the global environment: population and consumption. We show that fertility and consumption behavior harbor a class of externalities that have not been much noted in the literature. Both are driven in part by attitudes and preferences that are not egoistic but socially embedded; that is, each household’s decisions are influenced by the decisions made by others. In a famous paper, Garrett Hardin [G. Hardin, Science 162, 1243–1248 (1968)] drew attention to overpopulation and concluded that the solution lay in people “abandoning the freedom to breed.” That human attitudes and practices are socially embedded suggests that it is possible for people to reduce their fertility rates and consumption demands without experiencing a loss in wellbeing. We focus on fertility in sub-Saharan Africa and consumption in the rich world and argue that bottom-up social mechanisms rather than top-down government interventions are better placed to bring about those ecologically desirable changes.
Background Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. Monitoring progress towards these outcomes is well established for women of reproductive age (15–49 years) who are married or in a union (MWRA). For those who are not, limited data and variability in data sources and indicator definitions make monitoring challenging. To our knowledge, this study is the first to provide data and harmonised estimates that enable monitoring for all women of reproductive age (15–49 years) (WRA), including unmarried women (UWRA). We seek to quantify the gaps that remain in meeting family-planning needs among all WRA. Methods and findings In a systematic analysis, we compiled a comprehensive dataset of family-planning indicators among WRA from 1,247 nationally representative surveys. We used a Bayesian hierarchical model with country-specific time trends to estimate these indicators, with 95% uncertainty intervals (UIs), for 185 countries. We produced estimates from 1990 to 2019 and projections from 2019 to 2030 of contraceptive prevalence and unmet need for family planning among MWRA, UWRA, and all WRA, taking into account the changing proportions that were married or in a union. The model accounted for differences in the prevalence of sexual activity among UWRA across countries. Among 1.9 billion WRA in 2019, 1.11 billion (95% UI 1.07–1.16) have need for family planning; of those, 842 million (95% UI 800–893) use modern contraception, and 270 million (95% UI 246–301) have unmet need for modern methods. Globally, UWRA represented 15.7% (95% UI 13.4%–19.4%) of all modern contraceptive users and 16.0% (95% UI 12.9%–22.1%) of women with unmet need for modern methods in 2019. The proportion of the need for family planning satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 75.7% (95% UI 73.2%–78.0%) globally, yet less than half of the need for family planning was met in Middle and Western Africa. Projections to 2030 indicate an increase in the number of women with need for family planning to 1.19 billion (95% UI 1.13–1.26) and in the number of women using modern contraception to 918 million (95% UI 840–1,001). The main limitations of the study are as follows: (i) the uncertainty surrounding estimates for countries with little or no data is large; and (ii) although some adjustments were made, underreporting of contraceptive use and needs is likely, especially among UWRA. Conclusions In this study, we observed that large gaps remain in meeting family-planning needs. The projected increase in the number of women with need for family planning will create challenges to expand family-planning services fast enough to fulfil the growing need. Monitoring of family-planning indicators for all women, not just MWRA, is essential for accurately monitoring progress towards universal access to sexual and reproductive healthcare services—including family planning—by 2030 in the SDG era with its emphasis on 'leaving no one behind.'
The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use (from 0 per cent to 20 per cent) to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.
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