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BMJ-British Medical Journal, 2016.
We welcome the news item on the role of harm reduction in the ‘fight’ against HIV1 and we broadly agree with the findings of the report The Case for a Harm Reduction Decade: Progress, Potential and Paradigm Shifts.2 Clearly harm reduction for people who inject drugs (PWID) is having a positive impact on HIV in places such as the Ukraine, Nepal and parts of China and Kenya. This is supported by evidence of the long term impact of harm reduction approaches in controlling HIV among PWID in the United Kingdom, Switzerland and Australia. The increased benefits of even a modest proportional shift in resource from the so called ‘War on Drugs’ to evidence based harm reduction policies is a compelling argument. However, in addition to addressing the needs of established drug injecting populations such as heroin and stimulant injectors, we must also get ahead of the curve in relation to emerging patterns of injecting drug use to reduce the number of new cases of HIV. The injection of image and performance enhancing drugs (IPEDs) has been largely overlooked in relation to blood borne virus risks. IPEDs are a collective term for anabolic steroids, growth hormones, other drugs to increase musculature and associated ancillary drugs, together with peptide hormones such as melanotan II (a synthetic melanocortin analogue) and other drugs that are used for enhancement purposes. A recent meta-analysis and meta-regression of 187 studies on anabolic steroid use indicated a global lifetime prevalence of 3.3%.3 IPED users are growing as a client group in many countries with long standing provision of needle and syringe programmes, such as Australia4 and the United Kingdom where many services now report that over half of their clients inject IPEDs.5 Furthermore, in the United Kingdom there is conclusive evidence of HIV being present within this group of PWID, with an HIV prevalence of 1.5%6 amongst men injecting IPEDs, a level that is comparable to that among those injecting opioids and/or stimulants in the UK. Finally, there is evidence that people using IPED are a very sexually active population with low rates of condom use suggesting a risk of HIV transmission through their sexual networks.6 The use of IPEDs and in particular the injection of anabolic steroids by men, must be viewed as a serious public health concern requiring the attention of policy makers. Addressing the needs of emerging and often hidden populations of PWID should be part of the focus for harm reduction interventions. 1 BMJ 2016;352:i1479 2 Harm Reduction International. The case for a harm reduction decade: progress, potential and paradigm shifts. 2016. www.ihra.net/harm-reduction-decade 3 Sagoe D, Molde H, Andreassen CS, et al. The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Ann Epidemiol 2014;24:383-98. 4 Iversen J, Topp L, Wand H, et al. Are people who inject performance and image-enhancing drugs an increasing population of Needle and Syringe Program attendees? Drug Alcohol Rev. 2013;32:205-7. 5 Kimergård A, McVeigh J. Variability and dilemmas in harm reduction for anabolic steroid users in the UK: a multi-area interview study. Harm Reduct J 2014;11:19. 6 Hope VD, McVeigh J, Marongiu A, et al. Prevalence of, and risk factors for, HIV, hepatitis B and C infections among men who inject image and performance enhancing drugs: a cross-sectional study. BMJ Open 2013;3:e003207.
Professor Padam Simkhada, Aditi Sharma, Edwin van Teijlingen, Rachel Beanland
Nepal Journal of Epidemiology, Vol 6, No 1, 2016.
Abstract: Background: Increased travel abroad has a significant impact on the incidence and prevalence of Sexually Transmitted Infections (STIs). Previous reviews have focused on the knowledge, attitudes and behaviour of tourists and acquisition of STIs. Less is known about the impact on tourism operators in countries visited by tourists. The aim of this review is to ascertain factors influencing sexual behaviour between workers in the tourism industry and tourists; exploring the prevalence of sexual behaviour between the two populations, their perceptions of sexual risk while engaging in sexual activities and the knowledge of tourism operators regarding STIs. Methods: A systematic review was conducted. Database searches were performed in Medline/Ovid, EMBASE, Cochrane library and CINAHL for studies published between 2000 and March 2016. Grey literature searches were completed in the NHS database and Google Scholar between 2000 and December 2013. Papers were independently selected by two researchers. Data were extracted and critically appraised using a pre-designed extraction form and adapted CASP checklist. Results: The search identified 1,602 studies and 16 were included after review of the full text. Studies were conducted in nine countries. Findings suggest that STI knowledge, attitude and practice were fairly good among tourists and tourism workers, but there is a need for pre-travel advice for travellers, especially those travelling to low and middle-income countries. Greater importance was given to tourists than to tourism operators and locals interacting with tourists. Studies suggest that as a group both tourist and tourist workers were likely to engage in sexual activities. Overall, both condom use and STI screening were low, among tourists as well as tourism operators. Furthermore, studies reported links between drug and alcohol use and sexual behaviour and risk taking. Conclusion: Although less research appeared to have been conducted among tourism workers than tourists, it does demonstrate the need for education, training and promotion of travel medicine. STI screening, pre-travel advice, travel history in terms of contracting STIs and safe-sex awareness-raising are needed. More and better sexual health education and relevant tourism policies are needed globally.
Pramod Regmi, Edwin van Teijlingen, Vanora Hundley, Professor Padam Simkhada, Sheetal Sharma, Preeti Mahato
Health Prospect Vol 15, No 1, 2016.
In 2000, the United Nations (UN) adopted eight MillenniumDevelopment Goals (MDGs), three of these focused on health although several other MDGs included health-related components such as nutrition and sanitation (1). Overall progress towards the MDGs has been inspiring and specifically the health-related targets, e.g. MDG4 (reduce child mortality), MDG5 (improve maternal health) and MDG6 (combat HIV/ AIDS, malaria and other diseases) have been promising. For example, the global maternal mortality ratio (MMR) has fallen by 44% (from 341 in 2000 to 216 per 100,000 live births in 2015) and under-five mortality in the same period dropped by 53% (2). Despite these achievements, the world has failed to meet these MDG targets for both maternal mortality and under-five mortality, a fact recognised by maternal health practitioners, policy-makers and researchers across the globe (3). Moreover, progress has not advanced equally across the globe, for instance, improvements in MMR have been better in Southeast Asia (69% reduction) and the Western Pacific (64% reduction) (2).
Preeti Mahato, Pramod Regmi, Edwin van Teijlingen, Professor Padam Simkhada, Catherine Angell, Brijesh Sathian
Nepal Journal of Epidemiology 5(4): 518–519, 2015.
A massive earthquake hit Nepal in April followed by a strong aftershock in May. The earthquake had an impact in 31 districts out of the 75 districts of the country and total death toll reached 9,000, injured 23,000 and damaged 900,000 houses. Recent global and regional publications have indicated growing public health concerns and rebuilding infrastructures following the earthquake [2,3,4]; however none of the articles have focused on reproductive health care services, particularly on birthing centres in Nepal.
Edwin van Teijlingen, Professor Padam Simkhada, Bhimsen Devkota, Padmadharini Fanning, Jillian Ireland, Dr Bibha Simkhada, Lokendra Sherchan, Ram Chandra Silwal, Samridhi Pradhan, Shyam Maharjan, Ram Maharjan
Nepal Journal of Epidemiology, Vol 5, No 3, 2015.
Abstract: Mental health of pregnant women and new mothers is a growing area of concern in both low- and high-income countries. Maternity services in the UK, for example, have focused more attention on maternal mental health. We recognise that pregnancy, birth and the postnatal period is a time of major psychological and social change for women.
Ak Narayan Poudel, David Newlands, Professor Padam Simkhada
Nepal Journal of Epidemiology, Vol 5, No 3, 2015.
Abstract: Thousands of people are infected with HIV/AIDS in Nepal and most of them are adults of working age. Therefore, HIV/AIDS is a big burden in Nepal. This review was conducted to find the existing knowledge gap about the economic burden of HIV/AIDS at the household level in Nepal, the extent of economic burden exerted by the disease, and to provide policy recommendations. It is concluded that there was a considerable knowledge gap about the issue, and the economic burden exerted by HIV/AIDS was big enough to push the affected households into poverty. It is suggested that more studies need to be conducted to fill the knowledge gap. Similarly, Government of Nepal and other organisations working in the field of HIV/AIDS need to provide economic supports (e.g.- support for travel costs) to the HIV positive people and need to increase the awareness level among general population for reducing stigma and discrimination, and reducing economic burden on them.
Sarah Lewis, Andrew Lee, Professor Padam Simkhada
BMC Pregnancy & Childbirth, 15:162, 2015.
Abstract: Background: The role of husbands in maternal health is often overlooked by health programmes in developing countries and is an under-researched area of study globally. This study examines the role of husbands in maternity care and safe childbirth, their perceptions of the needs of women and children, the factors which influence or discourage their participation, and how women feel about male involvement around childbirth. It also identifies considerations that should be taken into account in the development of health education for husbands. Methods: This qualitative study was conducted in four rural hill villages in the Gorkha district of Nepal. Semi-structured, in-depth interviews were conducted with husbands (n = 17), wives (n = 15), mothers-in-law (n = 3), and health workers (n = 7) in Nepali through a translator. Interviews were transcribed and analysed using axial coding. Results: We found that, in rural Nepal, male involvement in maternal health and safe childbirth is complex and related to gradual and evolving changes in attitudes taking place. Traditional beliefs are upheld which influence male involvement, including the central role of women in the domain of pregnancy and childbirth that cannot be ignored. That said, husbands do have a role to play in maternity care. For example, they may be the only person available when a woman goes into labour. Considerable interest for the involvement of husbands was also expressed by both expectant mothers and fathers. However, it is important to recognise that the husbands’ role is shaped by many factors, including their availability, cultural beliefs, and traditions. Conclusions: This study shows that, although complex, expectant fathers do have an important role in maternal health and safe childbirth. Male involvement needs to be recognised and addressed in health education due to the potential benefits it may bring to both maternal and child health outcomes. This has important implications for health policy and practice, as there is a need for health systems and maternal health interventions to adapt in order to ensure the appropriate and effective inclusion of expectant fathers.
Lesley Milne, Edwin van Teijlingen, Vanora Hundley, Professor Padam Simkhada, Jillian Ireland
BMC Pregnancy & Childbirth, 15:142, 2015.
Abstract: Background: Nepal has made significant progress with regard to reducing the maternal mortality ratio but a major challenge remains the under-utilisation of skilled birth attendants who are predominantly facility based. Studies have explored women’s views of the barriers to facility birth; however the voices of staff who offer services have not been studied in detail. This research explores the views of staff as to the key reasons why pregnant women do not give birth in a maternity-care facility. Methods: This mixed methods study comprised qualitative interviews and non-participant observation. The study was conducted in two small non-governmental hospitals, one semi-rural and one urban, in Kathmandu Valley. Twenty interviews were conducted with health care providers and other staff in these hospitals. The interviews were undertaken with the aid of a Nepali translator, with some interviews being held in English. Twenty-five hours of non-participant observation was conducted in both maternity hospitals . Both observation and interview data were analysed thematically. Ethical approval was granted by the Nepal Research Health Council and Bournemouth University’s Ethics Committee. Results: Key themes that emerged from the analysis reflected barriers that women experience in accessing services at different conceptual levels and resembled the three phases of delay model by Thaddeus and Maine. This framework is used to present the barriers. First Phase Delays are: 1) lack of awareness that the facility/services exist; 2) women being too busy to attend; 3) poor services; 4) embarrassment; and 5) financial issues. Themes for the second Phase of Delay are: 1) birthing on the way; and 2) by-passing the facility in favour of one further away. The final Phase involved: 1) absence of an enabling environment; and 2) disrespectful care. Conclusion: This study highlights a multitude of barriers, not all of the same importance or occuring at the same time in the pregnancy journey. It is clear that staff are aware of many of the barriers for women in reaching the facility to give birth, and these fit with previous literature of women’s views. However, staff had limited insight into barriers occuring within the facility itself and were more likely to suggest that this was a problem for other institutions and not theirs.
Professor Padam Simkhada, Edwin van Teijlingen, Pramod Regmi, Prakash Bhatta, Roger Ingham, Nicole Stone
Journal of Manmohan Memorial Institute of Health Sciences Vol. 1, Issue 4, Page: 35-42, 2015.
Abstract: Tourism, a global industry, brings with it a number of public health problems, one of which is the spread of sexually transmitted infections transmitted between travelers and hosts. Previous studies have largely focused on sex workers and sex tourists. This study assesses sexual behavior, knowledge and condom use among male trekking guides in Nepal. A self-administered questionnaire survey (n=324) was conducted using snowball sampling amongst men working as mountain trekking guides in Nepal. Most respondents (59%) had initiated sex before the age of 18. Most (84 %) reported sexual relations with a woman other than their partner, 46% reported foreign partners, 43% had Nepalese partners, and 28% had concurrent foreign and Nepalese partners. Most (70 %) reported ever having sex with a foreign woman and two-thirds had had sexual intercourse with foreign women in the previous 12 months. Participants’ age, education status, age of first sex, smoking and drinking habits and English proficiency were significant predictors of having sex with foreign women. About 60% reported condom use during their most recent occasion of extra-marital sex. A similar proportion had used a condom during last sexual intercourse with a foreign woman. The likelihood of condom use was associated with a guide’s age, educational level, ethnicity, age of first sex and work experience. Most trekking guides reported sexual relations with foreign women as well as irregular use of condoms. Although sexual health knowledge about among trekking guides is high, some misconceptions still result in unsafe sex. Hence there is an urgent need to revise the existing training for trekking guides and implement appropriate health promotion programmes.
Sex work amongst people who inject drugs in England, Wales and Northern Ireland: Findings from a national survey of health harms and behaviours
Sara Croxford, Lucy Platt, Professor Vivian Hope, Katelyn Cullen, John V. Parry, Fortune Ncube
International Journal of Drug Policy Volume 26, Issue 4, April 2015, Pages 429–433, 2015.
Highlights: •One in seven PWID in EW&NI had a lifetime experience of sex work. •Sex work was found not to be associated with blood-borne viral infections. •SWs were significantly more vulnerable due to imprisonment and homelessness. •Harm reduction service provision needs to be maintained to reduce transmission of BBVs. •Services need to cater for the gendered differences in vulnerabilities amongst PWID.