Burkey, Matthew D. MD, MPH; Weiser, Sheri D. MD, MA, MPH; Fehmie, Desiree MPH, MSc; Alamo-Talisuna, Stella MD, PhD; Sunday, Pamella MS; Nannyunja, Joy; Reynolds, Steven J. MD; Chang, Larry W. MD, MPH
Objective: To delineate the association between baseline socioeconomic status (SES) indicators and mortality and lost to follow-up (LTFU) in a cohort of HIV-infected individuals enrolled inantiretroviral treatment(ART) in urban Uganda.
Design: Retrospective cohortstudynested in an antiretroviral clinic-based cohort.
Methods: SES indicators including education,employmentstatus, and a standardized wealth index, and other demographic and clinical variables were assessed at baseline among ART-treated patients in a clinic-based cohort in Kampala, Uganda. Confirmed mortality (primary outcome) and LTFU (secondary outcome) were actively ascertained over a 4-year follow-up period from 2005-2009.
Results: Among 1763 adults (70.5% female; mean age 36.2 years (SD=8.4)) enrolled in ART, 14.4% (n=253) were confirmed dead and 19.7% (n=346) were LTFU at 4-year follow-up. No formal education (Adjusted Odds Ratio (AOR) 1.76; 95% Confidence Interval (CI): 1.19 to 2.59), having fewer than 6 dependents (AOR 1.39; 95% CI: 1.04 to 1.86), unemployment (AOR 1.98; 95% CI: 1.48 to 2.66) and housing tenure index score (a component of the wealth index) (AOR 1.11; 95% CI: 1.00 to 1.23) were significantly associated with confirmed mortality at 4 years. SES indicators were not associated with LFTU at 4 years.
Conclusions: Baseline SES indicators, including education, number of dependents, employment status, and components of a standard wealth index, may indicate long-term vulnerability to mortality in patients with HIV/AIDS, despite uniform access to ART. Future studies delineating the pathways through which poverty and limited assets affect clinical outcomes may lead to more effective HIV interventions in low-resource settings.
Most of us have said, or heard a friend say, at one point or another “Hello birth control—goodbyecondoms!” I get the thought process behind this—but as ahealthcare providerfor young women, it worries me. Here’s why: young women have the highest risk for accidental pregnancyandsexually transmitted infections(STIs).
Arecent study in Northern Californiashowed that many youngwomen(ages 15-24) have trouble usingcondomsand hormonal birth control at the same time. The study followed 1,000 young women who started a new method of hormonal birth control. When they started the study, 36% of the women used condoms regularly for protection, and 5% used both condoms and birth control (a.k.a. “dual protection”). At first, starting a new method of birth control inspired these young women to double up, but over the months, the women stopped using condoms, stopped their other birth control, or stopped both. After a year, the majority were still worried about getting pregnant or getting an STI, but weren’t using condomsorbirth control.
Whenlifegets busy or complicated, it can be easy to get distracted and suddenly find yourself—like many of the couples in the study—not using any protection when you have sex. But the risks speak for themselves:
women ages 15-24 have about a1 in 30 chanceof contracting a common STI, like chlamydia or gonorrhea;
young women have a 1 in 20 chance of getting pregnant from having sex at any time in the menstrual cycle–and a1 in 4 chancearound the time of ovulation.
So what can you do?
Fortunately there are 4 steps you can take to double your protection:
Talk talk talk about condoms.With your partner, with your friends, with anyone who will listen. If your partner doesn’t like using them, find out why. You may be able to resolve the problem by checking out condoms made with different materials or ones withdifferent textures. Or bring him with you to your next clinic or doctor appointment so you can talk with ahealthcareprovider about using condoms and birth control together. Even though you both maypromiseto be only with each other right now, some infections take time to show up. This means an infection from the past could show up well into your relationship, even if you are both faithful. Using condoms every time you have sex is the only way to reduce your chance of infection.
Find a birth control method that is right for you.Try different methods until you find one that worksbest for your body and your lifestyle. Your healthcare provider can help you through this process, and help make sure that you stay protected even when you’re switching to something new.
Keep using condoms.Starting a hormonal or long-acting birth control method can helpprevent pregnancy, but you or your partner can still get an infection. Don’t stop using condoms just because you started birth control. Unless you’ve been in a monogamous relationship for more than six months and both been tested and cleared for STIs, keep up with the condoms.
Don’t stop your birth control without talking to your provider—or having a back-up plan.This is where many women get stuck. They used to use condoms, then they got on the pill, then they stopped using condoms, and now they’ve forgotten to take their pill so often that they decide to stop it altogether and don’t start using condoms again. To avoid being unprotected and frustrated,ask your provider when you start the method what you should do if you decide you don’t like it.I always tell my patients to let me know as soon as possible if they have questions or concerns about their method and are thinking about stopping it. Often,sideeffects can be controlled or will go away with time—or we can find a method that's easier to use or has fewer side effects. Regardless, if you ever stop using your birth control, always start using condoms immediately and every time you have sex to prevent pregnancy until you find a better method.
The bottom line?
Double up! Use condoms and a highly effective birth control method to take charge of your reproductive health.
Robin Wallace, MD, is a Family Physician for the San Francisco Department of Public Health and is currently a clinical fellow in Family Planning at the University ofCalifornia, San Francisco. As the middle of three daughters in her family, she has always been a passionate advocate for girl power and women's health, and appeared as Captain Contraception for a super heroes party inmedicalschool.