Population briefs vol. 21 no. 2

REPORTS ON POPULATION COUNCIL RESEARCH Volume 21, Number 2 September 2015 New Population Council analysis details HIV risks faced by adolescents in Tanzania. See page 2. I N S I D EUnderstanding the Adolescent Experience in Tanzania .2New Program Demonstrates Success in Reducing Gender-Based Violence in Bangladesh .4Effects of the New One-Year Reusable Nestorone®/Ethinyl Estradiol Contraceptive Vaginal Ring on Risks of Vaginal Infection .6Estimating Population-Based Characteristics of People Who Inject Drugs in Kenya .8 poverty, gender, and youth Understanding the Adolescent Experience in Tanzania In 2014, UNICEF and UNAIDS announced an initiative to reduce the high levels of HIV "Reducing HIV among young people in Tanzania infection among adolescents in Tanzania. Al-though adolescent girls and boys (ages 10–19) requires bold action. But in order to create in Tanzania make up nearly a quarter (23 percent) of the country's population, there was effective programs, we need evidence." a lack of evidence about adolescents, especially —Kelly Hallman younger girls. The Tanzania Commission for Senior Associate, Population Council AIDS (TACAIDS) and UNICEF-Tanzania com-missioned the Population Council to analyze multiple sources of data in order to better understand the situation faced by adolescents. Living locations and arrangements
ages 15–24 are living with partners at least 10 The Council's comprehensive analysis found years older. Girls ages 15–17 from the poorest that while young people's vulnerability to HIV is The analysis revealed that the migration of households are more than twice as likely as girls widely acknowledged, programs to address the young people is substantial: while 80 percent of of the same age from the wealthiest households risks they face are lacking. adolescents ages 10–14 live in rural areas, that to have ever been married. Married girls are "Reducing HIV among young people in proportion declines to 70 percent among young much less likely to continue their education: 58 Tanzania requires bold action," explains says adults ages 20–24. Rural–urban differences percent of young women ages 15–24 who had Kelly Hallman, Population Council Senior As- are also seen in living arrangements: while 25 been married by age 15 were unable to read sociate and primary investigator on the analysis. percent of girls and 20 percent of boys nation- a sentence, compared with 12 percent of their "But in order to create effective programs, we ally live with neither parent, this is true for 50 unmarried peers. percent of girls and 35 percent of boys ages Population Council researchers conducted 15–17 in urban areas. There are a number of a secondary analysis of data drawn from the possible explanations for this difference. Girls Sexual activity and pregnancy rates
2010 Tanzania Demographic and Health Survey, may migrate to urban areas to attend school or Approximately 50 percent of girls ages 20–24 the 2011–12 Tanzania HIV and Malaria Indica- seek employment (including domestic labor), had their first sexual encounter before the age of tor Survey, and the 2009 Violence against Chil- or they may move as a result of child marriage. 18; boys reported initiating sexual activity later dren in Tanzania Survey. To determine specific in life. Researchers found that girls from the vulnerabilities at national and regional levels School attendance, literacy rates,
wealthiest households were less likely to report and in urban and rural areas, the research- and child marriage
early pregnancy than girls from poorer house- ers analyzed approximately 40 key indicators holds. Overall, 5 percent of girls age 15 have related to knowledge, attitudes and behaviors, School attendance rates for young adolescents been pregnant, while nearly all young women and outcomes (including living arrangements, are similar for boys and girls ages 10–12 (over aged 24 (91 percent) have been pregnant. school attendance, illiteracy, marriage, preg- 90 percent of young boys and girls attend nancy, violence, and HIV) among females and school), but girls, particularly in rural areas, Violence against girls and women
males ages 10–14, 15–19, and 20–24 years. start to drop out at age 12, and the gender gap "Our objective was to provide fine-grained in attendance widens as children age. By age 14, Rates of physical and sexual violence, and the details on what it means to be a young female only 66 percent of girls nationally attend school, acceptance of violence toward women and girls, or male in Tanzania," says Hallman. "We are compared with 76 percent of boys. In urban vary considerably by region in Tanzania. Thirty thrilled that program managers and policy- areas, girls are more than twice as likely as boys percent of girls and 20 percent of boys ages makers are using this valuable information to ages 10–14 to be out of school and not living 15–24 report that their first sexual experience inform policy formulation, planning, monitor- with either parent (8 percent versus 3 percent). was forced. Ten percent of girls report that ing, and evaluation of HIV and AIDS, child mar- Around 5–6 percent of girls are married by they were hit or slapped during pregnancy. riage, education, child protection, and social age 15, and 31–37 percent by age 18. About 25 Furthermore, more than half (55 percent) of protection programs." percent of married or cohabiting young women young women ages 15–24 agree with at least

The Government of Tanzania and several organizations are using the Council's new report to shape programs for young people. one justification for wife beating, although this sex. More girls than boys ages 15–17 reported The Government of Tanzania and several rate is slightly lower among males of the same using a condom during premarital sex, but by organizations are using these rich data to age (50 percent). This is significant, because ages 20–24, men report greater condom use shape programs for young people. The findings acceptance of violence toward girls and women than women. Additionally, 15 percent of males and policy recommendations are being used early on can result in future violent physical and ages 15–24 report paying for sex in the past 12 by: the Government of Tanzania, to design a months, although less than half reported using national cash-transfer program to keep children a condom when they last paid for sex.
in school and facilitate their re-entry if they Knowledge of HIV prevention and
Modern contraception use among girls, drop out; TACAIDS, for national and regional use of modern contraception
especially in urban areas, is low; only 20 percent planning and to identify topics for high-impact of married girls and 30 percent of unmarried, interventions for adolescents; UNICEF, to form The majority of adolescents in Tanzania have ba- sexually active girls report using contraception. its adolescent strategy in Tanzania; and the U.S. sic knowledge of HIV-prevention methods. Most More than half (60 percent) of young women Agency for International Development mission young people are aware that using condoms ages 15–24 who have ever been pregnant were in Tanzania to shape its activities for young and limiting the number of concurrent sexual assisted by a health professional during their people. Tanzania is planned as a priority coun- partners can reduce the risk of HIV transmission. most recent delivery. try for the US government's new DREAMS (De- However, less than half of young people have termined, Resilient, AIDS-free, Mentored, and comprehensive HIV knowledge (for example, Safe) initiative and the report is also being used knowing that a healthy-looking person can to inform decisionmaking for that program.
have HIV), and more girls than boys know about The significant findings that have emerged preventing mother-to-child HIV transmission.
from this research can help guide government In general, adolescents are aware of HIV policies and programs focused on adolescents in testing locations, but they may not have access Tanzania. The study authors point specifically Population Council, Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), and to testing. Older adolescents and those living in to findings related to child marriage, school re- UNICEF-Tanzania. 2015. The Adolescent Experience urban areas are more likely to have been tested. entry after dropout, pregnancy, and HIV testing In-Depth: Using Data to Identify and Reach the Most Vulnerable Young People, Tanzania 2009–2012. Dar Although a relatively small proportion and counseling as areas where change is needed es Salaam: Population Council, TACAIDS, ZAC, and of adolescents report having multiple sexual in the government's approach. Overall, there partnerships, these partnerships are more typi- is an urgent need to improve coordination in ex- cal among older adolescents and those living isting adolescent sexual and reproductive health in rural areas. Young people report low use of programs, and to create policies to address criti- condoms in both paid and unpaid premarital cal gaps in such programs. poverty, gender, and youth New Program Demonstrates Success in Reducing Gender-Based Violence in Bangladesh A new study by the Population Council and the International Centre for Diarrhoeal "Most notably, spousal violence against women and Disease Research, Bangladesh (icddr,b) found that an innovative program in Bangladesh girls dropped. Group sessions that included both men has demonstrated a reduction in violence against women and girls. The "Growing and women seem to have been the key intervention." Up Safe and Healthy" project, also known as SAFE, sought to improve sexual and Senior Associate, Population Council reproductive health and reduce gender-based violence among women living in urban slums in Dhaka. The project ran from March 2012 to October 2013.
While it is illegal in Bangladesh for girls strategies, if any, would reduce violence faced increased access to support services, includ- under age 18 to marry, more than 60 percent by women and girls in urban slums. ing reproductive and maternal health and of Bangladeshi girls marry before they reach legal services. In communities that included this age. Girls married early are particularly group sessions with men, use of modern vulnerable to domestic violence, and legal SAFE evaluation methods
contraceptives increased and the proportion of and policy reforms to address gender-based The SAFE program's rigorous evaluation marriages that involved dowry declined. violence have had limited impact. Research explored sexual and reproductive health, "Most notably, spousal violence against shows that less than 2 percent of married gender-based violence, and marriage and women and girls dropped," said lead Popula- women in Bangladesh who have experienced childbearing outcomes. Participating com- tion Council researcher Sajeda Amin. "Group physical violence seek any kind of remedy or munities were randomly divided into three sessions that included both men and women intervention arms. Community campaign seem to have been the key intervention. These Young women and girls living in urban activities and health and legal services were proved most effective at reducing inequitable slums experience the highest rates of violence present in all three arms. The difference was gender attitudes." In fact, with respect to and poor sexual and reproductive health. the presence or absence of group sessions, and economic violence (i.e., cases where women This is of particular concern in Dhaka, where the goal of the evaluation was to determine were denied money, food, clothes, medicines, the slum population is growing rapidly as the impact—if any—of including group etc.), violence increased when only women young men and women migrate in search of sessions as part of the program. Arm A participated in group sessions, but decreased employment. These young people face pov- included sessions with men and women; Arm when men were included in the intervention. erty, insecure living arrangements, frequent B included sessions only with women; Arm C squatter evictions, weak social networks, the had no group sessions. A baseline survey was absence of civic society institutions, the lack conducted before SAFE was launched, and an Lessons learned and policy
of public services, and poor coordination endline survey was conducted following the conclusion of the program. SAFE was created to address some of The evaluation identified several key factors the problems faced by young women and that can explain SAFE's success: girls living in slums. The project provided • It is possible to improve sexual and repro- access to health and legal services, interactive SAFE increased awareness about women's ductive health and reduce violence but, to sessions with men, young women, and girls, sexual and reproductive health and rights, be successful, interventions must integrate and community-based awareness-raising gender-based violence, and rights and laws interactive group sessions, community campaigns to determine what combination of regarding marriage and dowry. In addition, it campaigns, and services.

The findings of the SAFE project in the slums of Bangladesh demonstrated that community awareness-raising sessions about gender equity that included both men and women were most effective at reducing gender-based violence. • It is critical to target vulnerable women and Future interventions that seek to improve girls and especially to reduce their isola- sexual and reproductive health and reduce Naved, Ruchira T. and Sajeda Amin. (Eds.). 2014. Im-pact of SAFE intervention on sexual and reproductive tion and build their confidence through gender-based violence in urban slum settings health and rights and violence against women and group sessions and peer-support networks so can use these findings to guide program devel- girls in Dhaka slums. Dhaka: icddr,b.
that they choose to seek help when they do opment. In particular, successful interventions experience violence. should take an integrated approach, strengthen The Embassy of the Kingdom of the Netherlands, informal (such as peer networks) and formal DANIDA, and the John D. and Catherine T. MacArthur • Working with men will significantly improve (i.e., legal systems) support systems, and engage men in order to alter gender norms and change • Community campaigns are critical for promoting awareness about sexual and gender-based violence and improving knowledge about laws and the availability of legal services. reproduCtIve heaLth Effects of the New One-Year Reusable Nestorone®/Ethinyl Estradiol Contraceptive Vaginal Ring on Risks of Vaginal Infection A study by the Population Council and partners has found that use of the Council's investiga- The researchers found Researchers found no significant changes in tional one-year reusable contraceptive vaginal the detection rate of vaginal infections between ring (CVR) does not increase the risk of vaginal no substantial effects on baseline to Cycle 6 or between baseline to Cycle infections or disrupt the balance of microbes in 13. In general, they found that the prevalence the vagina when it is used for up to 13 cycles. the vaginal ecosystem of of typical vaginal infections in the study popu- Although past studies have examined the effects lation was comparable to the overall prevalence of short-term contraceptive vaginal ring use on of infections among women of reproduc- risk of vaginal infection, this is the first study of long-term repeated use tive age. Similarly, there were no significant a CVR intended for a full year's use. changes in the prevalence or concentration The one-year reusable CVR contains of the NES/EE CVR. of the microorganisms that were cultured at Nestorone® and ethinyl estradiol. Nestorone baseline and at follow-up visits, i.e. Lactobacil- (NES) is an investigational progestin that has lus, Gardnerella vaginalis, Enterococcus been shown in clinical studies to prevent ovula- faecalis, Staphylococcus aureus, Escherichia tion and pregnancy. Ethinyl estradiol (EE) is coli, Candida albicans or other yeast, all of an approved, marketed, synthetic version of the rection of Dr. Mitch Creinin, and was supported which remained at very low levels. Although the female hormone estrogen. by the National Institute of Child Health and prevalence of microbes called anaerobic gram "We are very excited about this new con- Human Development (NICHD) of the National negative rods (GNRs) increased, the concentra- traceptive ring," said Ruth Merkatz, PhD, RN, Institutes of Health. The study protocol was tion remained very low. The researchers noted Director of Clinical Development, Reproductive approved by the Institutional Review Boards of that the presence of anaerobic GNRs can be Health, at the Council's Center for Biomedi- the NICHD Coordinating Center, the Population attributed to characteristics of individuals in a cal Research and corresponding author of Council, and the University of Pittsburgh. study population, including younger age and the study. "It can be inserted and removed by 120 women enrolled in the study. Partici- having a culture swab obtained within three the woman herself rather than by a specially pants were seen by the researchers seven times days after vaginal intercourse. Importantly, trained health care provider, it does not require throughout the study year and were interviewed the researchers found that the cultures they daily action, and it can be reused for a full year. about any problems they may have encountered took from the surface of the vaginal rings It has been designed so that refrigeration is not with the ring. At three of the visits researchers were similar to the microbes in the vaginal required when it is not being used, which will obtained vaginal swabs to measure vaginal fluid, suggesting that the ring surface does not be important in many low-resource settings." microflora and the presence of bacteria. At the completion of the study, the ring surface was promote proliferation of microorganisms that cause infections.
swabbed and compared with the vaginal swab sample to measure for the same organisms. To assess the microbiological safety of the new The researchers assessed the occurrence of Conclusion: The investigational CVR
CVR, the researchers looked for vaginal infec- common vaginal infections, specifically bacte- poses no increased risk of vaginal
tions and changes in the balance of microbes rial vaginosis, trichomoniasis, and vulvovagi- in the vagina during cyclic use of a single NES/ nal candidiasis. They also evaluated changes in The researchers found no substantial effects on EE CVR for up to one year. This study, part of a vaginal microflora. It is normal for micro- the vaginal ecosystem of long-term repeated Phase III safety and efficacy trial of the NES/ organisms to colonize the vagina. However, use of the NES/EE CVR for up to 13 cycles, EE CVR, took place at the Magee-Womens changes in the amount and type of bacteria and no significant change in the incidence of Research Institute in Pittsburgh under the di- present in the vagina may lead to infection.

The study findings suggest that the ring surface does not promote proliferation of microorganisms that cause infections. The researchers have confidence in their for this novel contraceptive that is under the findings because the study used a prospective control of women. It has the potential to Huang, Yongmei, Ruth B. Merkatz, Sharon L. Hillier, Kevin Roberts, Diana L. Blithe, Régine Sitruk-Ware, design to evaluate the effects of one-year use be an important addition to the contracep- and Mitchell D. Creinin. 2015. "Effects of a one of a single CVR. It also included assessments tive method mix available to women," said year reusable contraceptive vaginal ring on vaginal of more microorganisms than have previ- microflora and the risk of vaginal infection: An open-label prospective evaluation," PLOS ONE 10(8): ously been investigated prospectively with The Population Council has a long vaginal rings. Additionally, obtaining cultures history of developing long-acting, reversible of the vaginal rings themselves had not been contraceptives to meet the growing worldwide National Institute of Child Health and Human Devel- described previously. The researchers recom- demand for modern family planning methods. opment of the National Institutes of Health mend that future studies include women from Council-developed contraceptive products more diverse populations, specifically from include the Copper T intrauterine device countries in sub-Saharan Africa and South (IUD), the levonorgestrel intrauterine system Asia where the unmet need for contracep- known as Mirena®, and the implants Jadelle® tion remains high and vaginal infections are and Norplant®. Currently, 170 million women worldwide are using a Council-developed "The results of this study will be valuable in our efforts to gain regulatory approval Estimating Population-Based Characteristics of People Who Inject Drugs in Kenya A study of people who inject drugs in Kenya has found a high prevalence of HIV infection "This study has helped firmly establish the existence of an and high levels of risk behavior. This study, the first to report population-based prevalence HIV epidemic among people who inject drugs in Nairobi, of HIV, sexually transmitted infections, and risk behaviors among people who inject drugs and confirms an extremely high HIV prevalence rate in Kenya, was led by the Population Council and conducted with researchers from the US among those who have ever shared injection syringes." Centers for Disease Control and Prevention/ Kenya (CDC), the Kenya National AIDS and Senior Associate, Population Council STI Control Programme (NASCOP), the Kenya National AIDS Control Council (NACC), and the University of California (San Francisco).
and testing was offered to participants who "The high HIV prevalence among People who inject drugs are at very high elected to be tested, and participants were also women who inject drugs is very concerning. risk for HIV. Of the estimated 15.9 million tested for sexually transmitted infections. The higher prevalence in women may be a injection drug users globally in 2010, approxi- result of their having more high-risk sexual mately one in five was HIV-positive. While the Characteristics of Kenya's injection
partners and practices such as transactional majority of persons who inject drugs live in drug using population
sex and their inability to negotiate condom Southeast and East Asia, the number of such use with partners. They may also be more persons in sub-Saharan Africa is growing rap- The study found that the median age of people likely to be injected by someone else with idly. This is of particular concern because of who inject drugs in Kenya is 31 years, a ma- an unsterile needle and syringe," said lead African countries' limited capacity to address jority of whom are unmarried men who earn Council researcher Waimar Tun.
money through informal or irregular employ-ment. While almost half of the people who in- Study findings and implications for
ject drugs began only recently, over 20 percent future policies and programs
had been doing so for over five years. Most From January to March 2011, Population of this population also engages in high-risk Because the finding in this study of an 18.7 Council researchers used respondent-driven injection practices at least monthly, including percent HIV prevalence rate among injection sampling to recruit study participants. They sharing syringes and other equipment. Over drug users matches prevalence rates found in selected a small group of individuals who half the population was not sexually active previous studies, the researchers concluded met a specific set of characteristics—men or in the last month, and the majority did not that respondent-driven sampling is a reliable women aged 18 and older who reported inject- engage in casual or commercial sex. Among method. The authors make several recom- ing drugs in the previous 3 months, lived in or those who were sexually active, condom use mendations based on their results.
around Nairobi, and were willing to provide was rare and almost one-quarter of women "This study has helped firmly establish written informed consent. These people then interviewed reported selling sex. the existence of an HIV epidemic among recruited their peers, who in turn recruited A majority of participants had previ- people who inject drugs in Nairobi, and additional peers, and so on. More than 350 ously been tested for HIV. Among people who confirms an extremely high HIV prevalence individuals were recruited to the study; 269 inject drugs, HIV prevalence was 18.7 percent, rate among those who have ever shared injec- participants were eligible. compared to approximately 5.6 percent in the tion syringes," said Council researcher Scott Participants were interviewed by trained general Kenyan population. Notably, the rate Geibel. "This evidence base has also supported nurse counselors about their HIV knowledge, among women who inject drugs was much and justified recent policy decisions in Kenya sexual risk and prevention behaviors, drug higher, at approximately 60.7 percent, a find- facilitating the development of harm-re- use, HIV testing history, and experience with ing that is confirmed by other studies of people duction interventions, including needle and violence and discrimination. HIV counseling who inject drugs in Africa.
syringe exchange programs." The researchers contend that these HIV AND AIDS
Muraguri, Nicholas, Waimar Tun, Jerry Okal, Dita Broz,
programs are particularly critical because H. Fisher Raymond, Timothy Kellogg, Sufia Dadabhai, Barnable, Patrick, Giulia Calenda, Thierry Bonnaire,
Helgar Musyoki, Meredith Sheehy, David Kuria, Rein-
more than half of the sexually active men who Radhika Menon, Keith Levendosky, Agegnehu Gettie,
hard Kaiser, and Scott Geibel. "HIV and STI prevalence
James F. Blanchard, Michael Cooney, José Fernández-
inject drugs had non-injecting female partners, and risk factors among male sex workers and other men Romero, Thomas Zydowsky, and Natalia Teleshova.
meaning that there is a high likelihood of the who have sex with men in Nairobi, Kenya," Journal of "MIV-150/zinc acetate gel inhibits cell-associated simian- Acquired Immune Deficiency Syndromes 68(1): 91–96.
HIV epidemic moving from the injection drug human immunodeficiency virus reverse transcriptase infection in a macaque vaginal explant model," Antimicro- Musyoki, Helgar, Timothy Kellogg, Scott Geibel, Nicholas
using population to the general population, bial Agents and Chemotherapy 59(7): 3829–3837.
Muraguri, Jerry Okal, Waimar Tun, H. Fisher Raymond,
potentially compromising efforts to reduce the Bhattacharjya, Chiranjeev, Damodar Sahu, Sangram
Sufia Dadabhai, Meredith Sheehy, and Andrea Kim.
"Prevalence of HIV, sexually transmitted infections, and spread of HIV more broadly. The researchers Kishor Patel, Niranjan Saggurti, and Arvind Pandey.
"Causes of death among HIV-infected adults registered in risk behaviors among female sex workers in Nairobi, Ke- also recommend that prevention programs selected anti-retroviral therapy centers in north-eastern nya: Results of a respondent driven sampling study," AIDS should specifically target drug users who India," World Journal of AIDS 5(2): 90–99.
and Behavior 19(Suppl. 1): 46–58.
Parimi, Prabhakar, Sangram Kishor Patel, and Niran-
recently began injecting, in order to establish Enhancing Nigeria's HIV/AIDS Response (ENR) Pro- jan Saggurti. 2014. "Financial inclusion of marginalised
safer injection practices early on and ideally to gramme. 2014. "Enhancing Nigeria's Response to HIV & AIDS (ENR) Programme: A book of abstracts key populations in southern India," Indian Journal of stop drug use while the habit is new. (2010–2014)." Abuja: Enhancing Nigeria's HIV and AIDS Economics and Development 2(4): 98–102. Another recommendation responds to the Response Programme.
Patel, Sangram Kishor. 2014. "Integration of HIV and
other health programmes: Implications and challeng- very high HIV prevalence rate the study found ———. "HIV prevalence and sexual behaviours of persons with disabilities in Nigeria." Abuja: Enhancing es," International Journal of Medical Science and Public among women who inject drugs. They call for Nigeria's HIV and AIDS Response Programme.
Health 3(6): 643–648.
further research to better estimate the number ———. "HIV and sexual behaviours of out-of-school Population Council. "ARV-based HIV prevention for
women: State of the science and considerations for of women who inject drugs in Nairobi and to young persons in Nigeria." Abuja: Enhancing Nigeria's HIV and AIDS Response Programme.
implementation in Zimbabwe. Report from a provider identify their unique characteristics so preven- workshop." New York: Population Council.
, Carolyn Deal, Betsy C. Her- tion programs can be specifically targeted to old, John Schiller, Dorothy Patton, Thomas Zydowsky,
———. "Sexual and reproductive health and rights Joseph W. Romano, Christopher D. Petro, and Manjulaa among young people living with HIV in Uganda: Findings Narasimhan. "Multipurpose prevention technologies: The from the Link Up baseline survey," Link Up Research Brief. The authors call for increased HIV testing future of HIV and STI protection," Trends in Microbiology Washington, DC: Population Council.
among people who inject drugs, pointing out 23(7): 429–436.
———. "Sexual and reproductive health among young that at least one-quarter of HIV-positive indi- Firestone, Rebecca, Jorge Rivas, Sussy Lungo, A. Cabrera, female sex workers in Bangladesh brothels—Baseline findings from Link Up," Study brief. Washington, DC: viduals in this population did not know they S. Ruether, Jennifer Wheeler, and Lung Vu. 2014. "Ef-
fectiveness of a combination prevention strategy for HIV Population Council.
were infected. They caution that HIV prevention risk reduction with men who have sex with men in Central Population Council and Alliance Burundaise contre le
programs must ensure that people who inject America: A mid-term evaluation," BMC Public Health 14: Sida. "Burundi program implementation workshop, 3–5 June 2014: Link Up meeting report," Activity brief. Wash- drugs are not denied HIV treatment because of "Introducing antiretroviral (ARV)-based prevention prod- ington, DC: Population Council.
stigma and discrimination. ucts for women: A guide to strategic decisionmaking and Population Council, Miz-Hasab Research Center, and
Finally, the authors note that further re- planning." New York: Population Council.
Organization for Social Services for AIDS. "Experiences search and evaluations are needed to determine Jha, Pravin K., Padum Narayan, Saritha Nair, Deepika
with pregnancy among female sex workers in Ethiopia: A Ganju, Damodar Sahu, and Arvind Pandey. "An assess-
Link Up exploratory study," Study brief. Washington, DC: the effectiveness of harm-reduction efforts to ment of comprehensive knowledge of HIV/AIDS among Population Council.
reduce the HIV prevalence rate in this highly slum and non-slum populations in Delhi, India," Open Sadhu, Santhosh, Archana Rao Manukonda, Anthony vulnerable population. Journal of Preventive Medicine 5(6): 259–268.
Reddy Yeruva, Sangram Kishor Patel, and Niranjan
Kelly, Christine A., Barbara Friedland, Neetha S.
Saggurti. 2014. "Role of a community-to-community
Morar, Lauren L. Katzen, Gita Ramjee, Mathila Mok-
learning strategy in the institutionalization of community gatle, and Khatija Ahmed. "To tell or not to tell: Male mobilization among female sex workers in India," PLoS partner engagement in a Phase 3 microbicide efficacy ONE 9(3): e90592.
Tun, Waimar, Meredith Sheehy, Dita Broz, Jerry trial in South Africa," Culture, Health & Sexuality 17(8): Sahu, Damodar, Sowmya Ramesh, Ram Manohar
Okal, Nicholas Muraguri, H. Fisher Raymond, Helgar Mishra, K. Srikanth Reddy, Reena Bharadwaj, Niranjan
Musyoki, Andrea A. Kim, Mercy Muthui, and Scott Morrison, Charles S., Pai-lien Chen, Cynthia Kwok, Jared Saggurti, Arvind Pandey, Mandar Mainkar, and Bitra
Geibel. 2015. "HIV and STI Prevalence and Injec- M. Baeten, Joelle Brown, Angela M. Cook, Lut Van George. "Are truckers being over stigmatized as HIV car- tion Behaviors Among People Who Inject Drugs in Damme, Sinead Delany-Moretlwe, Suzanna C. Francis, riers in India? Evidences from behavioral and biological Nairobi: Results from a 2011 Bio-behavioral Study Barbara Friedland, Richard J. Hayes, Renee Heffron,
cross-sectional surveys among clients of female sex work- Using Respondent-Driven Sampling," AIDS Behavior 19:S24–S35. DOI 10.1007/s10461-014-0936-3.
Saidi H. Kapiga, Quarraisha Abdool Karim, Stephanie ers," Open Journal of Preventive Medicine 5(3): 85–91.
Skoler-Karpoff, Rupert Kaul, R. Scott McClelland, Sheena Saraswati, Lopamudra, Avina Sarna, Mary Philip
McCormack, Nuala McGrath, Landon Myer, Helen Rees, Sebastian, Vartika Sharma, Ira Madan, Ibou Thior,
Ariane van der Straten, Deborah Watson-Jones, Janneke The U.S. President's Emergency Plan for AIDS Relief Julie Pulerwitz, and Waimar Tun. "HIV, Hepatitis B and
van de Wijgert, Randy Stalter, and Nicola Low. "Hormonal through the Centers for Disease Control and Preven- C among people who inject drugs: High prevalence of HIV contraception and the risk of HIV acquisition: An indi- tion (CDC), through the Population Council's coopera- and Hepatitis C RNA positive infections observed in Delhi, vidual participant data meta-analysis," PLoS Medicine tive agreement of Award No. 5U62PS224506 India," BMC Public Health 15(726).
12(1): e1001778.
Recent Publications Sharma, Vartika, Avina Sarna, Stanley Luchters,
Jejeebhoy, Shireen, Rajib Acharya, Sharmistha
Bellows, Nicole M., Ian Askew, and Benjamin Bel-
Mary Philip Sebastian, Olivier Degomme, Lopamudra
Basu, and A.J. Francis Zavier. "Addressing gender-
lows. "Review of performance-based incentives in
Saraswati, Ira Madan, Ibou Thior, and Waimar Tun.
biased sex selection in Haryana, India: Promising ap- community-based family planning programmes," Journal "‘Women at risk': The health and social vulnerabilities proaches." New Delhi: Population Council.
of Family Planning and Reproductive Health Care 41(2): of the regular female partners of men who inject drugs Jejeebhoy, Shireen, Sharmistha Basu, Rajib Acha-
in Delhi, India," Culture, Health and Sexuality 17(5): rya, and A.J. Francis Zavier. "Gender-biased sex selec-
Berdichevsky, Karla, Claudia Díaz, Katharine Mc-
tion in India: A review of the situation and interventions Carthy, and Ann K. Blanc. 2014. "Validating indicators
Sharma, Varun, Niranjan Saggurti, and Shalini Bharat.
to counter the practice." New Delhi: Population Council.
of the quality of maternal health care: Final report, "Association between general media exposure and Population Council. "Curriculum on adolescent-friendly
Mexico." Mexico City: Population Council.
sexual behavior among mobile female sex workers in health services and health voucher mechanisms: Facilita- Bin Nisar, Yasir, Michael J. Dibley, and Ali M. Mir.
India," International Journal of Communication and tor's training manual." Lusaka: Population Council.
"Factors associated with non-use of antenatal iron and Health 6: 60–68.
———. "Gender-biased sex selection in South Asia: folic acid supplements among Pakistani women: A cross ———. "Association between system reach and The situation and promising approaches to restore bal- sectional household survey," BMC Pregnancy and Child- exposure to interventions and characteristics of mobile ance," Project Summary. New Delhi: Population Council.
female sex workers in four high HIV prevalence states in ———. 2014. "Nutrition education curriculum for the Bintou Mbow, Fatou, Babacar Mane, and Saumya
India," Global Journal of Health Science 7(4): 83–95.
Adolescent Girls Empowerment Program (AGEP)." Lu- RamaRao. "L'offre des anneux vaginaux contraceptifs—
Tolley, Elizabeth E., Barbara Friedland, Mitzy Gafos,
saka: Population Council.
La planification familiale postpartum: experience du K. Rivet Amico, Lut Van Damme, Cynthia Woodsong, Population Council and UNICEF Belize. "The adoles-
Sénégal." Dakar: Population Council. Kathleen M. MacQueen, Leila Mansoor, and Sheena Mc- cent experience in-depth: Using data to identify and Birungi, Harriet, Chi-Chi Undie, Ian MacKenzie, Anne
Cormack. 2014. "Socioeconomic and behavioral factors reach the most vulnerable young people—Belize 2011." Katahoire, Francis Obare, and Patricia Machawira.
influencing choice, adherence and success of microbicide New York: Population Council. "Education sector response to early and unintended formulations," in Drug Delivery and Development of Anti- pregnancy: A review of country experiences in sub- HIV Microbicides, pp. 569–628.
Psaki, Stephanie. 2014. "Addressing early marriage
and adolescent pregnancy as a barrier to gender parity Saharan Africa," Research Report, July 2015. Nairobi: Ugaonkar, Shweta, Asa Wesenberg, Jolanta Wilk,
and equality in education," Background Paper for the Population Council. Samantha Seidor, Olga Mizenina, Larisa Kizima,
2015 UNESCO Education for All Global Monitoring Re- Brody, Carinne D., John M. Irige, and Benjamin Bel-
Aixa Rodriguez, Shimin Zhang, Keith Levendosky,
port. New York: Population Council.
lows. "Burnout at the frontline: The effect of a repro-
Jessica Kenney, Meropi Aravantinou, Nina Derby,
ductive health voucher program on health workers in Brooke Grasperge, Agegnehu Gettie, James F. Blanchard, Puri, Mahesh and Anand Tamang. "Assessment of inter- Uganda," International Archives of Nursing and Health Narender Kumar, Kevin Roberts, Melissa Robbiani,
ventions on sex-selection in Nepal: Literature review." Care 1(1).
José Fernández-Romero, and Thomas Zydowsky. "A
Kathmandu: CREHPA. Chattopadhyay, Ishita, John Townsend, and Sau-
novel intravaginal ring to prevent HIV-1, HSV-2, HPV, and ———. "Understanding factors influencing adverse mya RamaRao. "An innovative financing model for the
unintended pregnancy," Journal of Controlled Release sex ratios at birth and exploring what works to achieve progesterone contraceptive vaginal ring through voucher 213(10 September): 57–68.
balance: The situation in selected districts of Nepal." Kathmandu: CREHPA. programs." Washington, DC: Population Council.
———. "Offering progesterone contraceptive vaginal POVERTY, GENDER, AND YOUTH
Santhya, K.G., A.J. Francis Zavier, and Shireen
Jejeebhoy. "School quality and its association with
rings for postpartum women through integrated family "Adolescent Girls Empowerment Program (AGEP): Pro- agency and academic achievements in girls and boys in planning and immunization services." Washington, DC: gram overview," fact sheet. Lusaka: Population Council.
secondary schools: Evidence from Bihar, India," Interna- Population Council. "Adolescent Girls Initiative—Kenya: Program overview," tional Journal of Educational Development 41: 35–46.
———. "Utilizing social marketing and social fran- fact sheet. Nairobi: Population Council.
Sathar, Zeba, Gul Rashida, Sabahat Hussain, and
chising models to expand access to the progesterone Bongaarts, John. "Fertility change: Quantum and
Anushe Hassan. "Evidence of son preference and result- contraceptive vaginal ring." Washington, DC: Population tempo," in International Encyclopedia of the Social & ing demographic and health outcomes in Pakistan." Behavioral Sciences (Second Edition), pp. 10–12.
Islambad: Population Council.
"Delivering contraceptive vaginal rings," Project brief. ———. "Global fertility and population trends," Semi- "Urban Adolescents' Needs Assessment Survey in Ban- New York: Population Council. nars in Reproductive Medicine 33(01): 005–010.
gladesh," Brief. Dhaka: BIED, BRACU, and Population Diop, Nafissatou and Ibrahima Diagne. 2014. "Facteurs
Bongaarts, John and Christophe Z. Guilmoto. "How
associés aux longs intervalles intergénésiques au Séné- many more missing women? Excess female mortality gal. Analyse approfondie de l'EDS-MICS 2010-2011,"Af- and prenatal sex selection, 1970–2050," Population and rican Population Studies 28(3): 1324–1331.
Development Review 41(2): 241–269.
Abuya, Timothy, Charlotte E. Warren, Nora Miller,
Dixit, Anvita, M.E. Khan, and Isha Bhatnagar. "Main-
———. "How many more missing women? [Correspon- Rebecca Njuki, Charity Ndwiga, Alice Maranga, Faith
streaming of emergency contraception pill in India: Chal- dence]," The Lancet 386(9992): 427.
Mbehero, Anne Njeru, and Benjamin Bellows. "Explor-
lenges and opportunities," Indian Journal of Community Bruce, Judith and Annabel Erulkar. "A short his-
ing the prevalence of disrespect and abuse during child- Medicine 40(1): 49–55.
tory of the long struggle to identify and eliminate child birth in Kenya," PLoS ONE 10(4): e0123606.
Esantsi, Selina F., Francis Onyango, Gloria Quansah
marriage: Amhara, Ethiopia as a case study," in Global African Population and Health Research Center (APHRC). Asare, Emmanuel Kuffour, Placide Tapsoba, Harriet
Institutions, pp. 318–331. London: Routledge.
2014. "Population and health dynamics in Nairobi's infor- Birungi, and Ian Askew. "Understanding the reproduc-
Building Assets Toolkit: Developing Positive Benchmarks mal settlements: Report of the Nairobi Cross-sectional tive health needs of adolescents in selected slums in for Adolescent Girls. New York: Population Council.
Slums Survey (NCSS 2012)." Nairobi: APHRC.
Ghana: A public health assessment," STEP UP Research Report, March 2015. Nairobi: Population Council.
Haberland, Nicole and Debbie Rogow. "iMatter:
Ashfaq, Seemin and Maqsood Sadiq. "Engaging the
Teaching about puberty, gender, and fairness." New York: missing link: Evidence from FALAH for involving men in Gao, Ying, Dolores D. Mruk, and C. Yan Cheng. "Ser-
Population Council.
family planning in Pakistan," Case Study. Washington, toli cells are the target of environmental toxicants in the testis—A mechanistic and therapeutic insight," Expert Hallman, Kelly and Adam Weiner. "Participatory tools
DC: Population Council, The Evidence Project.
Opinion on Therapeutic Targets 19(8): 1073–1090.
to capture qualitative aspects of adolescent girl pro- Bellows, Benjamin, Rachel Bach, Zoe Baker, and
grams: Tanzania 2015." New York: Population Council.
Charlotte E. Warren. 2014. "Barriers to obstetric
Hallman, Kelly, Ilan Cerna-Turoff, and Neema Matee.
fistula treatment in low-income countries: A systematic "Participatory research results from training with the review." Nairobi: Population Council. Mabinti Tushike Hatamu out-of-school girls program: Tanzania 2015." New York: Population Council.
Hardee, Karen, Shannon Harris, Mariela Rodriguez, Jan
McCarthy, Katharine, Saumya RamaRao, and Hannah
Undie, Chi-Chi, Harriet Birungi, and Ian Askew.
Kumar, Lynn Bakamjian, Karen Newman, and Win Brown. Taboada. "New dialogue for the way forward in maternal "'Changing the World': The Africa Regional Sexual and 2014. "Achieving the goal of the London Summit on fam- health: Addressing market inefficiencies," Maternal and Gender-Based Violence Network," BMC Proceedings 9(Suppl ily planning by adhering to voluntary, rights-based family Child Health Journal 19(6): 1173–1178.
planning: What can we learn from past experiences with Mir, Ali M., Saleem Shaikh, Siti Nurul Qomariyah, Gul
Undie, Chi-Chi, Catherine Maternowska, Margaret
coercion?" International Perspectives on Sexual and Repro- Rashida, Mumraiz Khan, and Irfan Masood. "Using com-
Mak'anyengo, and Ian Askew. "What women think: Hypo-
ductive Health 40(4): 206–214.
munity informants to estimate maternal mortality in a rural thetical notions of screening for intimate partner violence in Hazra, Avishek and Sandip Chakraborty. "Reproductive
district in Pakistan: A feasibility study," Journal of Pregnancy Kenyan hospital settings," BMC Proceedings 9(Suppl 4): A6.
health of married young women in the context of HIV/AIDS 2015 (Article ID 267923).
Unumeri, Godwin and Salisu Mohammed Ishaku. "De-
in India," Indian Journal of Public Health Research and De- Mozumdar, Arupendra and Praween Kumar Agrawal.
livering contraceptive vaginal rings: Review of postpartum velopment 6(2): 230–236.
"Prevalence, trends, and determinants of menopause in and postnatal care programs in Nigeria." Abuja: Population Hazra, Avishek, M.E. Khan, and Subrato Mondal. 2014.
India: NFHS 1992–93 to NFHS 2005–06," American Journal "Mobile phone messaging as an innovative approach to in- of Human Biology 27(3): 421–425.
———. "Delivering contraceptive vaginal rings—Task volve men to stimulate discussion and change family health Mozumdar, Arupendra, Bhubon Mohan Das, and Subrata
sharing policies and practices in the delivery of family plan- behaviors," Technical Report. FHI360: Washington, DC. Kumar Roy. 2014. "Life table analysis of a small sample of ning services: Experiences from Nigeria." Abuja: Population Juma, Milka, Jane Alaii, Ian Askew, L. Kay Bartholomew,
Santal population living in a rural locality of West Bengal, and Bart van den Borne. "Community perspectives on pa- India," Anthropological Review 77(2): 233–248.
"Utilization of national health insurance for family plan- rental/caregiver communication on reproductive health and Njuki, Rebecca, Timothy Abuya, James Kelly Kimani,
ning and reproductive health services by the urban poor in HIV with adolescent orphans and non-orphans in western Lucy Kanya, Allan Korongo, Piet Bracke, Benjamin Bel-
Uttar Pradesh, India," Activity Brief. Washington, DC: The Kenya," Journal of Child and Adolescent Behaviour 3(3).
lows, and Charlotte E. Warren. "Does a voucher program
Evidence Project.
Keya, Kaji T., Ubaidur Rob, Md. Moshiur Rahman,
improve reproductive health service delivery and access in Walugembe, David Roger, Suzanne N. Kiwanuka, Joseph Ashish Bajracharya, and Benjamin Bellows. 2014.
Kenya?" BMC Health Services Research 15(206).
K.B. Matovu, Elizeus Rutebemberwa, and Laura Reichen-
"Distance, transportation cost, and mode of transport in the Powell-Jackson, Timothy, Rajib Acharya, Veronique Filippi, bach. "Utilization of research findings for health policy
utilization of facility-based maternity services: Evidence from and Carine Ronsmans. "Delivering medical abortion at scale: making and practice: Evidence from three case studies in rural Bangladesh," International Quarterly of Community A study of the retail market for medical abortion in Madhya Bangladesh," Health Research Policy and Systems 13(1): 26.
Health Education 35(1): 37–51.
Pradesh, India," PLoS ONE 10(3).
Warren, Charlotte E., Timothy Abuya, Lucy Kanya,
Khan, M.E., Anvita Dixit, Jaleel Ahmad, and G. Pillai.
"Proceedings of the 1st Washington, DC Meeting of the Francis Obare, Rebecca Njuki, and Marleen Temmerman.
"Introduction of DMPA in public facilities of Uttar Pradesh Africa Regional Sexual and Gender-Based Violence Network, "A cross sectional comparison of postnatal care quality in and Rajasthan: An evaluation," Project brief. New Delhi: 2013," BMC Proceedings 9(Suppl 4).
facilities participating in a maternal health voucher program Population Council.
"Progesterone contraceptive vaginal ring: Prevents preg- versus non-voucher facilities in Kenya," BMC Pregnancy and Khan, M.E., Praween Kumar Agrawal, Kumudha Aruldas,
nancy," fact sheet. New York: Population Council.
and Subrato Mondal. 2014. Training Manual on Monitoring "Progesterone contraceptive vaginal ring: Safe for mothers Warren, Charlotte E., James Kelly Kimani, Jackline
and Evaluation of Social and Behavior Change Communica- and babies," fact sheet. New York: Population Council.
Kivunaga, Brian Mdawida, Charity Ndwiga, Katharine
tion Health Programs. New Delhi: IHBP. FHI, and Population McCarthy, and Ann K. Blanc. 2014. "Validating indicators
"The RAISE Health initiative for workers, companies, and communities," Activity Brief. Washington, DC: The Evidence of the quality of maternal health care: Final report, Kenya." Kimani, James Kelly, Remare Ettarh, Charlotte E.
Nairobi: Population Council.
Warren, and Benjamin Bellows. 2014. "Determinants
Watt, Claire, Timothy Abuya, Charlotte E. Warren, Lucy
of health insurance ownership among women in Kenya: RamaRao, Saumya and Anrudh K. Jain. "Family planning Kanya, and Benjamin Bellows. "Can reproductive health
Evidence from the 2008–09 Kenya Demographic and Health initiatives must focus on people, not numbers," RH Reality voucher programs improve quality of postnatal care? A Survey," International Journal for Equity in Health 13(27).
Check, 8 April.
quasi-experimental evaluation of Kenya's Safe Motherhood Li, Nan, Dolores D. Mruk, and C. Yan Cheng. "Actin bind-
"Respectful Maternity Care Resource Package." New York: voucher scheme," PLoS ONE 10(4): e0122828.
ing proteins in blood–testis barrier function," Current Opin- Population Council.
Yasmin, Reena, Ubaidur Rob, Ismat Ara Hena, Tapash
ion in Endocrinology, Diabetes and Obesity 22(3): 238–247.
Sandberg, Kathryn, Jason Umans, and Georgetown Ranjan Das, and Farid Uddin Ahmed. "Increasing access to Li, Nan, Dolores D. Mruk, Chris K.C. Wong, Daishu Han,
Consensus Conference Work Group. "Recommendations safe menstrual regulation services in Bangladesh by offering Will M. Lee, and C. Yan Cheng. "Formin 1 regulates ec-
concerning the new U.S. National Institutes of Health initia- medical menstrual regulation," Reproductive Health Matters toplasmic specialization in the rat testis through its actin tive to balance the sex of cells and animals in preclinical 22(44, Suppl. 1): 67–74. nucleation and bundling activity," Endocrinology 156(8): research," The FASEB Journal 29(5): 1646–1652.
Yavinsky, Rachel Winnik , Carolyn Lamere, Kristen P. Sitruk-Ware, Régine and Anita Nath. "Applying emerg-
Patterson, and Jason Bremner. "The impact of population, Liambila, Wilson, Saumya RamaRao, and Heather
ing science to contraception research: Implications for the health, and environment projects: A synthesis of evidence." Clark. "Delivering contraceptive vaginal rings: Review of
clinic," Expert Review of Endocrinology and Metabolism Washington, DC: Population Council.
postpartum service packages in Kenya." Nairobi: Population 10(1): 115–126.
"Strengthening the role of patent medicine vendors in the ———. "Delivering contraceptive vaginal rings—Task provision of injectable contraception in Nigeria," Activity shifting and task sharing in the delivery of family planning Brief. Washington, DC: The Evidence Project.
"Biomedical research at the Population Council," services: Experiences from Kenya." Nairobi: Population Talukder, Md. Noorunnabi, Ubaidur Rob, and Forhana
Momentum, May 2015. Rahman Noor. 2014. "Assessment of sex selection in Ban-
Fertility Transition: A Selection from Population and Mane, Babacar, Nafissatou Diop, and Saumya Ra-
gladesh." Dhaka: Population Council.
Development Review. New York: Population Council.
maRao. "Delivering contraceptive vaginal rings—Task shar-
Talukder, Md. Noorunnabi, Ubaidur Rob, Syed Abu Jafar "From Research into Policy and Practice: Annual Report,
ing in the delivery of family planning programs: Experiences Md. Musa, Ashish Bajracharya, Kaji T. Keya, Forhana
2014." New York: Population Council.
from Senegal." Dakar: Population Council.
Rahman Noor, Eshita Jahan, Md. Irfan Hossain, Jyotir-
Population and Development Review 41(2).
Manzini-Henwood, Cebile, Nokwanda Dlamini, and Francis
moy Saha, and Benjamin Bellows. 2014. "Evaluation of
Studies in Family Planning 46(2).
Obare. "School-based girls' clubs as a means of addressing
the impact of the voucher program for improving maternal sexual and gender-based violence in Swaziland," BMC Pro- health behavior and status in Bangladesh," Final Report. ceedings 9(Suppl 4): A5.
Dhaka: Population Council.
Publications are by Population Council staff members, consultants, or staff from partner organizations. Year of publication is 2015 unless otherwise noted. Names in boldface are staff members, consultants, or those seconded from partner organizations.

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The SAFE project increased awareness among people living in slums in Dhaka, Bangladesh about women's sexual and reproductive health and rights, and reduced intimate partner violence. See page 4.

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