User:Avanisingh94/Sexual and reproductive health

The Current Africa Section:

HIV/AIDS in Africa is a major public health problem. Sub-Saharan Africa is the worst affected world region for the prevalence of HIV, especially among young women. 90% of the children in the world living with HIV are in sub-Saharan Africa.

In most African countries, the total fertility rate is very high, often due to lack of access to contraception and family planning, and practices such as forced and child marriage. Niger, Angola, Mali, Burundi, Somalia, and Uganda have very high fertility rates. According to the United Nations Department of Economic and Social Affairs, Africa has the lowest rate of contraceptive use (33%) and the highest rate of unmet need for contraceptives (22%).

The updated contraceptive guidelines in South Africa attempt to improve access by providing special service delivery and access considerations for sex workers, lesbian, gay, bisexual, transgender, and intersex individuals, migrants, men, adolescents, women who are perimenopausal, have a disability, or chronic condition. They also aim to increase access to long-acting contraceptive methods, particularly the copper IUD, and the introductions of single rod progestogen implant and combined oestrogen and progesterone injectables. The copper IUD has been provided significantly less frequently than other contraceptive methods but signs of an increase in most provinces were reported. The most frequently provided method was injectable progesterone, which the article acknowledged was not ideal and emphasized condom use with this method because it can increase the risk of HIV: The product made up 49% of South Africa's contraceptive use and up to 90% in some provinces. Tanzanian provider perspectives address the obstacles to consistent contraceptive use in their communities. It was found that the capability of dispensaries to service patients was determined by inconsistent reproductive goals, low educational attainment, misconceptions about the side effects of contraceptives, and social factors such as gender dynamics, spousal dynamics, economic conditions, religious norms, cultural norms, and constraints in supply chains. A provider referenced an example of propaganda spread about the side effects of contraception: "There are influential people, for example, elders and religious leaders. They normally convince people that condoms contain some microorganisms and contraceptive pills cause cancer". Another said that women often had pressure from their spouse or family that caused them to use birth control secretly or to discontinue use and that women frequently preferred undetectable methods for this reason. Access was also hindered as a result of a lack of properly trained medical personnel: "Shortage of the medical attendant...is a challenge, we are not able to attend to a big number of clients, also we do not have enough education which makes us unable to provide women with the methods they want". The majority of medical centers were staffed by people without medical training and few doctors and nurses, despite federal regulations, due to lack of resources. One center had only one person who was able to insert and remove implants, and without her, they were unable to service people who wanted an implant inserted or removed. Another dispensary that carried two methods of birth control shared that they sometimes run out of both materials at the same time. Constraints in supply chains sometimes cause dispensaries to run out of contraceptive materials. Providers also claimed that more male involvement and education would be helpful. Public health officials, researchers, and programs can gain a more comprehensive picture of the barriers they face, and the efficacy of current approaches to family planning, by tracking specific, standardized family planning and reproductive health indicators.

In Mozambique, despite efforts in improving access to modern contraceptive methods, the general fertility rate is still high at 5.3 and the unmet need for contraceptives is also high at 26%. Among young women, the fertility rate has dramatically increased from 167 births per 1000 aged between 15 and 19 in 2011 to 194 in 2015 with a large increase in rural areas from 183 to 230. Contraceptive prevalence among 15 – 19 remains low at 14% in 2015 when compared to the national prevalence among the reproductive age group (15–49 years) at 25% in the same year.

What we plan to add:

The section called "Africa" in this article is very narrow. While it focuses on HIV/AIDS, it doesn't talk about any other sexually transmitted diseases. Also, the portion that talks about barriers to accessibility can be expanded on more and discussed differing from country to country. We plan on focusing on different types of barriers to accessibility and assessing them in more depth. For example, the legal/procedural barriers, along with the traditional and social attitudes that make it a challenge or looked down upon to obtain contraceptives. Also, the consequences of these formal and informal barriers as well are something we want to look more into. For example, is there a pipeline to unsafe abortion practices? How prevalent are unsafe medical procedures in Africa due to a lack of access to certain medical needs? What are the gender discrepancies between receiving/seeking medical attention? We additionally want to explore the movements on transsexual health, and what the support is for their health in the medical community in Africa. These are just a few subsections we want to add within Africa.

Sources we plan to include/look at right now:


 * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440826/#:~:text=Studies%20in%20Africa%20identified%20barriers,lack%20of%20access%20to%20services.
 * https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252745
 * https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10315-9
 * https://pubmed.ncbi.nlm.nih.gov/24044930/
 * https://www.hrw.org/news/2013/05/20/put-spotlight-african-womens-reproductive-rights
 * https://voelkerrechtsblog.org/the-status-of-womens-reproductive-rights-in-africa/
 * https://www.afro.who.int/health-topics/sexual-and-reproductive-health
 * https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0252745
 * https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071369/
 * https://www.researchgate.net/publication/328497482_Women's_sexual_and_reproductive_rights_in_contemporary_Africa
 * https://www.researchgate.net/publication/328497482_Women's_sexual_and_reproductive_rights_in_contemporary_Africa
 * https://www.un.org/en/chronicle/article/reproductive-health-african-region-what-has-been-done-improve-situation
 * https://www.prb.org/resources/the-democratic-republic-of-the-congo-leads-the-way-on-abortion-access-a-pathway-for-reproductive-rights-advocates-in-francophone-africa/
 * https://www.guttmacher.org/report/from-unsafe-to-safe-abortion-in-subsaharan-africa
 * https://www.jstor.org/stable/3583304
 * https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-018-0775-9
 * https://journals.sagepub.com/doi/pdf/10.1177/2158244019834368

Africa
HIV/AIDS in Africa

World AIDS Day 2006 event in Kenya

HIV/AIDS
HIV/AIDS in Africa is a major public health problem. The population of Sub-Saharan Africa is the worst affected region with the disease especially affecting the young female population. According to the National Library of Medicine, "Sub Saharan Africa (SSA) is occupied by 12% of the global population, but disproportionately has more than 90% of children younger than 15 years of age and 68% of adults that are living with HIV2." In Nigeria in specific, "There is early sexual maturity and considerable sexual activity between 9 and 15 years of age." HIV is also transmissible through breast milk, which proves that women infected with HIV/AIDS have to deal with more health consequences. South of the Sahara, the AIDS epidemic is the leading cause of death.

The reasons for the high spread of HIV/AIDS can be broken down into 7 main subsections: poverty, inadequate medical care, lack of prevention and education, taboo and stigma, sexual behavior, prostitution, and sexual violence against women. With a high population of individuals living in extreme poverty, condoms, HIV tests, and other forms of screening are not prioritized, leaving many individuals lacking the necessities to protect themselves from the disease. According to the International Finance Corporation, "Health care in Sub-Saharan Africa remains the worst in the world, with few countries able to spend the $34 to $40 a year per person that the World Health Organization considers the minimum for basic health care." Notably, though widespread poverty, "an astonishing 50 percent of the region's health expenditure is financed by out-of-pocket payments from individuals." This represents the lack of both affordability and accessibility surrounding the health care system in Sub-Saharan Africa. According to the United Nation, Sub-Saharan Africa struggles with the highest rate of education exclusion in the world; 60% of youth ages 15 to 17 are not in school. With this lack of education, information regarding HIV/AIDS and prevention practices are not transmitted to a number of individuals, leading to more citizens being unaware of the severity of the disease. Stigma surrounding HIV/AIDS further contributes to the high infection rate. In African villages, an individual's life is closely intertwined with their friends, families, and neighbors around them. Individuals who have HIV/AIDS are motivated to keep it a secret in fear of isolation and alienation. The extremity of this stigma is conveyed by some of the dialogue, people living with HIV are often ridiculed as "a walking corpse", referred to as "an HIV" and even called in Tanzania, "nyambizi", or submarine, which implies that an HIV-positive person is "menacing and deadly." Sexual behavior and prostitution also play a part in the increased rate of transmission of HIV/AIDS in Africa. Due to the high rates of poverty, prostitution is widespread, and sexual partners are often changing, increasing the likelihood of transmission. Africa has one of the highest rates of rape in the world, with many women getting AIDS due to raped and sexual violence by an HIV-infected offender. Similarly, gender roles within many African countries contribute to this, as "in much of sub-Saharan Africa, women are a subordinate group who are expected to become pregnant, bear children, and fulfill the sexual desires of their husbands without hesitation". Types of Contraceptives

The copper IUD has been provided less frequently than other contraceptive methods but there have been signs of an increase in most reported provinces. The most frequently provided methods are implants and injectable progesterone, which is not as ideal as condom usage, which is still required with this method to decrease the risk of HIV. In Nigeria, specifically, people who have multiple partners are often unwilling to protect themselves with condoms. "In a study conducted in a rural community in South West Nigeria in 1993, it was found that although 94.7% of 302 candidates aged between 20 and 54 years admitted hearing about the condom, only 51.3% admitted ever using it." According to the International Family Planning Perspective, "these injectable progesterone products made up 49% of South Africa's contraceptive use and up to 90% in some provinces." Though contraceptive use is rising in African countries, discontinuation rates are also high. Weak health systems challenge Sub-Saharan African countries in expanding contraceptive outreach, promotions and service.

Fertility Rates and Contraceptives
In most African countries, the total fertility rate is very high often due to a lack of access to contraception, family planning, and practices such as forced child marriage. For instance, Niger, Angola, Mali, Burundi, Somalia and Uganda have very high fertility rates. According to the United Nations Department of Economic and Social Affairs, "Africa has the lowest rate of contraceptive use (33%) and the highest rate of unmet need for contraceptives (22%)." In Mozambique, despite efforts in improving access to modern contraceptive methods, the general fertility rate is "still high at 5.3 and the unmet need for contraceptives is also high at 26%." Among young women, the fertility rate has dramatically increased from 167 births per 1000 aged between (15-19 years) in 2011 to 194 in 2015 with a large increase in rural areas from 183 to 230. Contraceptive prevalence among (15-19 years) remains low at 14% in 2015 when compared to the national prevalence among the reproductive age group (15-49 years) at 25% in the same year.

Contraceptive Accessibility
The updated contraceptive guidelines in South Africa attempt to improve accessibility by providing special service delivery and prompting awareness for adolescents, lesbian, gay, bisexual, transgender, intersex people, disabled people, chronically ill people, women who are perimenopausal, sex workers, migrants and males. They also aim to increase access to long-acting contraceptive methods such as the copper IUD, the single rod progestogen implant combined with estrogen and progesterone injectables. Tanzanian provider perspectives also realized the biggest obstacle in maintaining healthy contraceptive care in their communities: lack of consistency. Contraceptive dispensaries found that the capability of providing service to patients was inconsistent and substandard. This resulted in unsatisfied reproductive goals, low educational attainment, miseducation about the side effects of certain contraceptives.

Accessibility has also been hindered as a result of inadequate quantities of properly trained medical personnel. According to the African Journal of Reproductive Health, "Shortage of the medical attendant...is a challenge, we are not able to attend to a big number of clients, also we do not have enough education which makes us unable to provide women with the methods they want". The majority of medical centers are staffed by people without medical training and few doctors and nurses, despite federal regulations, due to lack of resources. One center had only one person who was able to insert and remove implants, and without her, they were unable to service people who required this method of contraceptive care. Another dispensary which carried two methods of birth control shared that they sometimes run out of both materials at the same time which makes it difficult to keep up with the supply and demand chain.

Social Factors Effect on Contraceptives
Unbalanced gender dynamics, spousal dynamics, economic conditions, religious norms, cultural norms, and constraints in supply chains all contribute to contraceptive rates and usage. One instance of this is a provider who referenced harmful propaganda about the side effects of contraceptive usage. The spread of this propaganda is one of the many examples of influential people in the community, such as elders and religious leaders, discouraging proper contraceptive care/health. In some cases, influential members of the community often convince others that condoms and contraceptive pills contain microorganisms that cause cancer.

In regards to spousal and gendered dynamics, many women often have faced pressure from their spouse or family members to use avoid birth control which resulted in them using it secretly. This is also one of the many reasons women frequently preferred undetectable contraceptive methods which can lead to less effective contraceptives.

Other Common Sexually Transmitted diseases in sub-Saharan Africa

Sub-Saharan Africa ranks first in STD yearly incidence compared to other world regions, reiterating the major problem that public health is in African countries. In sub-Saharan Africa, STDs are the most common reasons that individuals seek medical care. According to the World Health Organization, every year in Africa "there are 3.5 million cases of syphilis, 15 million cases of chlamydial disease, 16 million cases of gonorrhea, and 30 million cases of trichomoniasis."

Sexually Transmitted Diseases/Infections and Women

The majority of HIV infections, risks, and other sexually transmitted diseases in sub-Saharan Africa disproportionately impact women. Women, particularly under the age of 30, account for more than half of new infections on the African continent, employing incidence rates that are often double that of their male counterparts. Not only do women contain more risk of infection, but the consequences of these diseases are often significantly worse for women, as they can affect reproductive health as well. Some consequences of bacterial STIs include "pelvic inflammatory disease, chronic pelvic pain, tubal infertility, pregnancy complications, fetal and neonatal death." HIV infection is less unbalanced in gender infections, but other STDs disproportionately affect women, "who bear 80 percent of the disability." Previously stated, women are also more susceptible to infection due to social stigma and gendered expectations. "Most women with STDs will not seek medical care at all, or will only present late for treatment, when complications have already developed, complications that have devastating physical, psychological, and social consequences, particularly for women and their children." Women of lower-income status are often the least likely subgroup to receive any sort of medical attention.

More on Transsexual/LGBTQ+ Health

Individuals who identify as transgender often yield significantly higher rates of HIV in comparison to other subgroups. African politics and government are silent on LGBTQ+ issues in the political sphere, which translates in part to their accessibility and prioritization in healthcare. "It is possible that the invisibility of transgender people in epidemiological data from Africa is related to the criminalization of same-sex behaviour in many countries," representative of how traditional attitudes shape one's ability to participate similarly in society. Further research conducted among transgender women in South Africa shows more "health disparities and poor access to appropriate mental, sexual and reproductive health services." Still, however, there is limited data concerning transgender individuals within African countries.

Individuals identifying as part of the LGBTQ+ community, in a study conducted by BMC International Health and Human Rights, resulted all in facing some sort of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Violations took four distinct forms: availability, accessibility, acceptability, and quality. Facilities in South Africa lack services for specific LGBT concerns, providers refuse to care for patients identifying within the community, and if did, articulate moral disapproval. Finally, the lack of quality and knowledge about LGBTQ+ identities and health needs contributes to disproportionate negative harms, avoiding or delaying seeking healthcare with these implications.