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    • In Grabowski and colleagues report

    2019-06-27

    In , Grabowski and colleagues report that women consistently using DMPA were at nearly double the risk of acquiring herpes simplex virus type 2 (HSV2) compared with those using no contraception; in a sensitivity analysis limited to those whose main partner had HSV2, the risk increased by six times. HSV2, the cause of genital herpes, is prevalent in populations worldwide, including in Africa, and is a common cause of morbidity related to genital ulcer disease and of rare serious morbidity in infants with neonatal infection; it is also an important risk factor for HIV acquisition in adults. The results from Grabowski and colleagues build on a large and contentious body of evidence suggesting that DMPA might increase HIV risk, and a smaller number of studies exploring associations of contraceptives with other STIs. Although we have contributed to this discussion with observational data showing increased HIV risk associated with DMPA, we acknowledge that results across studies have been inconsistent and the answer is still unclear. Authors of meta-analyses have noted increased risk estimates for an association between DMPA and HIV association, but those results are only as strong as the observational data from which they derive, and important criticisms of the observational scientific literature in this discipline have been raised, including small sample sizes, reliance on self-reported contraceptive exposures, infrequent ascertainment of HIV and other STI outcomes, and inconsistent methods and findings, persisting even into recent studies. Notably, the Rakai Program previously identified no increased HIV risk related to DMPA in the Etoricoxib from which the present HSV2 risk was noted, and the only other cohort to explore DMPA\'s effects on HIV and HSV2 came to the opposite conclusion—increased HIV risk with no increase in HSV2 acquisition. We and others have argued that rigorous studies, with sufficient samples sizes and robust measurement of contraceptive exposures, infection outcomes, and behavioural confounders, including the potential for a randomised trial, are essential now to address outstanding questions related to contraceptives and HIV and STIs. The HSV2 results from Grabowski and colleagues\' study rest on just nine incident HSV2 cases of those using DMPA and infrequent annual assessments of contraceptive exposure, HSV2 outcome, and confounding factors, so we therefore agree with Grabowski and colleagues that the results are hypothesis-generating but not definitive evidence. For such a topic that intersects at two priority areas of global health—STIs and reproductive health—to have more hypotheses than clear evidence is frustrating—and sends a message to women that is complex and confusing.
    In , Yusra Shawar and colleagues assess the factors that have affected the limited priority given to global surgical care in contrast to other areas of the global health agenda. The most important finding of the study is that the global surgery community is fragmented and has little grassroots support, does not have a clear set of ideas about how to solve problems, and has faced challenges in attracting political attention from global health funders in comparison with disease-specific initiatives. Shawar and colleagues drew on public policy theories to analyse the strategic weaknesses of the global surgical community by use of process-tracing case study methods drawn from political science. This Article is part of a welcome trend of using research methods from other disciplines to gain greater analytical traction on the research questions one faces. The analytical value added of process tracing as a case study research method is that it focuses attention on within-case processes, enabling us to shed empirical and theoretical light on the causal processes that produce outcomes in particular cases. Process-tracing case studies focus on whether the evidence that we predict should be present if the processes functioned as theorised is actually present or not. This analysis requires the development of a set of clear hypotheses about what evidence should be present that include an explicit discussion of why this empirical material might be evidence of the causal process being present and functioning as theorised.