Icrh global activity report 2011 by Uplifted Studios

INTERNATIONAL CENTRE FOR REPRODUCTIVE HEALTH

ACTIVITY REPORT

“Reproductive freedom is critical to a whole range of issues. If we can’t take charge of this most personal aspect of our lives, we can’t take care of anything. It should not be seen as a privilege or as a benefit, but a fundamental human right.” Faye Wattleton

2011 INTERNATIONAL CENTRE FOR REPRODUCTIVE HEALTH

ACTIVITY REPORT

ICRH Activity Report 2011

TABLE OF CONTENTS

1 2 3

4 5 6 7 ICRH Activity Report 2011

PREFACE Message from the Director

4 5

INTRODUCTION International Centre for Reproductive Health (ICRH)

ACTIVITIES 2011

3.1 The HIV/STI Team 3.1.1 Projects 3.1.2 Other Activities of the HIV/STI Team

9 9 12

3.2 Sexual and Gender Based Violence Team 3.2.1 Projects 3.2.2 Other Activities of the Sexual and Gender Based Violence Team

13 13 17

3.3 The Maternal Health Team 3.3.1 Projects 3.3.2 Other Activities of the Maternal Health Team

19 20 22

3.4 The Health Systems Team 3.4.1 Projects 3.4.2 Other Activities of the Health Systems Team

24 24 25

3.5 The HPV/Cervical Cancer Team 3.5.1 Projects 3.5.2 Other Activities of the HPV/Cervical Cancer Team

27 27 31

3.6

Non-Team Related Activities

PUBLICATIONS 4.1 4.2 4.3 4.4

A1 Articles Other Articles Chapters and Books Presentations and Posters

HUMAN RESOURCES ICRH Workforce

ICRH AND THE ENVIRONMENT 6.1 6.2 6.3 6.4

Transportation Energy Consumption Waste Production The Ghent University Sustainability Pact

ICRH GROUP

40 41 50 51 51

54 55

56 57 58 58 58

ICRH Global ICRH Kenya ICRH Mozambique

61 61 62

Contacts Donations List of Abbreviations

62 62 63

PREFACE

ICRH’S VISION ICRH INTENDS TO BE A CENTRE OF EXCELLENCE IN SEXUAL AND REPRODUCTIVE HEALTH RESEARCH AND INTERVENTIONS. 4

ICRH Activity Report 2011

“ICRH wants to focus on priorities in sexual and reproductive health and rights. One of these priorities that has not received the attention it deserves is family planning, a crucial but neglected area that needs more attention, as too many people in the world are in need of safe and reliable contraceptive methods.”

arm greetings and best regards from ICRH 2011! In this report, we are pleased to tell you about our activities, publications and other achievements. I hope you will enjoy this concise summary of a wide range of ICRH projects from across the globe.

Looking back and reflecting at what we have been able to accomplish at ICRH, I feel happy and proud because of what we have realized as an organization, hopeful when I see many young people knocking at our door looking for a place to work, even as volunteers who want to contribute to a better world. Yet, I am also worried and concerned because of the financial crisis hitting the research world, especially international research partnering with developing countries, and even more because of the impact of the crisis on development aid as many donor countries face difficulties to pledge their contributions. This leads to serious negative effects on the health and well-being of the most vulnerable groups, often women and children in poor countries. Moreover, the opposition to sexual and reproductive rights and health seems to get stronger, more organized, and aims to obstruct policies and programs related to gender, sexuality, sexual and reproductive health, reproductive rights, comprehensive sexuality education, young people’s and adolescents’ sexual and reproductive health and rights, harmful traditional practices such as female genital mutilation/ cutting, and gender equality. Therefore, our mission is even more crucial than ever before. ICRH wants to focus on priorities in sexual and reproductive health and rights. One of these priorities that has not received the attention it deserves is family planning, a crucial but neglected area that needs more attention, as too many people in the world are in need of safe and reliable contraceptive methods. Notwithstanding the commitments made during the ICPD Conference in Cairo in 1994, there has been an alarming neglect from the international community for the topic since the year 2000. As a result, the progress made during the second half of the nineties slowed down considerably between 2000 and 2010; in a sense, one could say that ten years were almost wasted! This is astonishing, the more since meeting the need for family planning would have beneficial impacts on public health, environmental sustainability and social and economic development. It is time for a family planning decade! I am very happy to see the ICRH family grow in different countries and network with more organizations all over the globe. In that way we are better equipped to accomplish our mission by conducting health and social science research, bridging the gaps between research and policies, investing in education and advocacy, and promoting policies and practices for better sexual and reproductive health and rights. As we move towards the 20th anniversaries of the International Conference on Population and Development in Cairo (1994) and the World Conference on Women in Beijing (1995), ICRH will be focusing on working with many allies and friends to uphold the Cairo Program of Action and the Beijing Platform for Action agreements, to advance the sexual and reproductive rights and health agenda forward, and to achieve the health and gender related Millennium Development Goals. Prof. Dr. Marleen Temmerman Director ICRH ICRH Activity Report 2011

IN TRO D UC TION ICRH SEEKS TO IMPROVE THE ACCEPTABILITY, ACCESSIBILITY AND QUALITY OF SEXUAL AND REPRODUCTIVE HEALTH SERVICES, AND INTEGRATES A HUMAN RIGHTS BASED AND GENDER SENSITIVE APPROACH IN ITS ANALYSIS.

ICRH Activity Report 2011

THE INTERNATIONAL CENTRE FOR REPRODUCTIVE HEALTH (ICRH)

he International Centre for Reproductive Health (ICRH) was established in 1994 in response to the International Conference on Population and Development (ICPD, Cairo, 1994) as a multidisciplinary centre of excellence aiming at contributing to sexual and reproductive health and at promoting it as a human right. ICRH conducts research and intervention projects in all areas of reproductive health, implements capacity building, provides community education, prevention and HIV testing services, and advocates for sexual and reproductive health and rights. ICRH is active in Africa, Latin America, Asia and Europe. ICRH is a WHO Collaborating Centre for Research on Sexual and Reproductive Health and has experience in attracting donor funds from a wide range of agencies. The main fields of expertise are: • HIV and sexually transmitted infections (STI) with a particular focus on prevention • Maternal Health including mother & child health, with specific attention for safe motherhood and family planning • Sexual and gender based violence (SGBV), harmful traditional practices such as female genital mutilation (FGM) and forced/child marriage • Integration of sexual and reproductive health and rights within health systems • Human Papilloma Virus (HPV) ICRH conducts fundamental, epidemiological, social, clinical, health systems as well as policy research related to the themes listed above, but beside that, the Centre is also active in: • Training and capacity building: academic programmes (such as Masters and PhDs), courses and workshops but also on-site training, monitoring, evaluation and supervision to strengthen local capacity • Reproductive health services: advice, consultancies, technical assisistance, policy support, designing, planning, implementing, monitoring and evaluation • Advocacy: awareness raising at all levels (including the scientific and the political), and keeping sexual and reproductive health and right on the policy agenda.

ICRH Activity Report 2011

ACTIVI TI ES 2 011

THE MULTIDISCIPLINARY APPROACH OF ICRH IN TACKLING PROBLEMS RELATED TO SEXUAL AND REPRODUCTIVE HEALTH INTEGRATES MEDICAL ANALYSIS WITH POLITICAL, LEGAL, SOCIAL, CULTURAL AND ECONOMIC CONSIDERATIONS. 8

ICRH Activity Report 2011

3.1 THE HIV/STI TEAM

The HIV/STI team comprises all ICRH-Belgium staff involved in projects and activities in the domain of HIV and other sexually transmitted infections, excluding Human Papilloma Virus (HPV), and consists of 7 members. The objectives of the team are to coordinate all ICRH-Belgium HIV/STI activities, exchange information, develop joint initiatives and build capacity among team members. The focus is on HIV prevention, with special attention for a combination prevention approach. Other topics addressed by the team include mathematical modelling of HIV transmission and of the effect of different HIV prevention strategies, HIV risk reduction among youth in an African context, HIV prevention among mostat-risk populations, the link between HIV and infertility, the prevention of mother-to-child transmission (PMTCT), HIV counselling and testing in Europe, vaginal microbicides trials and the role of mycoplasmas and bacterial vaginosis. The team is led by Yves Lafort. 3.1.1 PROJECTS 3.1.1.1 Improved Sexual and Reproductive Health and Rights Services for Most at Risk Populations (MARP) in Tete, Mozambique

During 2011 ICRH initiated a project that aims at expanding and improving sexual and reproductive health and Financed by: Flemish International Cooperation Agency; rights (SRHR) among most-at-risk populations in the United States Agency for International Development; Vale Tete-Moatize area in central Mozambique. The main target do Rio Doce Coordinator: ICRH Belgium populations are female sex workers (FSW) and their male Partners: ICRH Belgium - Belgium clients. The project builds further on the previous projects ICRH Mozambique - Mozambique supporting a drop-in centre (‘night clinic’) for FSW and Provincial Health Directorate of Tete - Mozambique truck drivers in Moatize. During the course of the project, Budget: 1,162,819 EUR the current centre will be replaced by two clinics, one in Start date: 1 October 2010 Moatize and one in Tete-City, and the offered services End date: 31 March 2014 will be expanded to a comprehensive package of all Contact person at ICRH: Yves Lafort SRHR services. The health facility-based services will be yves.lafort@ugent.be complemented by community outreach activities, comprising behaviour change communication and structural interventions to create a supportive environment for a sustained behaviour change. Special attention will be given to reaching FSW clients through interventions in entertainment venues and at the workplace. The impact of the project will be carefully assessed through a pre-post assessment comparison that includes qualitative and quantitative data collection techniques. During 2012, the qualitative components of the baseline assessment (key informant interviews, in-depth interviews with FSW and clients, and focus group discussion with FSW) were initiated and the plots for the construction of the new clinics identified. 3.1.1.2 Diagonal Interventions to Fast Forward Enhanced Reproductive Health (DIFFER)

In October 2011, the DIFFER project was officially launched in Mombasa, Kenya. DIFFER stands for ‘Diagonal Interventions to Fast-Forward Enhanced Reproductive health’ and aims at improving access to sexual and reproductive health (SRH) for the most vulnerable by a better linkage between interventions targeted at most-atrisk populations, in particular female sex workers, and the general reproductive health services. It is implemented at four sites in Kenya (Mombasa), Mozambique (Tete), South Africa (Durban) and India (Mysore). The project has a strong south-south component and will translate previous successes and lessons learned in India to the Sub-Saharan African context. First, a thorough policy and situational analysis will identify the gaps and provide the information needed to design the intervention. Then, a package ICRH Activity Report 2011

Financed by: European Commission – FP7 Coordinator: ICRH Belgium Partners: ICRH Belgium - Belgium Ashodaya Samithi - India ICRH Kenya - Kenya ICRH Mozambique - Mozambique University of The Witwatersrand - MatCH & Centre for Health Policy - South Africa University College London, Centre for International Health & Development - United Kingdom Budget: 2,997,443 EUR Start date: 1 October 2010 End date: 30 September 2016 Contact person at ICRH: Yves Lafort yves.lafort@ugent.be

of comprehensive SRH services will be developed for both female sex workers and women of the general population together with site-specific models of how to best integrate these two packages. At the end of the 5-years project the models will be evaluated for their feasibility, acceptability, effectiveness, cost-effectiveness and sustainability.

ICRH Activity Report 2011

3.1.1.3 Characterisation of Novel Microbicide Safety Biomarkers in East and South Africa (BIOMARKERS)

Financed by: EDCTP Coordinator: ICRH Kenya Partners: ICRH Kenya - Kenya WRHI (formerly RHRU) - South Africa Projet Ubuzima - Rwanda MITU/NIMR - Tanzania ITM - Belgium AIGHD (formerly AMC-CPCD) - Netherlands ICRH - Belgium Ghent University - Belgium LSHTM - United Kingdom MRC-CTU - United Kingdom Budget: 2,688,595 EUR Start date: 5 April 2009 End date: 5 January 2013 Contact person at ICRH: Rita Verhelst rita.verhelst@UGent.be

Vaginal microbicides are being developed to expand HIV prevention options for women and couples. A healthy vaginal environment protects women from infections and should therefore remain intact during and after product administration. Until recently, microbicide safety trials included naked-eye pelvic exams and colposcopy to visualize genital epithelial disruption and inflammation, and vaginal fluid microscopy to evaluate the vaginal microbiota. However, recent experiences with the candidate microbicide cellulose sulfate gel suggest that these measurements are insufficient to predict harm. The purpose of this study is to establish baseline ranges of biomarkers related to the vaginal environment in groups of women targeted for microbicide trials in Kenya, Rwanda, and South Africa. Biomarkers of inflammation, epithelial integrity, immune activation, and antimicrobial activity in relation to the cervicovaginal microbiome will be assessed in healthy HIV-negative adult women at low risk for HIV, healthy HIV-negative adult women at high risk for HIV, HIV-negative adult women with BV, HIV-negative adult women using traditional vaginal practices, HIV-negative adult pregnant women, HIV-negative adolescents, healthy HIV-positive adult women. The expected outcomes are the identification of promising biomarkers that could be introduced in the next generation of microbicide safety trials, and baseline data on these biomarkers against which future assessments in women whom are using candidate microbicide products can be compared. In 2011, the study was implemented in all African study sites. All 430 volunteers were enrolled and follow up is foreseen to end in April 2012. STI and bacterial vaginosis prevalences were assessed and reported on the EDCTP forum at Addis Ababa (Ethiopia). Furthermore, the composition of the vaginal microbiome was assessed by micro-array analysis and further molecular and immuno-assays were planned. 3.1.1.4 Assessment by Molecular Methods of Safety and Colonization Potential from Well Characterized Probiotic Strains in South African Women with Healthy and Disturbed Vaginal Microflora (PROBIOGENOMICS) Financed by: NRF-FWO Coordinator: ICRH Belgium Partners: ICRH Belgium - Belgium WRHI (formerly RHRU) - South Africa Budget: 420,000 EUR Start date: 1 October 2010 End date: 30 September 2013 Contact person at ICRH: Rita Verhelst rita.verhelst@UGent.be

Alterations in the vaginal microbiome contribute to the risk of preterm birth and increased transmission of sexually transmitted agents and increased mother-to-child-transmission of HIV. Exogenous supplementation of vaginal bacteria to maintain and restore a healthy vaginal microbiota could lead to important intervention strategies. Using a combination of classical biochemical and molecular methods at WRHI (Wits Reproductive Health and HIV Institute, formerly RHRU) and high throughput genome sequencing technologies (probiogenomics) available at UGhent ICRH Activity Report 2011

(NXTGNT platform), this project will provide fundamental knowledge on how probiotic bacteria sense and adapt to the vaginal microbiome and influence vaginal ecology. Also, molecular based methods (real time PCR) for quantification of vaginal bacteria will be implemented at WRHI. This technology will allow our South-African partner to assess the safety of vaginal microbicides in future studies. In 2011, participant recruitment was initiated and bacteria were cultured, isolated and stored. Three WRHI staff members and two lab volunteers were trained in bacterial culturing and isolation. Furthermore, two South African masters students were trained in basic molecular diagnostic techniques. 3.1.1.5 HIV Testing and Counselling in Europe: from Policies to Effectiveness

In the European Union (EU) and neighbouring countries, an estimated 30% of people living with HIV are unaware of their Financed by: positive serostatus. Therefore they do not benefit from timely Coordinator: ICRH Belgium treatment and may transmit HIV unknowingly. OpportuniPartners: ties to diagnose HIV are being missed, particularly in regular Budget: Start date: 1 July 2010 health care settings, resulting in increased incidence of AIDS End date: 30 June 2011 defining illnesses, non-AIDS related events and potentially Contact person at ICRH: Jessika Deblonde death. While it is recognised that most EU countries have jessika.deblonde@ugent.be national policies and/or professional guidelines on antenatal HIV screening, systematic information on national HIV testing policies in other settings and population groups is lacking. Moreover, it has not been systematically assessed if and how HIV testing policies are being implemented and there is a lack of structured information on barriers to HIV testing and counselling in Europe. The overall aim of the study is to contribute to the improvement of the access, the offer, the uptake and the effectiveness of HIV testing and counselling to populations at increased risk for, and vulnerable to HIV in EU countries. Specific objectives are 1) to map HIV testing policies and guidelines; 2) to identify practices and barriers with regard to HIV testing and counselling; 3) to develop a framework to improve the effectiveness of HIV testing and counselling. In 2011, national HIV testing practices in Europe were reviewed to explore the characteristics and variations across European countries. Study results were disseminated. In addition, a research consortium has been set up at the Ghent University with the aim to elaborate an integrated model for improving STI/HIV prevention and uptake of testing among MSM. 3.1.1.6 The Added Value of a Theory Driven Design for HIV Risk Reduction Programs: a Case Study in Secondary Schools in Rwanda

With 22.9 million people living with HIV and 1.9 million new infections in 2010 the HIV epidemic seems to be levelling Financed by: Research Foundation Flanders (FWO), off in sub-Saharan Africa, but remains at an unacceptably Belgium high level. Nearly half of the new HIV infections worldwide National Lottery Fund, Belgium Coordinator: ICRH Belgium occur among young people aged 15-24 years, resulting in a Partners: Belgian Red Cross Flanders - Belgium regional HIV prevalence of 1.4% in young males and 3.3% Rwandan Red Cross - Rwanda in young females. Interventions aiming to reduce sexual risk Sensoa - Rwanda behaviour of youth show little to no effect. The overall aim Budget: 155,600 EUR of the study is to improve the effectiveness of sexual and Start date: October 2007 reproductive health interventions for young people. End date: September 2011 The study assesses, through a longitudinal survey and Contact person at ICRH: Kristien Michielsen qualitative research, the effectiveness of a HIV Peer Educakristien.michielsen@ugent.be tion programme implemented by the Red Cross in Rwanda and studies the determinants of sexual behaviour of Rwandan youth. In 2011, the focus was on data cleaning, analysis and reporting. The peer education intervention had little impact on knowledge, attitudes and reported sexual behaviour. Qualitative data showed that two stereotypical sexual interactions co-exist: experimental sex, taking place unprepared, driven by desire among same-age youth, and transactional sex, occurring after negotiation between older men/women and younger girls/boys in exchange for money or goods. Young people have little capacity to manage their vulnerability in these relationships: they have limited SRH knowledge, and lack support and easy access to condoms.

ICRH Activity Report 2011

3.1.1.7 Age-disparity, Sexual Connectedness and HIV Infection in Disadvantaged Communities around Cape Town, South Africa

In 2010, ICRH-Belgium, in collaboration with SACEMA embarked on a 5-year project to investigate the role of the Financed by: Research Foundation Flanders (FWO), sexual network structure in the spread and control of HIV in Belgium South Africa. Crucial connections between sexual network VLIR-UOS, Belgium Coordinator: ICRH Belgium structure and the spread of HIV remain inadequately underPartners: SACEMA - South Africa stood, especially as regards the role of multiple, concurrent Hasselt University - Belgium and age-disparate relationships, and how these features Budget: 500,000 EUR correlate with each other and other risk factors. Start date: 1 January 2010 A first challenge in addressing this knowledge gap is Social End date: 31 December 2014 Desirability bias when surveying sexual behaviour and relaContact person at ICRH: Wim Delva tionship histories. To this end, we developed a study protocol wim.delva@ugent.be for a sexual network survey with a focus on timing and age disparity of relationships, condom use and the use of drugs and alcohol at the time of the first sexual intercourse with each new partner. The physical administration of the questionnaire combines the use of a safe and confidential mobile interview space, audio computer-assisted self-interview technology with orientation material and warm up questions, a choice of languages including appropriate use of local slang and visual feedback of temporal information. The survey will be administered in three per-urban disadvantaged communities in the greater Cape Town area with a high burden of HIV, which have previously participated in a TB/HIV study, from which HIV test results will be anonymously linked to analysis data sets. Representatives of the study populations responded supportively to the proposed study design in cognitive interviews which also formed the basis of questionnaire refinement. Statistical analysis of the data will comprise mainly descriptive demographic, epidemiological, and sociological analyses, linear mixed-effects models for the inter- and intrasubject variability in the age difference between sexual partners, recurrent events analysis for concurrency patterns, and logistic regression for association of HIV status with age disparity and sexual connectedness. 3.1.2 OTHER ACTIVITIES OF THE HIV/STI TEAM 3.1.2.1 Belgian HIV/AIDS Working Group

The HIV team is an active member of the Belgian HIV/AIDS working group. The working group wants to mobilize the different Belgian actors working in the field of HIV/AIDS in order to contribute to the implementation of an AIDS policy that reduces the impact of HIV/AIDS worldwide. The working group does this by exchanging knowledge, information and experiences in the field of HIV/AIDS and by means of advocacy. In 2011 ICRH continued to take part in a specific working group that supported a study aimed at making an inventory of all activities in the field of HIV/AIDS supported by official Belgian development aid. Contact persons at ICRH: Kristien Michielsen and Yves Lafort. 3.1.2.2 BREACH

ICRH is member of the Belgian AIDS and HIV Research Consortium (BREACH). This consortium unites al Belgian AIDS Reference Laboratories (ARLs) and AIDS Reference Centres (ARCs), as well as other organizations that play a significant role in AIDS-related research or prevention, such as ICRH and Sensoa. BREACH aims among others at setting up a Belgian AIDS cohort, that will centralize all data on HIV/AIDS in Belgium and make them available for research purposes. In 2011, the drafting of the cohort protocol was finalized, a symposium was organized on the 30th of September in Leuven, and the establishment of a separate legal entity was initiated. In addition, a Public Health Working Group was constituted. Researchers, policy makers and other stakeholders working in the field of HIV/STI prevention, treatment and care in Belgium are invited to participate. The role of this Public Health Working Group is (1) to advise (inform) on specific HIV public health matters, either on its own initiative either on request of the BREACH Board; (2) to provide a forum for information, discussion and consultation with regard to HIV public health research; (3) to seek networking and collaboration, both nationally and internationally, on specific HIV public health topics. Contact person at ICRH: Jessika Deblonde

ICRH Activity Report 2011

“THE TERM VIOLENCE AGAINST WOMEN MEANS ANY ACT OF GENDER BASED VIOLENCE THAT RESULTS IN OR IS LIKELY TO RESULT IN, PHYSICAL, SEXUAL OR PSYCHOLOGICAL HARM OR SUFFERING TO WOMEN, INCLUDING THREATS OF SUCH ACTS, COERCION OR ARBITRARY DEPRIVATION OF LIBERTY, WHETHER OCCURRING IN PUBLIC OR IN PRIVATE LIFE.” 14

ICRH Activity Report 2011

3.2 THE SEXUAL AND GENDER BASED VIOLENCE TEAM 3.2.1 PROJECTS 3.2.1.1 Phenomenological Research on Honour Related Violence in Belgium

This exploratory research was launched in November 2010 and aimed at mapping and contextualising the various forms Financed by: Belgian Ministry of Home Affairs of honour related violence, and at documenting of good pracInstitute for the Equality of Women and Men (IGVM) tices in dealing with this phenomenon, in order to formulate Coordinator: Vrije Universiteit Brussel (VUB) Partners: ICRH Belgium - Belgium recommendations for the Belgian context. The qualitative Faculty of Criminology (VUB) - Belgium research consisted of a literature review, a situation analysis RHEA Centre for Gender and Diversity (VUB) - Belgium for Belgium (21 interviews with professionals from various Academic Medical Centre St Pieters - Belgium sectors), case studies (interviews with stakeholders: profesBudget: 66,833 EUR sionals, perpetrators and victims; and document study of Start date: 1 November 2010 these case studies), and a situation analysis for 3 European End date: 1 November 2011 countries (UK, the Netherlands and Sweden) in order to docuContact person at ICRH: Anke Van Vossole ment good practices in policies and interventions (semi-strucanke.vanvossole@ugent.be tured interviews with 28 experts from various sectors). After data analysis, two focus groups were organised to provide feedback on the research findings. The final report ‘Wetenschappelijk fenomeenonderzoek naar eergerelateerd geweld in België. Eindrapport’, was submitted by the end of November 2011. A follow up seminar will be organised during 2012, to present and discuss the results with relevant public authorities, professionals and other stakeholders. 3.2.1.2 Mapping the Multi-sectorial Support for Survivors of Sexual Violence in South Kivu Province, DR Congo.

The fight against sexual violence is a priority for the government of the DRC in the process of rebuilding the country and Financed by: VLIR-UOS in the fight against poverty. The overall objective of this acaCoordinator: ICRH demic project is to strengthen the Catholic University of BuPartners: Université Catholique de Bukavu - DRC Budget: 200,000 EUR kavu as a leader in the fight against sexual violence in DRC. Start date: September 2010 The overall development objective is to increase the quality End date: September 2012 of care for women survivors of sexual violence. The direct Contact person at ICRH: Steven Callens beneficiaries of the project are researchers from the Faculsteven.callens@ugent.be ties of Medicine, Law and Economics, as well as researchers at the local nongovernmental partner, ‘Vision d’Espoir’. The indirect beneficiaries are the agents involved in national and international programmes to support women survivors of sexual violence. The main project activities are: building capacity in research methodologies, training in English, in depth analysis of a database on sexual violence of UNFPA and the development of a mapping of stakeholders in the territory Walungu and Bukavu. 3.2.1.3 Study to Map the Current Situation and Trends of Female Genital Mutilation in the 27 EU Member States and Croatia

The ultimate goal of the study is to support and contribute to the future development of strategies for the elimination of Financed by: European Institute for Gender Equality different forms of violence against women. The specific aim Coordinator: ICRH Belgium Partners: Yellow Window Management Consultants of the study is to assess and analyse the current situation of (Group Member) female genital mutilation in all 27 member states of the EuroBudget: 436,125 EUR pean Union and Croatia, in particular with regard to current Start date: December 1, 2011 policies and policy developments on FGM at EU level and at End date: December 15, 2012 national level, existing prevalence data, current actors and Contact person at ICRH: Els Leye their activities with regard to prevention of FGM, clinical care els.leye@ugent.be for women with FGM, protection and prosecution. Finally, the study will provide recommendations on data collection on FGM in the EU. The overall goal has been broken down into five specific objectives: - SO 1: Mapping existing Information and data on FGM in the EU + Croatia, on prevalence, policies and actors and tools and methods they use; - SO 2: Analyse collected information and assess accessibility, reliability and comparability of data on prevalence of FGM; - SO 3: In-depth qualitative study in selected EU member states; ICRH Activity Report 2011

- SO 4: Identify gaps in data collection and provide good practices in dealing with FGM; - SO 5: Provide recommendations on how to improve data collection. The study consists of a desk study, in which existing information and data on FGM prevalence, policies, actors, tools and methods in the EU and Croatia, will be made by compiling an annotated bibliography of international and national literature in each of the 27 EU Member States and Croatia, as well as a national analytic report per country. Criteria will be developed on availability, reliability, comparability and sustainability of data and their relevance to policy making on FGM in the EU. Based on the annotated bibliography, the national reports and the country fact sheets, an analysis will be performed to assess the accessibility, reliability and comparability of data; identify trends of occurrence of FGM in the EU in the past 3 decades, particularly on prevalence, health sector responses, prevention efforts, legislation and asylum; identify good practices in prevention, care, prosecution and data collection; identify existing gaps in data collection on FGM and to identify Member States where field research will be done. During the second phase of the project, a qualitative study will be conducted. The aim of the qualitative study is two-fold: 1) to explore the views of key informants on data collection (including barriers to data collection and suggestions for improvement) and other encountered problems and 2) to identify, among others, statistics or estimates (including nationality, citizenship, age, education) of women who are affected by FGM. This will allow to check the outcome of the desk study (only for those countries where interviews are done), but more importantly, to identify gaps, barriers in the current service delivery and policies regarding FGM, and to make suggestions for change. The data collection for this part of the study will consist of conducting face-to-face interviews with key informants in a selected number of Member States. Additionally, up to ten interviews will be performed with experts who are not country-specific but who may complement and/or validate data, and share views on what constitutes ‘good practice’ as well as ideas and suggestions for policy recommendations. The selection of Member States for the qualitative study will be based on the outcome of the desk study. The main selection criteria for a country will be the prevalence of FGM in this country and the number of specific initiatives, i.e. court cases, asylum cases granted, specific health services, NGOs and CBOs working on FGM and existing national action plans or other policies. Key informants to be interviewed in a country will be identified at the following levels: government, health sector, community based level, child protection and asylum sector. One person per sector will be interviewed, which limits the number of interviews to five per country. The number of countries included in the interviews will be limited to eight. Based on the criteria developed during the first phase of the project, and based on the national analytic reports from the desk study, the annotated bibliography, and the analysis of the interviews, good practices will be identified and recommendations for improvement will be provided on: data collection on prevalence; health care delivery for women with FGM; prevention and child protection and law implementation. 3.2.1.4 Girls and Women Forced into Marriage: Understanding the Impact of Migration on Kenyan and Moroccan Communities Financed by: VLIR-UOS Coordinator: ICRH Belgium Partners: Université Mohammed V - Rabat, Morocco Association El Amane pour le développement de la Femme - Marrakech, Morocco Budget: 180,000 EUR Start date: 1 October 2009 End date: 30 September 2013 Contact person at ICRH: Alexia Sabbe alexia.sabbe@ugent.be

The project studies the impact of context on the occurrence of forced marriage in Morocco, and among Moroccan immigrants in Belgium. In general, the project explores to what extent migration has an influence on perceptions and decision-making processes of forced marriage. More specifically, it examines to what degree the cultural and religious perceptions have been transferred in migratory circumstances. In addition, the impact of different context, policies, law enforcement, etc. is investigated. Overall, an in-depth understanding of the phenomenon of forced marriage will provide policy makers and program managers with factual support

and background knowledge for potential interventions. In 2011 a paper was published concerning the implications of policy in Europe on forced marriage in light of the concept ‘Harmful Traditional Practices’. Additionally, field research was carried out in Morocco with the aim to organise the Moroccan component of the comparative research project. With the assistance of the local partner, stakeholders were identified and meetings were set up with local, national and international organisations/institutions. Stakeholder interviews were carried out with a wide range of experts on the topic of violence against women and forced marriage. A women’s association (‘Association El Amane pour le Développement de la Femme’) in the Marrakech region was identified to carry out household interviews and Focus Group Discussions. The research fits in with their on-going programme, so sensitization & educational activities, capacity building of its local community partners and facilitators will be carried out at the same time. A detailed framework, which encompasses the Intergenerational Dialogue as well, was drawn up. In the meantime facilitators have been trained and a first round of Focus Group Discussions has taken place in the rural Marrakech region.

ICRH Activity Report 2011

In the framework of the Belgian research activities, meetings were set up with stakeholders such as community organisations, municipal facilities, integration services, etc., to organise activities in the ‘Managers of Diversity’ programme. Interviews and Focus Group Discussions using the Intergenerational Dialogue method are scheduled for 2012. 3.2.1.5 International training course ‘Multi-Sectorial Response to Gender-Based Violence in Humanitarian Settings’

From 7 November till 18 November 2011, the fifth edition of the International Training Course ‘Coordination of MultiFinanced by: European Commission Humanitarian Aid Sectorial Response to Gender-Based Violence in Humanitarian Department (ECHO) Settings’ was organized in Ghent. Based on international UNFPA Coordinator: ICRH Belgium developments, and experiences of humanitarian workers in Partners: United Nations Population Fund (UNFPA) - USA the field, we can conclude that this international training Budget: 140, 680 EUR course continues to meet an urgent need for more trained Start date: 7 November 2011 experts on GBV Coordination. The course aims to improve End date: 18 November 2011 knowledge, understanding, and communication skills to efContact person at ICRH: Anke Van Vossole fectively prevent and respond to gender-based violence (GBV) anke.vanvossole@ugent.be in humanitarian settings, and to build capacity to coordinate multi-sectorial responses to GBV in humanitarian settings. A total number of 20 humanitarian high-level professionals participated in the course, working in emergency or (post)conflict environments in 15 countries. Their organizations included UN agencies, government organizations and national or international NGO’s. The different settings the participants were active in, enhanced their opportunities to learn from each other’s experiences. At present over a 100 humanitarian professionals have been trained, working at over 30 countries in emergency and (post)conflict situations. Capacity building and rolling out of the course in local settings will continue to be a priority for the organizers. 3.2.1.6 Focal Point on Harmful Cultural Practices (F HCUS)

F HCUS wishes to promote the health, well-being and human rights of vulnerable groups by contributing to a critical reflection, by increasing knowledge and by delivering better services for those living with the consequences of, or who are at risk of undergoing, harmful cultural practices. In 2011, the following activities were carried out. • Research: o Phenomenological research on honour related violence in Belgium (see supra) o The influence of migration on forced marriages in Belgium, UK and Morocco (see supra) o KAP-study (Knowledge-Attitude-Practice) among Flemish gynaecologists on hymen reconstructions o Literature study on the effects of polygamy on sexual and reproductive health of women o Descriptive study on cosmetic vaginal surgery in Flanders o Study to map FGM in 27 EU Member States and Croatia (see infra) ICRH Activity Report 2011

• Service delivery: o UZ F HCUS consultations for vulnerable women: Financed by: Flemish Government every Friday afternoon in the University Hospital, specialCoordinator: ICRH Belgium ized Partners: United Nations Population Fund (UNFPA) - USA Budget: 69,364 EUR consultations are foreseen for women with female geniStart date: 1 April, 2010 tal mutilation, women requesting hymen reconstructions End date: 31 March, 2011 and victims of sexual violence. Two research protocols Contact person at ICRH: Els Leye were developed to collect socio-demographic data on els.leye@ugent.be women attending the consultations. o African Training and Research Centre on Female Genital Mutilation The University of Nairobi hosted from 17 to 19 October 2011 an International Conference on Research, Healthcare and Preventive Measures for Female Genital Mutilation/Cutting and Support for Capacity Strengthening of Leadership and Research in Africa. The conference was organized in collaboration with University of Sydney in Australia, the International Centre for Reproductive Health at Ghent University in Belgium and the University of Washington, Seattle, USA, UNFPA, UNICEF and WHO. Els Leye presented ‘Measures for FGM/C and support for strengthening of leadership and research in Africa’. • Expertise delivery: o Els Leye is advisory member of the END FGM –European Campaign, led by Amnesty International. o Els Leye was also advisor for two resolutions by the parliament: a resolution on care for women and girls with FGM as well as a resolution on reimbursement for repair surgeries. o FGM in Europa is one of the themes covered by ICRH/F HCUS within its assignment as World Health Organisation Collaborating Centre. o Els Leye performed a consultancy for the Association of European Parliamentarians for Africa, by writing a manual for parliamentarians on FGM. The purpose of these guidelines is to provide an instrument for Parliamentarians (in Africa), to put the issue of FGM/C high on the agenda and to accelerate the abandonment of FGM/C in their respective countries. The guidelines will be instrumental in the organization of capacity building seminars or workshops in Africa, by AWEPA. The guidelines are equally accessible through AWEPA’s website: http://www.awepa.org/ index.php/en/resources/doc_details/115-abandoning-female-genital-mutilationcutting-guidelines-for-parliamentarians.html • Tutorials, training and dissemination of research results of F HCUS: o Policy group Zij-kant, presentation of F HCUS and themes honour related violence and forced marriages (Gent, 18 January 2011); o Cosmetic genital surgeries and FGM, (Mariakerke, February 2011); o Ethical issues regarding treatment of women with FGM, Flemish Midwifes conference (Gent, March 2011); o Conference ‘HIV in context: sexual and gender based violence’, presentation on FGM (Cape Town, 28-30 March 2011); o Congress Gynaecology and Obstetrics, presentation ‘Ethical issues on FGM in medical practice’ (Rotterdam, 8 April 2011); o Debate ‘Dilemma’s in dealing with harmful cultural practices’ (Gent, 2 May, 2011); o Roundtable Honour Related Violence (Brussels, 18 May 2011); o Meeting of the European Network for the Prevention of FGM (Stockholm, 19-22 May 2011); o FGM and reproductive health: a intertwined relation (Senate, Parliamentarians for the Millennium Goals, Brussels, 15 June) o ‘Honour based violence in migration settings, Gent Summer School ‘Health and Migration’, and ‘Forced and Early Marriage: a transnational issue’, (Gent Summer School ‘Health and Migration’, 13 July 2011) o Striking the right balance between prevention and prosecution of FGM in the EU (Middlesex University, London, 8 September, 2011) o Expert meeting on prevalence studies on FGM in the EU, (The Hague, 12-13 September 2011) o Inaugural lecture ‘FGM in Europe. Achievements and remaining challenges’, Universitat Autonoma de Barcelona, (Barcelona, 16 September 2011) o Lecture ‘Vaginal practices across cultures’ (Gent, 27 October 2011) o ‘Vaginal practices across cultures’, Annual meeting of the American Association of Anthropologists, Montréal, 16-20 November, 2011 o Guest lectures at Hogeschool Universiteit Brussel (Bachelors Health Care, 24 November), University Hospital Ghent (Mother and Child Care, 8 November), Artevelde Hogeschool Gent (Masters Midwifery, 1 December), Studium Generale Ghent University Hospital (December 13), Ghent University Hospital (medical students, 30 November) o ‘Policies on forced marriage in Europe: at the crossroads of migration, culture and gender’, Madrid Conference ‘Negotiating identity in Migration Processes’, 26-28 October.

ICRH Activity Report 2011

3.2.1.7 DOVE (Domestic Violence Against Women/men in Europe)

The DOVE project aims at: Developing a research methodology for the multi-national Financed by: European Commission – DG SanCo detection of domestic violence (DV) against women and men, Coordinator: University of Porto, Department of Hygiene and Epidemiology its risk factors and effects (e.g. health). Partners: Mid Sweden University - Sweden • Describing DV experiences in Europe using a clear definiProtestant University of Applied Sciences Ludwigsburg tion of DV and an established measure of DV in a randoGermany mly selected, representative, proportionally stratified University of Granada - Spain sample of the total population (women/men aged 18-64 Hungarian Academy of Sciences - Hungary years) living in urban centres in 8 EU states. National School of Public Health - Greece • Contributing to a public health strategy for managing ICRH Belgium - Belgium DV primarily in the 8 participating States by disseminatKingston University & St. George’s, University of London ing to key persons the survey findings and the policy or United Kingdom Budget: 999,137 EUR practice solutions. Start date: 01 June 2009 • Organizing a European symposium for a wider dissemi End date: 30 November 2011 nation of the survey findings to relevant governmental Contact person at ICRH: Els Leye stakeholders, but also NGO´s and academics. els.leye@ugent.be In 2011 the collected data were analysed for all countries included in the study. A report describing the project’s findings will be finalized early 2012. 3.2.1.8 Partner Violence and Pregnancy, an Intervention Study within Perinatal Care

The aim of this research project is twofold: firstly a large-scale prevalence/incidence study on intimate partner violence during pregnancy and secondly an intervention study to reduce violence during pregnancy. By means of a written questionnaire, the prevalence/ incidence study measures physical, psychological and sexual partner violence in a pregnant population. Moreover, this study wants to determine if there are effective and safe methods to improve help seeking behaviour, reduce partner violence and hence some negative consequences for mother and child. Therefore, several pregnant victims of partner violence will be selected (based on the questionnaire) and interviewed in the second part of the study. We will test if, when we screen for violence during pregnancy and refer ICRH Activity Report 2011

Financed by: Research Foundation Flanders (FWO), Belgium Coordinator: ICRH Belgium Partners: University Hospital Ghent, Dpt. Of Ob/Gyn Belgium ZNA Middelheim Antwerpen - Belgium UZA, OLV ziekenhuis Aalst - Belgium AZ St Jan Brugge - Belgium AZ St Jan Palfijn Ghent - Belgium Budget: 180, 000 EUR Start date: 1 October 2009 End date: 30 September 2013 Contact person at ICRH: An-Sofie Van Parys ansofie.vanparys@ugent.be

women to local resources, the prevalence/incidence of partner violence is reduced, women seek more help and/or the negative effects of violence on the pregnancy decrease. In 2010, the first recruitment wave was performed in 7 participating hospitals. Until now around 687 women filled out the questionnaire and around 64 women are randomised into the RCT. We have initiated the interviews and started the second wave of the recruitment in 5 additional hospitals. Preliminary analysis of the questionnaire-data of the first wave of the recruitment, was also initiated. 3.2.1.9 Partner Violence and Pregnancy, an Intervention Study within Perinatal Care

The first part of this study started in 2007. This study is coordinated by the NTNU in Norway and is a collaboration Financed by: EU DAPHNE program of 6 European countries (BIDENS: Belgium, Iceland, Norway, Coordinator: NTNU, Norwegian University of Science and Denmark, Estonia and Sweden). The study-hypothesis is that Technology Faculty of Medicine Partners: ICRH Belgium - Belgium women who experienced violence during their lifetime, will University Hospital, Department of Obstetrics and Gynaedevelop more fear of childbirth and therefore have more cology - Iceland instrumental deliveries. Up to this moment over 7000 women National Hospital, Copenhagen, Juliana Marie Center, were included in the database. Ultrasound - Denmark In 2009 the study received additional funding to finalise the Karolinska University Hospital - Sweden initial goals of the first part of the study. The aims of this proTartu University Clinicum Department of Obstetrics and longation are to continue the analysis of the collected data Gynaecology - Estonia and to continue the national and international dissemination Budget: 205,029 EUR of the results Start date: 2007 End date: 2012 An international seminar has taken place in 2010 and a Contact person at ICRH: An-Sofie Van Parys national seminar (roundtable on screening for violence during ansofie.vanparys@ugent.be pregnancy) took place on 21 November, 2011. A presentation of the results at the European congress of obstetrics and gynaecology in Mai 2012 is planned. Several articles linked to the BIDENS study have been published (see articles section) and the main BIDENS papers are currently being written. 3.2.1.10 Addressing Interpersonal Violence within a Hospital Context Financed by: Belgian Federal Agency Public Health Coordinator: ICRH Belgium & St Luc Hospital Partners: Hospital St Luc Bouge Ghent University Hospital - Belgium Budget: 91.000 EUR Start date: 1 December 2010 End date: 30 September 2011 Contact person at ICRH: Ines Keygnaert ines.keygnaert@ugent.be

This project aims to sensitize and train health workers in Belgian hospitals in addressing, assisting and referring patients in interpersonal violence situations adequately. To this purpose 3 pathways were set up. The first pathway is one of giving basic trainings of 3 hours to 18 hospitals in Belgium (10 Dutch speaking and 8 French speaking ones). These trainings comprised two parts. The first part addressed from an interactive yet scientific approach what interpersonal violence is and how a health worker can detect it. The second part provided the health workers with tools and guidelines on how to assist patients adequately. The second pathway consists of an advanced training course of 24 hours on different topics ranging from detecting signals and symptoms of different types of violence, communication skills on violence, adequate care of patients in violent situations, implementation of guidelines, tools and procedures from a holistic approach to victims and aggressors and developing hospital specific protocols. This advanced training was provided to 18 hospitals that participated in the basic training in 2009, during a previous project. Finally, the third pathway provided those hospitals who participated in the advanced training also with assistance in and coaching of the development of their hospital specific protocols on child abuse and maltreatment, elderly abuse and maltreatment, intimate partner violence and sexual abuse. The project was warmly welcomed by the hospitals and positively evaluated by the Federal Agency, assuring a follow-up in 2012.

ICRH Activity Report 2011

3.2.2 OTHER ACTIVITIES OF THE SGBV TEAM

The SGBV team gave several tutorials, training sessions and guest lectures on SGBV topics. For example, the SGBV team organised, in collaboration with UNFPA, the fourth edition of the International Course ‘Coordination of multi-sectorial response to gender based violence in humanitarian settings’. Members of the SGBV team also participated in research projects such as: - Study of the prevalence of FGM in Belgium, a study conducted by the Institute of Tropical Medicine, Antwerp; - Excision and migration, a qualitative study on FGM in Belgium, a study conducted by Facultés Saint Louis, Observatoire du Sida; - French criminological detection of FGM and lessons learned for the Netherlands, a study conducted by the Dutch University of Leiden, Institute for Criminology and Criminal Law. The SGBV team was an invited expert in the following meetings: o Unaccompanied minors and mental health Conference organised by ‘Mineurs en exile’ plenary lecture on prevention of sexual violence in the asylum sector: tips & tricks in October 2011. o Round table on Sexual and Reproductive Health of migrants in Belgium organised by Sensoa, ITM and ICRH in October 2011 In addition to the national and international conferences and workshops that were organized within the context of the projects listed above, the SGBV team members participate in the following advisory committees and/or networks: o Board of European Network for the Prevention of FGM o Advisory commission of ‘END FGM European Campaign – strategy for EU institutions’, Amnesty International Ireland o Board of EN-HERA!: European Network for the Promotion of Sexual and Reproductive health of refugees, asylum seekers and undocumented migrants in Europe and beyond. o Sexual abuse expert group Sensoa o Belgian round table on honour-related violence o Y-SAV: a European network of people who address youth sexual aggression and victimization in Europe. The network will build up a dialogue on youth sexual aggression and victimization and its determinants, develop a standard set of indicators to study and monitor sexual aggression and victimization, and to gather knowledge that will form the basis for effective policy. o ‘Parliamentarians for the Millennium Development Goals’: Female Genital Mutilation & reproductive health: an intertwined relationship, Federal Parliament Brussels, 15 June 2011 o International Conference ‘Negotiating Identity in Migration Processes’, Presentation: ‘Policies on Forced Marriage in Europe: at the Crossroads of Migration, Culture and Gender’, 26-28 October 2011, Centro de Ciencias Humanas y Sociales, Madrid

ICRH Activity Report 2011

“THOUGH GLOBAL MATERNAL DEATHS ARE IN DECLINE AND WOMEN’S HEALTH HAS AT LAST BECOME A GLOBAL PRIORITY, OUR GOAL OF REDUCING MATERNAL MORTALITY BY 75% IN 2015 IS STILL A LONG WAY OFF.” JAKAYA MRISHO KIKWETE

ICRH Activity Report 2011

3.3 MATERNAL HEALTH TEAM Every year, worldwide an estimated number of 273,500 women die from pregnancy or childbirth related causes. Furthermore every year an estimated 2.9 million babies die in the first four weeks of life. And although the international community agreed at the International Conference on Population and Development (ICPD) in Cairo (1994) to make reproductive health care universally available no later than 2015, many ICPD agenda items on sexual and reproductive health remain unfinished after more than 15 years. Though lots of efforts to reduce global maternal and neonatal mortality and morbidity took place during the last decade, among others the Millennium Development Goals (MDG) initiative, neonatal and maternal mortality remains unacceptably high. The MDGs on maternal and child health, which aim to reduce the maternal mortality ratio by three quarters between 1990 and 2015 and the under-five mortality rate by two thirds, are far from reaching their targets. Even though data show progress on reducing maternal and neonatal mortality, this progress is still way beyond the annual decline needed to meet the MDG targets and most developing countries will take many years past 2015 to achieve these targets.

273,500

women

die from pregnancy or childbirth related causes, worldwide, every year

2.9 million

babies

die in the first four weeks of life every year.

ICRH Activity Report 2011

The overall objective of the ICRH ‘maternal health team’ is conducting research to contribute to improve maternal and neonatal health and well-being. This research aims to provide access to good quality maternal, neonatal, sexual and reproductive health care for all, with a focus on vulnerable populations and the integration and continuity of care. Working with and involving all levels of the society from community level to policy makers and all levels of the health system from community health workers to specialized hospitals is also considered crucial by the maternal health team in order to accomplish its objectives. 3.3.1 PROJECTS 3.3.1.1 Missed Opportunities in Maternal and Infant Health: Reducing Maternal and Newborn Mortality and Morbidity in the Year after Childbirth through Combined Facility- and Community-based Interventions (MOMI)

Improving maternal and new-born health requires innovative approaches that maximise opportunities for impact throughFinanced by: European Commission – FP7 out the continuum of care. In the past decade, maternal Coordinator: ICRH Belgium health services have largely focused on the management of Partners: Institut de Recherche en Sciences de la Santé intrapartum complications and on rationalising the package Burkina Faso ICRH Kenya - Kenya of antenatal services to include emergency obstetric care Kamuzu Central Hospital + Ministry of Health; Parent and provided by skilled birth attendants. These interventions have Child Health Initiative - Malawi sought to target what are widely considered to be the most ICRH Mozambique - Mozambique common and immediate causes of maternal death. Eduardo Mondlane University – Faculdade de Medicina, Yet this approach fails to address many underlying morbidiMaputo - Mozambique ties that are instrumental in generating high rates of maternal Faculdade de Medicina da Universidade do Porto - Departmortality, such as anaemia and inadequate birth spacing. Also ment of Hygiene and Epidemiology - Portugal missing is a direct focus on the substantial proportion of maCentre for International Health & Development, University ternal deaths in the postpartum. Indeed, as a component of College of London - United Kingdom Budget: 2,997,647 EUR maternal health, postpartum care has been neglected, along Start date: 1 February 2011 with the whole field of new-born health in Africa. The essenEnd date: 31 January 2016 tial package and optimum structure of postpartum services Contact person at ICRH: Els Duysburgh for women and new-borns in Africa remains poorly defined, els.duysburgh@ugent.be with many missed opportunities for improved care. Birgit Kerstens The MOMI project intends to develop and implement an inbirgit.kerstens@ugent.be tegrated package of interventions targeting new-born health and women in the early postpartum period and throughout the first year after childbirth. This package will be delivered through a combined facility- and community-based approach designed to integrate services and strengthen health systems. It will be implemented in four African countries (Burkina Faso, Kenya, Malawi and Mozambique) by a consortium of five African and three European partners. The intervention design will be preceded and informed by a situational analysis of postpartum policies and practices in the four countries and a feasibility assessment. This will ensure that interventions are amenable to scaling up and appropriately tailored to local contexts. Implementation will be followed by health systems research to evaluate effectiveness and impact, and to identify determinants of sustainable and scalable health care improvements. The project will help to define the optimum package of postpartum interventions required to improve maternal and new-born health in Africa and – through its on-going policy outcomes – impact on overall maternal and child mortality, thus contributing to Millennium Development Goals 4 and 5.

Causal analysis stakeholders’ workshop Malawi: problem analysis tree – September 2011

ICRH Activity Report 2011

From 14 till 16 February 2011 the MOMI kick-off meeting took place at Ghent. This meeting was the first opportunity for the involved researchers to discuss intensively the MOMI project and had as main results a clear work plan for the first project year and several agreements on issues concerning the financial, administrative and technical management of the project. The first project phase, the maternal and new-born health situation analysis at each of the study sites, started in March 2011 with the development of a detailed research protocol and tools needed for conducting this situation analysis. The situation analysis field work being the collection of needed data at each of the MOMI research sites, started in September and is still going on. Also during 2011 a causal analysis stakeholders’ workshop to identify and discuss problems and possible solutions in mother and new-born post-partum care was conducted in each of the African research countries and the first policy advisory board meeting took place in each of these countries. Project website: http://www.momiproject.eu/ 3.3.1.2 Quality of Maternal and Prenatal Care: Bridging the Know-Do Gap (QUALMAT)

From the estimated 273,500 global maternal deaths per year 57% occur in sub-Saharan Africa. The lifetime risk for an Financed by: European Commission – FP7 African mother to die from complications of pregnancy and Coordinator: University of Heidelberg, Germany Partners: ICRH Belgium - Belgium childbirth is 1 in 32 compared to 1 in 2,900 in Europe. Every Centre de Recheche en Santé de Nouna - Burkina Faso year an estimate of 2.9 million babies die in the first 4 weeks Navrongo Health Research Centre - Ghana of life. In addition to a lack of financial and human resources Karolinska Institute - Sweden in developing countries, health care is hampered by poor Muhimbili University of Health and Allied Sciences quality of care caused among others by low staff motivation Tanzania and poor management structures. Budget: 2,915,228 EUR The QUALMAT project wants to improve the quality of maStart date: 1 May 2009 ternal and neonatal care through addressing the existing gap End date: 30 April 2014 between ‘knowing what to do’ and ‘doing what you know’. Contact person at ICRH: Els Duysburgh els.duysburgh@ugent.be The project is designed as an intervention research project and aims to increase staff motivation through developing and implementing a system of performance based incentives for health care workers and through introducing a computerassisted clinical decision support system which will help providers to comply with established standards of care. The QUALMAT programme is implemented by a consortium of 6 European and African partners in three resource-poor countries highly burdened by maternal and neonatal mortality: Burkina Faso, Ghana and Tanzania;. In each country, an intervention and a control district were selected, and in each of these districts 6 health facilities were selected to be included in the research project. In the QUALMAT project ICRH is responsible for documenting changes in the quality of care and services caused by the QUALMAT intervention package. In 2011 the baseline assessment of the quality of antenatal and childbirth care before the implementation of the QUALMAT interventions was finalized at the 3 African research sites. In October the assessment results were presented at the ‘Federation of European Society for Tropical Medicine and International Health’ conference in Barcelona, Spain. The main findings of the quality assessment are; (1) lack of access to basic emergency obstetric care, (2) poor counselling practices, (3) poor use of the partograph, (4) poor PMTCT management and haemorrhage prevention. In general the childbirth quality scores are worse than antenatal care quality scores. Project website: http://www.qualmat.net/

The QUALMAT team at the consortium meeting in Dar es Salaam, Tanzania, May 2011.

ICRH Activity Report 2011

3.3.1.3 Reducing Maternal Mortality trough Maternity Waiting Homes

In Africa, one out of 210 mothers dies during pregnancy or delivery. One of the causes is the relatively low rate of Financed by: National Lottery Belgium institutional deliveries, due to transport problems and lack of Collibri Foundation for Education infrastructure, but also due to cultural prejudices and resistCoordinator: ICRH Global ance against giving birth outside the family circle. One of the Partners: ICRH Kenya - Mombasa, Kenya ICRH Mozambique - Maputo, Mozambique ways to facilitate and encourage institutional deliveries is the Budget: 100,000 EUR establishment of ‘maternity shelters’ or ‘maternity waiting Start date: 1 October 2011 homes’ (‘casas de espera’ in Portuguese): facilities where End date: 30 September 2013 future mothers can spend the last few days of their pregContact person at ICRH: Dirk Van Braeckel nancy close to a maternity hospital, so that they are assured dirk.vanbraeckel@ugent.be of timely professional care during the delivery. This type of facilities exists in many African countries, but often the functioning is not optimal and the occupancy rate is much lower than it could be. ICRH launched a project in Kenya and in Mozambique, aimed at promoting the use of maternity waiting homes and improving their functioning. Activities consist in: - Informing en sensitizing community leaders, future mothers, their partners and facilities, and the community in general about the purpose and the importance of maternity waiting homes; - Reinforcing the functioning of a number of selected homes; - Looking, together with the staff and management of the selected homes, for ways to improve the service delivery and to provide health education on nutrition, family planning and infections to the women staying in the homes. The maternity waiting homes that were selected for the project are located in Malindi and Kilifi in Kenya, and in Meluco and Ancuabe in Mozambique. If the project turns out to be successful, it will be rolled out to other locations and other countries. The project funding from the Collibri Foundation for Education is linked to an initiative to sell birth cards (meant to be given as a birth present) in Dreambaby shops. The revenue from the sales goes entirely to the project, and in addition, Dreambaby donates an amount for every card that is sold. Information on the Dreambaby/Collibri Foundation can be found at http://www.dreambaby.collishop.be/ecom/nl/promo/DreamBaby/1212445722624_Promotion (in French and in Dutch).

3.3.2 OTHER ACTIVITIES OF THE MATERNAL HEALTH TEAM 3.3.2.1 Be-cause Health Sexual and Reproductive Health and Rights Working Group (SRHR WG)

The ICRH-maternal health team is a member of the Be-cause Health SRHR WG and is as such actively involved in the activities organized by this WG and participates in its 2-monthly meetings. This workgroup is an initiative of several Be-cause Health member institutions which are specifically concerned in the implementation of the policy note ‘The Belgian Development Cooperation on Sexual and Reproductive Health and Rights’ of March 2007. (see: http://www.be-causehealth.be/en/member-area/sexual-and-reproductive-health-rights.aspx) Contact person at ICRH: Els Duysburgh, els.duysburgh@ugent.be 3.3.2.2 Conference on ‘Post-Abortion Contraception’ in Beijing

ICRH Activity Report 2011

On 28 May 2011, ICRH and the Society of Family Planning, Chinese Medical Association, organized the second China Obstetrics & Gynaecology Hospital President Forum on ‘Post-Abortion Contraception’ (PAC) in Beijing. Dr Wei-Hong Zhang from ICRH presented the new FP7 project, INPAC (Integrating Post-Abortion Family Planning service into China’s existing abortion services in hospital settings), which will start in 2012. The aim of the conference was to share experiences between participants and prepare the INPAC project at national level in China. 3.3.2.3 Two Postdocs were Granted under the LOTUS Program

ICRH was successful in the application of two postdoctoral grants financed by the European Commission. Dr. Chen Qiju and Dr. Li Jinke joined ICRH to conduct their postdoc research from December 2011 to June 2012. Dr Chen is an associate professor of the Shanghai Institute of Planned Parenthood Research in China and has a PhD degree in Gynaecology and Obstetrics from Shanghai Jiaotong University (2007). Dr Li is a young physician in Department of Obstetrics and Gynaecology of West China Second Hospital and gained a PhD in the June, 2008 at Sichuan University. Their postdoc research projects focus on the effect of post-abortion family planning services and the contraception use in China and is supervised by Prof Dr Marleen Temmerman and Dr Wei-Hong Zhang.

“THE OVERALL OBJECTIVE OF THE ICRH ‘MATERNAL HEALTH TEAM’ IS CONDUCTING RESEARCH TO CONTRIBUTE TO IMPROVE MATERNAL AND NEONATAL HEALTH AND WELL-BEING.”

ICRH Activity Report 2011

“IN NOTHING DO MEN MORE NEARLY APPROACH THE GODS THAN IN GIVING HEALTH TO MEN.” CICERO 28

ICRH Activity Report 2011

3.4 HEALTH SYSTEMS TEAM 3.4.1 PROJECTS 3.4.1.1 Community Embedded Reproductive Care for Adolescents in Latin America (CERCA)

CERCA, Community-Embedded Reproductive health Care for Adolescents in Latin America, is an interventional research Financed by: European Commission – Framework 7 project that seeks to contribute to global knowledge about Programme how health systems can be more responsive to teenagers’ Coordinator: ICRH Belgium Partners: South Group - Bolivia sexual and reproductive health needs . Its immediate objecUniversity of Cuenca - Ecuador tive is to create a community-embedded health care intervenKaunas University of Medicine - Lithuania tion that will empower adolescents. University of Amsterdam - The Netherlands Adolescents in Latin America are confronted with serious National Autonomous University of Nicaragua - Nicaragua sexual and reproductive health (SRH) problems. Studies show Instituto Centro Americano de la Salud - Nicaragua that most of the adolescents younger than 20 years have had Budget: 2,893,700 EUR sexual intercourse with different partners without taking any Start date: 1 March 2010 precaution for preventing sexually transmitted infections (STI) End date: 28 February 2014 or pregnancy. Up to 50% of the women in the region give Contact person at ICRH: Peter Decat peter.decat@ugent.be birth for the first time during their adolescence and a signifiSara De Meyer cant proportion of these pregnancies are unwanted. saraa.demeyer@ugent.be The ‘community-embedded reproductive health care for adolescents’ research is based on the hypothesis that a comprehensive strategy of community-embedded interventions helps to meet the SRH needs of adolescents. Those interventions are targeting at improved access to adolescent-friendly reproductive health care in primary health services, a supporting and enabling environment and strengthened adolescent competence to make reproductive health choices. The CERCA project will test this hypothesis and describe the development, implementation and testing of intervention strategies and related factors in selected research settings in three Latin American cities: Cochabamba in Bolivia, Cuenca in Ecuador and Managua in Nicaragua. Based on these results a framework will be developed for health system interventions to improve the responsiveness to the health needs. During the first phase of the project a situation analysis was conducted in the research settings to assess the determinants of adolescents´ sexual and reproductive health. Data for the situation analysis were collected from different documental sources: statistical data at local level (civil registration, reports of health centres, household surveys etc.), national level (national health information systems, demographic and health surveys etc.) and international level (WHO/PAHO, UNFPA, World Bank, etc.). Apart from these

ICRH Activity Report 2011

documents additional information was obtained through qualitative research. The methodology developed for qualitative research included Focus Group (FG) discussions, in-depth and semi-structured interviews, and also a collaborative ethnographic method involving the recruitment and training of community members to develop research questions and conduct interviews with their ‘peers’. Quantitative pre-intervention surveys were conducted between July and October 2011 in the three research settings. In total about 9000 adolescents between the age of 13 and 18 were interviewed. The collected quantitative data will be used for a double purpose namely for a further assessment of determinants of adolescents’ SRH and for the comparison with post-intervention data in order to evaluate the impact of the interventions. Identified determinants for adolescents’ SRH are amongst other: education level, residence (rural or urban), ethnicity, religion, self-esteem, gender, socio-economic status, social literacy, family context, health facilities environment and health policies. The issue of internal and external migration is commonly mentioned but it’s relation to adolescents SRH status is still to be explored in depth. The results of this situation mapping guided the construction of the quantitative surveys among adolescents and the development of an intervention strategy. Based on the results of the situation analysis and health behaviour theories (the Health Belief Model, the Theory of Planned Behaviour and the Social Cognitive Theory) an intervention strategy was developed. A mapping of adolescents’ SRH determinants was realized by means of an analysis tree. Personal determinants, external determinants and strategies on how to address those determinants were listed in matrices for all target groups and all objectives. These matrices form the basis for the operational plans. During the implementation phase, those operational plans will continuously be assessed and adapted accordingly. In the intervention strategy, special attention is given to the use of new media which make it possible to reach out to adolescents in a youth-friendly and efficient way, to communicate among partners and to disseminate project information and results. A website (www.proyectocerca.org) that presents CERCA and the consortium and provides background documents and tools was constructed. A system was developed for sending and receiving text messages to and from adolescents. The three countries also created a Facebook page targeted to teenagers where they can find useful information and make contacts with other teens (Icas Cerca Nicaragua Cerca Uc, Proyecto cerca). In order to increase the responsiveness of research to existing health policy concerns, CERCA endeavours to involve policy-makers (politicians, civil servants, health policy advisors, health system managers) in the research process from the beginning. Related to the establishment of these relationships, the project also pays much attention to dissemination. Information is available and actively diffused on regular basis about the concept, objectives and progress of the research. A large

ICRH Activity Report 2011

variety of media is used for informing a broad local, national and international audience at public, academic and political level. Project website: www.proyectocerca.org 3.4.1.2 Quality Health Care in Primary Health Services in Nicaragua

The project aims to improve the quality of primary health care in Nicaragua. The pivotal theme of the project is reproductive Financed by: VLIR-UOS health care delivery in primary health services. Since 2007, Coordinator: ICRH Belgium the Ministry of Health of Nicaragua is gradually implementPartners: Universidad National Autónoma de Nicaragua, facultad de Medicina - Nicaragua ing a new model of care in public primary health services Budget: 306,758 EUR (MOSAFC, modelo de salud familiar y comunitaria) that aims Start date: 1 October 2008 towards a more comprehensive, equal and accessible care. End date: 30 September 2012 The idea for this research project arose from the concern of Contact person at ICRH: Sara De Meyer researchers and academics of the UNAN in maintaining the saraa.demeyer@ugent.be benefits of the previous reproductive health programmes Peter Decat within the new model of primary health care. Action Research peter.decat@ugent.be is the main methodology. Stephanie Demaesschalck In 2011 interventions aiming for a quality improvement of stephanie.demaesschalck@ugent.be (sexual) health services were running in four primary health centres. The project interventions are targeting the priorities identified by different actors during the situation analysis, namely the doctor-patient communication, conflict management and medical prescriptions and the implementation of the MOSAFC model. Interventions include organizational aspects, capacity building and skill training. The interventions were combined with research and monitoring activities. Amongst other, more than 450 doctor-patient contacts were videotaped in primary health centres. The consultations of the doctors who participated in the communication skills training were recorded before and after the workshops. The objectives of the recording were twofold: 1) the recorded consultations were used as a tool for an individual feedback to the physicians on their communication skills; 2) the recorded consultation will be used for a scientific analysis of the communication parameters. Also a study on the prescriptive behaviour of health providers and on the supply of medicaments has been carried out in two primary health centres. There is also growing interest for capacity building in health communication in other Latin American countries. This common interest resulted in a new proposal that recently has been accepted for funding as a south initiative. 3.4.2 OTHER ACTIVITIES OF THE HEALTH SYSTEMS TEAM 3.4.2.1 Be-cause Health People Centred Care Working Group (PCC WG)

ICRH is an active member of Be-cause health, an informal and pluralistic Belgian platform which is open to institutional and individual members that are involved in international health issues. The health systems team presides within Because health the working group about people centred care (PCC). In PCC, the health needs of the individual and the community are central. It enhances care which puts the expectations, feelings and environment of the patient and the community first. On the 6th of April 2011 an international workshop ‘people-centred care: a global concept’ was organized by ICRH and the PCC working group. The workshop, attended by more than 100 participants from all over the world, aimed to share concepts and evidence, to reflect on personal experiences and best practices, to identify further areas for reflection and to enhance action. (see www.be-causehealth.be). Contact person at ICRH: Peter Decat, peter.decat@ugent.be 3.4.2.2 Round Table Conference on Sexual and Reproductive Health for Vulnerable Migrants in Flanders.

Due to the high prevalence of sexual and reproductive health (SRH) problems of vulnerable migrants living in Flanders and Brussels, the health systems team of ICRH, Sensoa and the HIV-SAM project of ITM organized on October 25th 2011 a round table discussion on this topic. First, the results of the preliminary research, conducted by the three partners and based on 25 interviews with stakeholders and 3 focus discussions with the target group were presented. Secondly, all participants belonging to 35 different organizations were divided in 3 working groups each dealing with different topics: reception and asylum, integration and services. Within each group the good practices and needs of vulnerable migrants and SRH were discussed. Policy and services recommendations were mentioned and feasible actions were agreed on. The results of this round table are available in a report that can be downloaded from the ICRH website. Contact person at ICRH: Sara De Meyer, saraa.demeyer@ugent.be

ICRH Activity Report 2011

THE HPV TEAM IS CHARACTERIZED BY A BROAD RANGE OF SCIENTIFIC ACTIVITIES, RANGING FROM SOCIAL SCIENCES TO FUNDAMENTAL LABORATORY RESEARCH. 32

ICRH Activity Report 2011

3.5 HPV/CERVICAL CANCER TEAM The HPV/cervical cancer team comprises researchers from ICRH Belgium, involved in Human Papilloma Virus (HPV) research. The team is a spin-off from the broader HIV/STI research team and counts 3 core members and hosts 2 guest faculty members (prof. Dr Bogers, UA; Dr Marc Arbyn, IPH). The objectives of the team include coordination of research activities in the field of HPV/cervical cancer in Belgium, but also in Kenya. The HPV team is characterized by a broad range of scientific activities, ranging from social sciences to fundamental laboratory research. 3.5.1 PROJECTS 3.5.1.1 Surveillance of HPV Infections and HPV Related Disease Subsequent to the Introduction of HPV Vaccination in Belgium (SEHIB)

The introduction of the HPV vaccine could lead to a change in the distribution of HPV types in the population. The vaccine Financed by: Sanofi Pasteur includes the types 16 and 18 which are causing the majority Coordinator: ICRH Belgium of all cervical cancers (~70%). There is a possibility that these Partners: ICRH Belgium - Belgium Belgian Universities - Belgium could be replaced by other types which are also carcinogenic Labo Riatol - Belgium and which are currently not covered by the vaccine. Therefore Institute for Public Health - Belgium monitoring and surveillance of the HPV type distribution Budget: 1,007,555 EUR after the introduction of the vaccine is necessary. In addition, Start date: December 2009 cross-protection (protection of the vaccine against disease End date: September 2012 associated with types other than the vaccine types but related Contact person at ICRH: Davy Vanden Broeck to them) will result in a protection of the vaccinated populadavy.vandenbroeck@ugent.be tion that is greater than expected. Detailed surveillance can help to disentangle these possible effects. The current study proposal is in line with the request of the European Medicines Agency (EMA) to investigate the HPV type-specific prevalence and the potential non-vaccine type replacement in the post-vaccine era in non-Nordic EU member states. This population-based, cross-sectional study has a duration of 3 years and will be conducted 5 times. Study samples will be collected from women between 18 and 64 years of age, attending cervical cancer screening in 5 university and 4 periphery centres. The main objectives of the study are to assess the HPV vaccination status in the study population, to estimate the crude and age-standardized prevalence of HPV infection and of cytological cervical lesions in both the vaccinated and the general study population and to study the correlation between HPV vaccination status and cytological and histological findings. Furthermore, the detection rate of cytology for histological confirmed lesions, the correlation between HPV type infection and cytological and histological findings and the interaction of HPV vaccination on the correlation of HPV infection and cytology/histology will be studied. Activities 2011: • Study administration • Sample collection on-going • Interim analysis publication 3.5.1.2 HPV/BV Interaction

Bacterial vaginosis (BV) has been described to be an important cofactor in acquisition of several STIs. Alterations of the Financed by: FWO vaginal flora are more frequently found in an African populaCoordinator: ICRH Belgium tion, and this could also contribute to the higher prevalence Partners: ICRH Kenya - Kenya Budget: 234,000 EUR of STIs and related disease in Sub-Saharan Africa. Regarding Start date: October 2008 HPV and related cervical cancer, the relationship BV/VPV End date: September 2014 remains less clear, with contradicting scientific evidence, and Contact person at ICRH: Davy Vanden Broeck even lacking evidence for the African continent. davy.vandenbroeck@ugent.be This research aims to investigate the relationship of HPV and BV, focusing on African women. Via meta-analysis, potential associations on existing data will be investigated. Furthermore, a nested cross-sectional study will enrol women with BV and confirm HPV infection in this population (Mombasa, Kenya). These samples will be subjected to state-of-the-art laboratory techniques, to unravel potential underlying cell biological reasons. In cervico-vaginal samples, obtained from women with and without HPV infection, differentially expressed proteins will be detected and their functionality investigated. Preliminary results show indeed a positive correlation between BV and HPV and BV and cervical lesions. Data on African women are being collected and laboratory methods have been prepared. ICRH Activity Report 2011

Activities 2011: • Fund aquisition • Sample collection ongoing 3.5.1.3 Cervical Cancer Prevention in Kenya: Introduction of the HPV Vaccines

In Kenya, HPV vaccination is not part of the national immunization scheme. Both vaccines are however approved and Financed by: Fund for Scientific Research Flanders, FWO allowed to use in country. Dr Hillary Mabeya, National Advisor Coordinator: ICRH Belgium on Adolescent Vaccination at the Ministry of Health (Kenya), Partners: ICRH Kenya - Kenya received a grant of 9600 HPV vaccines from the GARDASIL Moi University - Kenya Budget: 180,000 EUR Access Program. The vaccines that arrived in Eldoret in 2011 Start date: 1 October 2010 will be used to pilot HPV vaccination, focusing on completion End date: 30 June 2014 of the vaccination scheme (3 doses in 6 months), the possible Contact person at ICRH: Heleen Vermandere occurrence of adverse effects and practical problems arising heleen.vermandere@ugent.be when offering a new vaccine to adolescent girls. Primary school girls (standard 4 to 9, i.e. approximately 9 to 14 years of age) enrolled in public schools will be the target group. Because of financial and logistic constraints, it was decided to select schools from Eldoret Municipality only. 10 schools were randomly selected, through which we estimate to target 3700 girls. Promotion will take place at school level only (through teachers) in order not to create a demand the program cannot handle (only 3000 girls can get vaccinated). The vaccination itself will happen in Moi Referral and Teaching Hospital and will start in March 2012. In 2010 Heleen Vermandere became a PhD fellow at the ICRH, funded by FWO, in order to conduct research regarding the feasibility and acceptability of HPV vaccination in Kenya. Through a pre- and post-vaccination survey related to the GARDASIL Access Program introduction of the HPV vaccines in Kenya will be studied. The objectives are: • To measure the acceptability, intention and behaviour towards HPV vaccination in Kenya • To define the impact of referents’ opinions, and the impact of personal, socio-cultural and structural factors on the decision regarding HPV vaccination of young girls. • To assess the willingness-to-pay for HPV vaccines • To generate achievable recommendations on how to design, implement and promote HPV vaccination in Kenya Activities 2011: • Literature research o Cervical cancer and HPV infections: epidemiology, preventive methods

ICRH Activity Report 2011

o HPV vaccines: efficacy and safety, cross protection, etc. o HPV vaccination: formative research and implementation policies o Health behaviour theories • Developing of research objectives, research questions and methodology • Protocol and questionnaires • Requesting ethical approval (Ghent University and Moi University) A first exploratory visit in February 2011 formed part of the mid-term evaluation of the on-going VLIR-IUC project (Flemish Interuniversity Council – Institutional University Cooperation) with Moi University (Eldoret). During that stay, links were established with clinical and social researchers and initial information about the health care system and health care seeking behaviours was obtained. 3.5.1.4 Vertical Transmission of HPV

HPV is a very common, sexually transmitted virus; the lifetime incidence is estimated to be as high as 80% (Einstein, 2009). Until relatively recently, it was generally assumed that HPV infection and related diseases in children was due to sexual abuse. This paradigm, however, has been changed over the past decade. Children with no history of sexual abuse can equally suffer from HPV related diseases, the latter presumably including: skin and anogenital warts, oral papillomas and recurrent respiratory papillomatosis. Data on HPV infection in children, including new-borns, is slowly becoming available.

Financed by: Ghent University Coordinator: ICRH Belgium Partners: Free University of Brussels (VUB) - Belgium Budget: Start date: 01 October 2010 End date: 30 September 2015 Contact person at ICRH: Davy Vanden Broeck davy.vandenbroeck@ugent.be

The extent to which HPV and HPV related diseases in minors can be found, remains however ambiguous. Prevalence rates of HPV infections ranging from 0% up to 70% have been described in the recent literature. Factors contributing to this extremely large range potentially include technical limitations; some studies were conducted when optimal HPV detection (PCR based) was not readily available and probably resulted in false negative outcomes. Towards infection of a child, the route of effective infection with HPV remains still unclear. Suggested is that infection can occur in a vertical manner, i.e. in utero and during birth, but also an important contribution of horizontal transmission, e.g. during nursing or breastfeeding cannot be excluded. The existence of new and better techniques will now make it possible to find clear answers regarding mother-to-child-transmission (MTCT) of HPV and its prevalence. Objectives: 1. To determine HPV type specific prevalence in different sample sites, including amniotic fluid, vaginal swab, placenta and breast milk. 2. To elucidate MTCT of HPV during pregnancy, delivery and breastfeeding: -To correlate type specific presence of HPV in the vagina, amniotic fluid, placenta and oral cavity. -To correlate type specific presence of HPV in breast milk and oral cavity of the new-born. 3. To correlate HPV infections with adverse pregnancy outcomes (preterm birth, eclampsia). Activities in 2011: • Literature review • Meta Analysis • Proposal writing/fund acquisition/PhD proposal 3.5.1.5 Factors Associated with Delayed Consultation of Women with Advanced Stages of Cancer of the Cervix

Background of the Research Topic Cervical cancer (CC), caused by the oncogenic human papillomavirus (HPV), has a very high incidence in Kenya (12.7/100000 a year). As in many resource-limited settings, screening for precancerous lesions is rare (3.2% of all women get screened every 3 years) and access to treatment is limited. CC is also the leading reason of cancer mortality in Kenya (8.6/100.000 women a year). Many women in sub-Saharan Africa present themselves when the cancer is at ICRH Activity Report 2011

Financed by: VLIR UOS Coordinator: ICRH Belgium Partners: Moi University - Kenya Budget: 53, 000 Start date: October 2008 End date: September 2014 Contact person at ICRH: Davy Vanden Broeck davy.vandenbroeck@ugent.be

advanced stage, unsuitable for surgery and with little chance of recovery from radiotherapy. Less than 10% of women with cancer present earlier than stage IIA in Kenya. Women endure abnormal bleeding and discharge months before they look for appropriate health care. In order to optimize cervical cancer diagnosis and treatment strategies it is crucial to understand acceptability and users’ perspectives towards screening. Factors causing delay – at personal but also at provider level – need to be identified and tackled. Understanding the mechanisms of decision-making regarding health care seeking behaviour will help to better prepare future cervical cancer screening and treatment programs. In addition, (practical) barriers for implementing different screening and treatment techniques need to be identified. Aims of the Study Overall objective: To identify the factors responsible for women presenting in advanced stages of cancer of the cervix and their health-seeking behaviour. Specific objectives: 1. To determine knowledge and attitudes towards HPV and CC, of secondary school girls (16-18yrs), women of reproductive age and married men (19-35). a. Awareness and perceived risk of CC b. Risk factors/beliefs on causes of abnormal vaginal discharge/bleeding 2. To determine the presence and duration of early clinical signs/symptoms that may be suggestive of CC. a. Clinical signs and duration of symptoms (prior to diagnosis of CC) 3. To asses current health practices regarding CC a. Community level: i. action taken when the vaginal discharge/bleeding is abnormal ii. perceived quality of care b. Health care provider level: i. Attitudes towards patients with abnormal discharge/bleeding ii. Self-reported quality of care 4. To provide informative sessions to create awareness, provide correct information and tackle misbeliefs among the interviewees 5. To identify drivers and barriers for health care seeking behaviour of women with abnormal discharge/bleeding 6. To assess the impact of CC on the quality of life 7. To identify potential pathways to fortify screening and to increase awareness of CC Methodology (research design, used methods, selection of respondents (number, power), analyses, …) - Focus group discussions with: high school girls age 16-18, married women age 18-35, married men age 18-35, - In-depth interviews with: CC patients, their caretakers and husbands; traditional healers, community elders - Semi-structured interviews with: community health workers and doctors and nurses of health centers and district hospitals. - Quantitative data: women with CC on follow-up at the gynae-oncology clinic and ward at Moi Teaching and Refferal Hospital, Eldoret. Selection of participants: through the DSS, a close relationship has been established between the community of Webuye and the Moi-University research team. All community members are registered into the DSS database making it possible to extract and select randomly those who fit the characteristics we are looking for. Participants will be invited through local enumerators of the DSS. CC patients will be tracked through the DSS, patient files in Webuye’s district hospital and Moi Teaching and Referral Hospital (the regional referral hospital). Potential participants will only be interviewed if they agree to participate and sign the consent form. Quantitative data will be analysed using Stata software. Bivariate and multivariate analysis will be used to explain measured knowledge among participants. Nvivo software will be used to facilitate qualitative data analysis. Analytic domains will be identified, including major and minor thematic areas. This will lead to a theoretical framework and interpretation of the data. Research plan (timing) Year 1 –Literature review, preparation study documents and ethical approval for pilot study and field work. Year 2-3 – collection and analysis of data Year 4 – final analysis publication and dissemination results Activities in 2011: • Literature review • Proposal writing/fund acquisition

ICRH Activity Report 2011

3.5.1.6 HPV Infection in Children

Currently, focus is being put on HPV infection in adults, with sexual transmission as the main route of infection. However, Financed by: Koning Boudewijn stichting (pending) data on HPV infection in children is slowly becoming available Coordinator: ICRH Belgium (for excellent review, see Syrjanen et al., 2010). Indeed, the Partners: Free University of Brussels (VUB) - Belgium Institute for Public Health - Belgium extent to which HPV and HPV related diseases in minors can Budget: 200,000 EUR be found is still ambiguous. Taking into account that most Start date: 01 February 2011 studies exploit study specific methodologies and that not all End date: 31 January 2013 HPV infections result in disease, only rather crude prevalence Contact person at ICRH: Davy Vanden Broeck estimations are currently at hand. davy.vandenbroeck@ugent.be An important indicator that HPV infection in minors is not essentially asymptomatic can be deduced from the presence of HPV in a wide range of pathologies in children. Based on limited data, these include: genital warts, recurrent respiratory papillomatosis, and lichen sclerosis. Also here no consensus has been reached in the type-specific prevalence. Another important limitation lies in the fact that available data are frequently restricted to knowledge on HPV presence or absence (genotyping data are generally lacking) and/or determined in a non-standardized manner. New insights in the genotype distribution are essential to further explore the role of HPV infection and its biology in children. Host specific characteristics play an important role in the infection process and the determination towards further disease development. It has been suggested that hormones like estrogens are involved in tumour promotion and especially estrogens have also been implicated in the promotion of cervical cancer (Chung at al., 2010). The uterine cervix is well known to be highly responsive to estrogen. Estrogen levels fluctuate according to different phases in life, in children huge fluctuations can be found. No data are at hand to relate mucosal estrogen impregnation with the susceptibility of individuals for HPV infection/promotion. Aim/objectives: • To describe the prevalence and distribution of HPV genotypes in children aged 0 – 12, subdivided in age groups • To describe the topical and quantitative distribution of HPV in children, subdivided in age groups. • To determine prevalence of HPV and HPV genotypes in related child pathologies. • To perform a descriptive study on HPV genotypes in Flanders in minors presenting for opportunistic screening Activities in 2011: • Literature review • Proposal writing/fund acquisition • Data analysis 3.5.1.7 Evolution of Human Papillomavirus Infection in Pregnant Women Infected with Human Immunodeficiency Virus

Background Human papillomavirus (HPV) infection is the main etiological Financed by: factor for cervical cancer, the second most common cancer Coordinator: ICRH Belgium in women worldwide. In immune compromised women, as Partners: ICRH Kenya - Kenya Budget: 20,000 EUR human immunodeficiency virus infected (HIV) patients, HPV Start date: 01 February 2011 infection displays a different natural history with a faster End date: 31 January 2013 disease progression, more and higher grade disease, and with Contact person at ICRH: Davy Vanden Broeck less efficient response to treatment. Furthermore, pregnant davy.vandenbroeck@ugent.be women have been proven to be at higher risk to develop HPV related cervical lesions. In addition, the effect of HAART on HPV infection is still a matter of debate. The combination of both immune suppression, different regimens of HAART, and pregnancy is largely unknown, hence the topic of this research proposal. Objectives The overall objective of this study is to gain insight in HPV co-infection in HIV positive pregnant women. Specific objectives include: 1- To determine the prevalence of type-specific HPV infections in HIV positive women during pregnancy and at 3 months postpartum 2- To assess the influence of different HAART regimens on clearance of HPV infection 3- To assess the relationship between CD4 cell count and genotype specific HPV infection

ICRH Activity Report 2011

Methodology Evolution of human papillomavirus infection in pregnant women infected with human immunodeficiency virus. A total of 250 participants from the Kesho Bora study Mombasa site who had 2 cervicovaginal samples taken; one during pregnancy and one at three months postpartum were selected for HPV genotyping. The sample is a convenience sample from a large multi-country, multi-centre interventional study. Timelines HPV genotyping started in July 2011 at the International Centre for Reproductive Health laboratory in Kenya and is currently on-going. A total of 250 samples taken during pregnancy have been analysed and results interpreted. The next batch of 250 samples will be completed in the first quarter of 2012. Thereafter data entry, cleaning and analysis up to the end of March 2012 when the first daft will be available. First publication is planned for the second half of 2012, other manuscripts will be presented for publication end 2012, early 2013. Activities in 2011: • Literature review • Proposal writing/fund acquisition • Sample Analysis 3.5.2 OTHER ACTIVITIES OF THE HPV/CERVICAL CANCER TEAM 3.5.2.1 ICRH-UZ Ghent HPV Platform

The launch of an HPV research platform has provided researchers from Ghent University and the University Hospital a forum to discuss and harmonize their research activities in the field of cervical cancer/HPV research. Next to colleagues from Ghent, also partners from Antwerp University and the national Institute for Public health join the meetings. The main goal of the platform is to streamline existing research efforts and to launch new projects. Contact person at ICRH: Davy Vanden Broeck, Heleen Vermandere 3.5.2.2 VLIR-Moi IUC Collaboration

Within a long-lasting collaboration between VLIR-UOS and the Moi University (Eldoret, Kenya), an important section is dedicated to reproductive health and focuses on HPV research. Not only will Heleen Vermandere do her PhD research within this setting, also a Kenyan PhD student will investigate the impact of cervical cancer at the social level. During this year, the collaboration was setup and in total 3 PhD Projects initiated. Contact person at ICRH: Davy Vanden Broeck, Heleen Vermandere

ICRH Activity Report 2011

3.5.2.3 Capacity Building HPV Genotyping ICRHK

In order to perform HPV genotyping for the various on-going projects in Kenya, ICRH Kenya staff has been trained to perform HPV genotyping assays. This capacity will allow efficient sample analysis on the ground and this capacity has been nationwide recognized. Indeed, other researchers have requested ICRHK service to facilitate sample analysis. Future planning includes introduction of an in-house pre-screening, prior to HPV genotyping. Contact person at ICRH: Davy Vanden Broeck, Rita Verhelst

ICRH Activity Report 2011

3.6 NON-TEAM RELATED ACTIVITIES 3.6.1 Knooppunt (‘Junction’) Financed by: Flemish Government Coordinator: ICRH Belgium Partners: Budget: 412,500 EUR Start date: 01 January 2007 End date: 31 December 2011 Contact person at ICRH: Els Leye els.leye@ugent.be

The aim of this project is to consolidate ICRH as focal point for sexual and reproductive health and rights, by which it contributes to the international recognition of the Flemish region. The following strategic aims have been formulated: - To increase the national and international visibility of ICRH - To reinforce and develop national and international collaborative efforts regarding scientific research and regarding knowledge transfer through education and training - To enhance the applicability of scientific research through service delivery and through policy support - To participate in a broad scientific and societal debate on sexual and reproductive health and rights through participation in national and international networks and in discussion fora. In 2011, ICRH met the above mentioned aims through the following activities: - ICRH established 46 national and international research projects and collaborations with national and international organizations - ICRH organized or participated actively in 28 national guest lectures and 11 international training initiatives - ICRH participated in 16 (inter)national expert meetings - ICRH organized 20 conferences/workshops/symposia ICRH participated in 57 conferences/workshops/symposia and 16 networks/discussion fora. 3.6.2 FWO International Coordination

ICRH IS ONE OF THE LARGEST ACADEMIC UNITS OF ITS KIND IN EUROPE AND ENJOYS A HIGH-LEVEL PROFILE BOTH REGIONALLY AND INTERNATIONALLY. ICRH Activity Report 2011

Financed by: Research Foundation Flanders Coordinator: ICRH Belgium Partners: Budget: 208,800 EUR Start date: 01 January 2008 End date: 31 December 2010 Contact person at ICRH: Els Leye els.leye@ugent.be

The Research Foundation Flanders supports the International Research Network of ICRH ‘WHO Col-

laborating Centre for Research on Sexual and Reproductive Health’. The aim of this network is to provide technical and logistical support for: - operational and applied research, - the design, planning, implementation, monitoring and evaluation of reproductive health programmes, - established and new networks - training - policy dialogue and advocacy. The themes included in these terms of reference concern HIV/AIDS in women and children; prevention and management of cervical cancer; female genital mutilation; research capacity building; violence against women. ICRH and its partners are involved in several international research projects and capacity building programmes, including Interuniversity Collaborations with the University of Western Cape in South Africa, Jimma University of Ethiopia; the Catholic University of Bukavu, University Eduardo Mondlane in Mozambique and the MOI University in Kenya. The official end date of the project was December 2010, but activities continued throughout 2011. A new FWO International Coordination grant has been awarded, starting on the 1st of January 2012. 3.6.3 Beyond Figures

Popularizing scientific research is a topic that, unfortunately, does not seem to be part of the scientific research cycle. With the project ‘Popularizing science’ ICRH has attempted to give insight to a large audience in its research projects and their results. This resulted in 2010 in an exposition and a book (English and Dutch versions) entitled ‘Beyond Figures’ (Dutch title: ’Vanuit de onderbuik’). Central to both products are black-and-white photographs by Liesbet Christiaen, taken in Kenya, Rwanda, Nicaragua and Belgium. These pictures are accompanied by accessible texts that focus on the stories behind people who are involved in ICRH projects. The exhibition can be borrowed for free. In 2011, ‘Beyond Figures’ has been shown during 17 weeks, at four different locations.

ICRH Activity Report 2011

3.6.4 Institutional University Cooperation Programme with the University Eduardo Mondlane of Mozambique (DESAFIO)

ICRH is coordinating the VLIR-UOS-funded Institutional University Cooperation (IUC) Programme with the University Financed by: Belgian Development Cooperation through Eduardo Mondlane (UEM) of Mozambique. The programme, the Flemish Interuniversity Council - University Cooperacalled DESAFIO, has the objective to strengthen UEM as a tion for Development (VLIR-UOS) Coordinator: ICRH Belgium developmental actor in Mozambican society in the area of Partners: University Eduardo Mondlane - Mozambique sexual and reproductive health and rights (SRHR) and HIV/ Ghent University - Belgium AIDS. It is based on a long term collaboration between UEM University of Antwerp - Belgium and all Flemish universities, comprising a 2-years preparatory Vrije Universiteit Brussel - Belgium pre-partner programme and two 5-years partner programmes. Katholieke Universiteit Leuven - Belgium The programme consists of 8 projects. Five projects address a Hasselt University - Belgium sub-theme of the central theme (human rights, social rights, Budget (phase 1): 3,480,000 EUR gender and family health, reproductive health, and HIV/AIDS Start date (phase 1): 01 April 2008 and STI) and 3 cross-cutting projects strengthen capacity in End date (phase 1): 31 March 2013 Contact person at ICRH: Laurence Hendrickx specific areas. Activities include conducting joint research desafio.lh@gmail.com in the different areas of reproductive health and HIV/AIDS; Olivier Degomme enhancing the capacity of UEM academic staff through trainolivier.degomme@ugent.be ing, including master and PhD degrees; strengthening UEM’s training capacity by developing master courses; strengthening teaching and research skills, ICT, library sciences, academic English and biostatistics at UEM; and conducting community-based outreach activities. During 2011, the third year of the first Partner Programme was successfully completed and the fourth started. 3.6.5 Focusing on Medical Health Problems in (post)Conflict Situations

Several years of recurrent conflict in the Congo have ended up destroying the health system of the Republic of Congo (DRC) Financed by: Flemish Interuniversity Council in general, but particularly the South Kivu Province, resulting Coordinator: ICRH in: Partners: Université Catholique de Bukavu - DRC Budget: 252,871 EUR (1) Rising rates of mother and child morbidity. The fight Start date: April 2011 against diseases of reproductive health is a priority of the End date: April 2013 Congolese government in the process of reconstruction in Contact person at ICRH: Steven Callens post-conflict. steven.callens@ugent.be (2) An increase in chronic non-communicable diseases during this decade. In the first year this project focuses on the integration within the faculty of medicine of the Catholic University of Bukavu. Particular attention will be focused on building strategic relationships between sub-disciplines of medical school and the newly established school of public health. A document with a strategic vision and mandate of the Research Office will be prepared after consultation between the sub-disciplines of medicine, the rector and the university authorities. The research focus will be placed on finding suitable sites for cohorts to be followed longitudinally in rural and urban areas. The scientific focus is on chronic non-communicable diseases. Finally, there is a project on sexual health, where we first examine the use of traditional methods of family planning. Particular attention will be given to traditional methods potentially dangerous to the health of women and barriers to using modern methods. It will also examine which of the modern methods of family planning are acceptable and economically viable in the long term. 3.6.6 Research and Education Unit of the Department of Obstetrics and Gynaecology at the Ghent University

ICRH is represented in this platform in order to assure good information exchange and coordination between the two institutions, which are both based in the same hospital, belong to the same faculty and deal with interrelated topics and projects. Contact person at ICRH: Jessika Deblonde, e-mail: jessika.deblonde@ugent.be 3.6.7 Sexuality Education in the European Region

On 6 and 7 October 2011 the Federal Centre for Health Education (BZgA) and WHO Regional Office for Europe hosted a workshop in Cologne, Germany, on the further development of good quality sexuality education in the European Region. ICRH participated as one of the members of the expert group which was composed of participants from 11 European countries. Together they worked on an implementation strategy for sexuality education. This strategy is based on the jointly developed ‘Standards for Sexuality Education in Europe’ that were published last year by WHO Regional Office for Europe and BZgA. The implementation strategy will be finalized early 2012. The ‘Standards for Sexuality Education in Europe’ are available through the following website: http://www.bzga-whocc. de/?uid=d81b5778fc1470a568093fe75f37d58d&id=Seite4489 ICRH Activity Report 2011

3.6.8 Be-cause Health Seminar: Will our Generation Close the Gap? Comprehensive and Innovative Strategies to Address Social Determinants of Health

The seventh annual seminar of Be-cause Health took place on 15 and 16 December 2011 at the Belgian Technical Cooperation in Brussels and addressed the social determinants of health in different ways. The seminar presented the global picture on SDH and was structured according to the three principles of action (‘tracks’) referred to in the WHO 2008 publication of the Commission on Social Determinants of Health: [1] conditions of life, better services for the people; [2] power relations and resources; and [3] monitoring, research and advocacy. The objectives of the seminar were to raise awareness amongst the stakeholders in international cooperation and to clarify the challenges. Birgit Kerstens, together with Prof. Yvo Nuyens, coordinated the four sessions of track 3 which dealt with identification of the critical issues and problems in monitoring and research, provided some examples and good practices of monitoring and research at country level and discussed how data and research on social determinants can be better integrated into policy, practice and action. Kristien Michielsen and Dirk Van Braeckel were actively involved in the first session of track 1 on the social determinants of adolescent’s sexual health with as main themes sexual education at school and teenage pregnancies in Latin America. One of the invited speakers was Dr Bernardo Vega, Professor in Gynaecology at the Department of Medical Sciences at the University of Cuenca in Ecuador and partner in the CERCA project, which is led by ICRH (Dr Peter Decat and Sara De Meyer). This project has conducted surveys among adolescents in Bolivia, Ecuador and Nicaragua and Prof Vega presented the preliminary results. The challenges identified during the presentations of the keynote speakers and related discussions with the audience and the recommendations on how to bridge the worlds of research and policy were highlighted in a final plenary session. 3.6.9 Millennium Development Goals Campaign: ‘2015 – Time is Running’

ICRH is member of the coalition of Flemish development NGOs ‘2015 – de tijd loopt’ (‘2015 – time is running’). This coalition aims at keeping the millennium development goals (MDG) on the public and the political agenda. In 2010, five years before the target date for realisation of the millennium goals, the 2015 coalitions has launched an intensive campaign, consisting of televisions and newspaper adds, brochures, posters, and numerous local activities, culminating in a large-scale public event in Ghent, the ‘Wachtnacht’ (‘Waiting Night’), on 11 September. In 2011, the coalition continued its work, but the focus was now rather on the content than on public campaigns. For each of the Millennium Development Goals, concrete demands

ICRH Activity Report 2011

towards the Belgian authorities were formulated and handed over to the government during a demonstration on the 15th of September 2011. 3.6.10 ICRH Kenyan PhD Week

From 6 to 8 July, three ICRH PhD scholars have successfully defended their dissertation: Jerry Okoth Okal, Scott Geibel and Avina Sarna (right). It was a most inspiring and cheerful week for ICRH. All three dissertations were based on research that has been conducted in Kenya. Scott and Jerry are working for Population Council in Nairobi, Avina is affiliated to the Population Council’s Delhi office. After their public defence, the three were awarded the title ‘Doctor of Medical Science’. On the occasion of the Kenyan PhD Week, we received the visit of three representatives of ICRH Kenya: Lou Dierick (Director F&A of ICRHK), Dr Kishor Mandalya (Biomarkers Project Coordinator) and Prof Walter Jaoko (Acting Country Director). 3.6.11 Support for Asylum Seekers at Ghent University

In December 2011 Ghent University decided to respond to the question of Fedasil (The Federal Agency for the Reception of Asylum seekers) to shelter asylum seekers. ICRH organized financial aid and collected clothing and nonperishable food such as canned food and biscuits. In January some colleagues attended the gathering, organized by UGhent to thank everybody who helped the asylum seekers. The movie ‘Illégal’ was shown and discussed under the guidance of Paul Pataer, ex-president of the Flemish Refugee Action and city councillor of the Flemish ecological party in Ghent. 3.6.12 MoU Signed between Ghent University and Hebei Medical University (China)

From 23 to 25 May 2011, an official delegation of the province of Eastern Flanders visited Hebei province, China. Several successful meetings on future cooperation were held with members of Hebei Province Department of Education and with representatives of key provincial universities. On the 24th of May, 2011, a Memorandum of Understanding was signed between Ghent University and Hebei Medical University. Mr Mark De Burk, Vice Governor of Eastern Flanders, Dr Wei-Hong Zhang from ICRH (coordinator of this MoU) and Mr Hedwig De Pauw, Director of the International Department of Province of East Flanders, signed this Memorandum of Understanding during a special ceremony.

ICRH Activity Report 2011

3.6.13 Visiting Professor Position for Wei-Hong Zhang

In 2011, Dr Wei-Hong Zhang, senior researcher at ICRH-Ghent, was offered a position of Visiting Professor by two Chinese institutions: Chongqing Medical University (CQMU) and National Research Institute for Family Planning (NRIFP). CQMU is located in the city of Chongqing, which is an economic centre on the upper reaches of the Yangtze River and the newest municipality directly under the administration of the Central Government. With more than fifty yearsâ&#x20AC;&#x2122; development, CQMU has become a key university under the administration of Chongqing Municipal Government with an integrated educational system of Bachelor, Master, Doctoral and Postdoctoral programs in medicine and related fields. The university has 5,228 employees of which over 300 are professors and over 800 associate professors. NRIFP is located in Beijing and affiliated to National Population and Family Planning Commission of China. NRIFP is the only country-level multidisciplinary research institute for research in family planning and reproductive health in China. It has a good network across the whole county in China and works closely with the provincial Research Institutions for Family Planning in 31 provinces. NRIFP, a sister institutes with ICRH-Ghent since 2009, has collaborated with ICRH in two FP6 projects in China and will from February 2012 onwards participate in a new FP 7 project coordinated by ICRH.

ICRH Activity Report 2011

3.6.14 First ‘China-Belgium Education Forum’

On 22 October, Dr Wei-Hong Zhang on behalf of ICRHGhent participated in the first ‘China-Belgium Education Forum’ at the Peking University in Beijing, which was part of the Belgian economic mission to China and was attended by the Belgian Crown Prince Philippe and Princess Mathilde. This event brought together more than 500 Chinese and Belgian academics and representatives of the government from both countries. Contacts were made with several Chinese universities and the ICRH’s collaborators in China. 3.6.15 ICRH Belgium Lectures

ICRH Belgium organized a series of lectures on ‘Reproductive health in global perspective’. The lectures were aimed at a broad target audience of students, researchers, people from NGOs and policy makers, and in order to reach that goal they took place on evenings, in a popular venue in the centre of Ghent. Dates and themes were: 2 March: Reproductive Health in Global Perspective 9 March: Reproductive Health in Humanitarian Settings 30 March: HPV and Cervical Cancer 2 May: Ethical dilemmas in the attitude of health workers towards harmful cultural practices 11 May: The effectiveness of HIV prevention The initiative turned out to be very successful, and will certainly be repeated in the future. 3.6.16 Intercultural Women Network ‘Oog in Oog’ In 2011 ICRH became a member of the Intercultural Women Network ‘Oog in Oog’. This network is a collaboration of more than twenty organizations, all active in Ghent and the Province of East-Flanders and working on the topic of gender. Besides ICRH, representatives of the city of Ghent, of the Province of East-Flanders and of migrant- women- and homosexual and lesbian organizations participate. Together, they realize different activities. In 2011 they organized, among others, an intercultural celebration on 8 March, the International Women’s Day, gatherings about poverty, a scientific lunch meeting about female genital mutilation and a flash mob against domestic violence. For more information: saraa.demeyer@Ugent.be 3.6.16 Ghent Africa Platform ICRH is an active member of the Ghent Africa Platform (GAP). GAP is an umbrella organisation of several, sometimes very diverse, ‘actors’ belonging to the Ghent University Association, that focus on the African continent. it offers a forum within which they can intensify mutual contacts, get to know and discuss their collective, interdisciplinary interests and possibly turn this into joint research, publications and/or the implementation of these within the scope of development aid. On 2 December 2012 GAP organized its fifth annual symposium: ‘(r)Urban Africa: multidisciplinary approaches to the African city’. ICRH was, as a core member of the Platform, a co-organizer of the symposium and was represented in the scientific committee.

ICRH Activity Report 2011

P UBLIC ATI ONS

ICRH Activity Report 2011

4.1 A1 ARTICLES

PLoS One. 2011;6(12):e28363. Sex Work during the 2010 FIFA World Cup: Results from a Three-Wave Cross-Sectional Survey. Delva W, Richter M, De Koker P, Chersich M, Temmerman M. Abstract BACKGROUND: In the months leading up to the 2010 FIFA World Cup in South Africa, international media postulated that at least 40,000 foreign sex workers would enter South Africa, and that an increased HIV incidence would follow. To strengthen the evidence base of future HIV prevention and sexual health programmes during international sporting events, we monitored the supply and demand of female sex work in the weeks before, during and after the 2010 FIFA World Cup. METHODOLOGY/PRINCIPAL FINDINGS: We conducted three telephonic surveys of female sex workers advertising online and in local newspapers, in the last week of May, June and July 2010. The overall response rate was 73.4% (718/978). The number of sex workers advertising online was 5.9% higher during the World Cup than before. The client turnover rate did not change significantly during (adjusted rate ratio [aRR] = 1.05; 95%CI: 0.90-1.23) or after (aRR = 1.06; 95%CI: 0.91-1.24) the World Cup. The fraction of non-South African sex workers declined during (adjusted odds ratio [aOR] = 0.50; 95%CI: 0.32-0.79) and after (aOR = 0.56; 95%CI: 0.37-0.86) the World Cup. Relatively more clients were foreign during the World Cup among sex workers advertising in the newspapers (aOR = 2.74; 95%CI: 1.37-5.48) but not among those advertising online (aOR = 1.06; 95%CI: 0.60-1.90). Self-reported condom use was high (99.0%) at baseline, and did not change during (aOR = 1.07; 95% CI: 0.16-7.30) or after (aOR = 1.13; 95% CI: 0.16-8.10) the Word Cup. CONCLUSIONS/SIGNIFICANCE: Our findings do not provide evidence for mass-immigration of foreign sex workers advertising online and in local newspapers, nor a spike in sex work or risk of HIV transmission in this subpopulation of sex workers during the World Cup. Public health programmes focusing on sex work and HIV prevention during international sporting events should be based on evidence, not media-driven sensationalism that further heightens discrimination against sex workers and increases their vulnerability

“YOU DON’T WRITE BECAUSE YOU WANT TO SAY SOMETHING; YOU WRITE BECAUSE YOU’VE GOT SOMETHING TO SAY.” F. SCOTT FITZGERALD ICRH Activity Report 2011

PLoS One. 2011;6(11):e28180. Longitudinal study of the dynamics of vaginal microflora during two consecutive menstrual cycles. Santiago GL, Cools P, Verstraelen H, Trog M, Missine G, El Aila N, Verhelst R, Tency I, Claeys G, Temmerman M, Vaneechoutte M. Abstract

BACKGROUND: Although the vaginal microflora (VMF) has been well studied, information on the fluctuation of the different bacterial species throughout the menstrual cycle and the information on events preceding the presence of disturbed VMF is still very limited. Documenting the dynamics of the VMF during the menstrual cycle might provide better insights. In this study, we assessed the presence of different Lactobacillus species in relation to the BV associated species during the menstrual cycle, assessed the influence of the menstrual cycle on the different categories of vaginal microflora and assessed possible causes, such as menstruation and sexual intercourse, of VMF disturbance. To our knowledge, this is the first longitudinal study in which swabs and Gram stains were available for each day of two consecutive menstrual cycles, whereby 8 grades of VMF were distinguished by Gram stain analysis, and whereby the swabs were cultured every 7(th) day and identification of the bacterial isolates was carried out with a molecular technique. METHODS: Self-collected vaginal swabs were obtained daily from 17 non pregnant, menarchal volunteers, and used for daily Gram staining and weekly culture. Bacterial isolates were identified with tDNA-PCR and 16 S rRNA gene sequencing. RESULTS: Nine women presented with predominantly normal VMF and the 8 others had predominantly disturbed VMF. The overall VMF of each volunteer was characteristic and rather stable. Menses and antimicrobials were the major disturbing factors of the VMF. Disturbances were always accompanied by a rise in Gram positive cocci, which also appeared to be a significant group within the VMF in general. CONCLUSIONS: We observed a huge interindividual variability of predominantly stable VMF types. The importance of Gram positive cocci in VMF is underestimated. L. crispatus was the species that was most negatively affected by the menses, whereas the presence of the other lactobacilli was less variable. Hum Reprod. 2011 Dec;26(12):3319-26. Chlamydia trachomatis infection in fertile and subfertile women in Rwanda: prevalence and diagnostic significance of IgG and IgA antibodies testing. Muvunyi CM, Dhont N, Verhelst R, Temmerman M, Claeys G, Padalko E. Abstract BACKGROUND: In many developing countries, little is known about the prevalence of genital Chlamydia trachomatis infections and complications, such as infertility, thus preventing any policy from being formulated regarding screening for C. trachomatis of patients at risk for infertility. The objective of the present study was to determine the prevalence of C. trachomatis and evaluate the diagnostic utility of serological markers namely anti-C. trachomatis IgG and IgA antibodies in women attending an infertility clinic. METHODS: Serum and vaginal swab specimens of 303 women presenting with infertility to the infertility clinic of the Kigali University Teaching Hospital and 312 fertile controls who recently delivered were investigated. Two commercial species-specific ELISA were used to determine serum IgG and IgA antibodies to C. trachomatis and vaginal swabs specimens were tested by PCR. Hysterosalpingography (HSG) was performed in subfertile women. RESULTS: The PCR prevalence of C. trachomatis infection was relatively low and did not differ significantly among subfertile and fertile women (3.3 versus 3.8%). Similarly, no significant differences in overall prevalence rates of C. trachomatis IgG and IgA among both groups were observed. The only factor associated with C. trachomatis infection in our study population was age <25 years. The seroprevalence of IgG in both assays (86.4% for ANILabsystems and 90.9% for Vircell) was significantly higher in the group of PCR C. trachomatis-positive women compared with that of PCR-negative women. Evidence of tubal pathology identified by HSG was found in 185 patients in the subfertile group (67.8%). All the serological markers measured in this study had very low sensitivities and negative predictive values in predicting tubal pathology. The specificities for ANILabsystems IgG, Vircell IgG, Anilabsystem IgA and positive C. trachomatis DNA to predict tubal pathology were 84, 86, 95 and 98%, respectively, whereas their respective positive predictive values were 73, 76, 81 and 80%. CONCLUSIONS: The prevalence of C. trachomatis in our study population in Rwanda appears to be low and women aged <25 years are more likely to have genital infection with C. trachomatis. Since serological testing for Chlamydia shows an excellent negative predictive value for lower genital tract infection, specific peptide-based serological assays may be of use for screening in low prevalence settings. Our data suggest that C. trachomatis is not the primary pathogen responsible for tubal pathology in Rwandan women. Eur J Contracept Reprod Health Care. 2011 Sep;16 Suppl 1:S1-70. The reproductive health report: The state of sexual and reproductive health within the European Union.

ICRH Activity Report 2011

Oliveira da Silva M, Albrecht J, Olsen J, Karro H, Temmerman M, Gissler M, Bloemenkamp K, Hannaford P, Fronteira I. Health Policy. 2011 Dec;103(2-3):101-10. HIV testing in Europe: mapping policies. Deblonde J, Meulemans H, Callens S, Luchters S, Temmerman M, Hamers FF. Abstract OBJECTIVES: In the absence of treatment and in the context of discrimination, HIV testing was embedded within exceptional procedures. With increasing treatment effectiveness, early HIV diagnosis became important, calling for the normalization of testing. National HIV testing policies were mapped to explore the characteristics and variations across European countries. METHODS: Key informants within the health authorities of all EU/EEA countries were questioned on HIV testing policies, which were assessed within a conceptual framework and the level of exceptionalism and normalization was scored based on defined attributes. RESULTS: Twenty-four out of 31 countries participated in the survey. Policies tended to support confidential voluntary testing, informed consent, and counselling. In the majority of countries, specific groups were targeted for provider-initiated testing. Taking together all attributes of HIV testing, 14 countries obtained a high score for exceptionalism, while only 3 achieved a high score on normalization. Italy, Lithuania and Romania had primarily exceptional procedures; Norway leant more towards normalization; Netherlands, the United Kingdom, and Denmark scored high in both. CONCLUSIONS: In most EU/EEA countries, policies are integrating HIV testing in health care settings, through voluntary and targeted testing strategies. Current HIV testing policies exhibited a high level of exceptionalism with varying degrees of normalization. Further research should compare HIV testing policies with practices. Am J Obstet Gynecol. 2011 Dec;205(6):569.e1-7. Prior knowledge of HPV status improves detection of CIN2+ by cytology screening. Benoy IH, Vanden Broeck D, Ruymbeke MJ, Sahebali S, Arbyn M, Bogers JJ, Temmerman M, Depuydt CE. Abstract OBJECTIVE: The objective of the study was to investigate whether knowledge of human papillomavirus (HPV) deoxyribonucleic acid test results increases sensitivity of guided cytology screening for the detection of cervical intraepithelial neoplasia (CIN)-2 or higher-grade cervical lesions. STUDY DESIGN: This was a prospective colposcopy-controlled study of 2905 BD SurePath samples to identify cases with CIN2+ within a 24 month follow-up period. Sensitivity and specificity to detect CIN2+ was evaluated, comparing guided cytology screening with and without prior knowledge of HPV status. RESULTS: Prior knowledge of HPV status resulted in significantly higher detection rate of CIN2+ compared with screening blinded to HPV status (P = .005) with limited loss of specificity (P = .026). Gain in sensitivity is higher in older women (43.8%, P = .008) vs in younger women (10.2%, P = .317), whereas loss of specificity is more pronounced in younger women (P < .001) vs older women (P = .729). CONCLUSION: Guided cytological screening performed with prior knowledge of HPV status results in an improved detection of CIN2 or higher-grade lesions. J Womens Health (Larchmt). 2011 Jul;20(7):1097-109. Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: findings from a multicountry household survey. Hull T, Hilber AM, Chersich MF, Bagnol B, Prohmmo A, Smit JA, Widyantoro N, Utomo ID, Franรงois I, Tumwesigye NM, Temmerman M; WHO GSVP Study Group. Collaborators (10) Lestari H, Madras B, Mariano E, Mbofana F, Kenter E, Wacharasin C, Siriratmongkhon C, Siriratmongkhon K, Kunene B, Scorgie F. Abstract BACKGROUND: Women worldwide use various vaginal practices to clean or modify their vulva and vagina. Additional population-level information is needed on prevalence and motivations for these practices, characteristics of users, and their adverse effects. ICRH Activity Report 2011

METHODS: This was a household survey using multistage cluster sampling in Tete, Mozambique; KwaZulu-Natal, South Africa; Yogyakarta, Indonesia; and Chonburi, Thailand. In 2006-2007, vaginal practices and their motivations were examined using structured interviews with women 18-60 years of age (n=3610). RESULTS: Prevalence, frequency, and motivations varied markedly. Two thirds of women in Yogyakarta and Chonburi reported one or more practices. In Yogyakarta, nearly half ingest substances with vaginal effects, and in Chonburi, external washing and application predominate. In Tete, half reported three or four current practices, and a quarter reported five or more practices. Labial elongation was near universal, and 92% of those surveyed cleanse internally. Two third’s in KwaZuluNatal practiced internal cleansing. Insertion of traditional solid products was rare in Chonburi and Yogyakarta, but one tenth of women in KwaZulu-Natal and nearly two thirds of women in Tete do so. Multivariate analysis of the most common practice in each site showed these were more common among less educated women in Africa and young urban women in Asia. Explicit sexual motivations were frequent in KwaZulu-Natal and Tete, intended for pleasure and maintaining partner commitment. Practices in Chonburi and Yogyakarta were largely motivated by femininity and health. Genital irritation was common at African sites. CONCLUSIONS: Vaginal practices are not as rare, exotic, or benign as sometimes assumed. Limited evidence of their biomedical consequences remains a concern; further investigation of their safety and sexual health implications is warranted. Diagn Microbiol Infect Dis. 2011 Sep;71(1):29-37. Evaluation of a new multiplex polymerase chain reaction assay STDFinder for the simultaneous detection of 7 sexually transmitted disease pathogens. Muvunyi CM, Dhont N, Verhelst R, Crucitti T, Reijans M, Mulders B, Simons G, Temmerman M, Claeys G, Padalko E. Abstract We evaluated a new multiplex polymerase chain reaction (mPCR), ‘STDFinder assay’, a novel multiplex ligation-dependent probe amplification (MLPA) assay for the simultaneous detection of 7 clinically relevant pathogens of STDs, i.e., Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, Treponema pallidum, and herpes simplex virus type 1 and 2 (HSV-1 and HSV-2). An internal amplification control was included in the mPCR reaction. The limits of detection for the STDFinder assay varied among the 7 target organisms from 1 to 20 copies per MLPA assay. There were no cross-reactions among any of the probes. Two hundred and forty-two vaginal swabs and an additional 80 specimens with known results for N. gonorrhoeae and C. trachomatis, obtained from infertile women seen at an infertility research clinic at the Kigali Teaching Hospital in Rwanda, were tested by STDFinder assay and the results were confirmed by single real-time PCR using different species-specific targets. Compared to the reference standard, the STDFinder assay showed specificities and sensitivities of 100% and 100%, respectively, for N. gonorrhoeae, C. trachomatis, and M. genitalium; 90.2% and 100%, respectively, for Trichomonas vaginalis; and 96.1% and 100%, respectively, for HSV-2. No specimen was found to be positive for HSV-1 by either the STDFinder assay or the comparator method. Similarly, the sensitivity for Treponema pallidum could not be calculated due to the absence of any Treponema pallidumpositive samples. In conclusion, the STDFinder assays have comparable clinical sensitivity to the conventional mono and duplex real-time PCR assay and are suitable for the routine detection of a broad spectrum of these STDs at relatively low cost due to multiplexing. BMC Public Health. 2011 Aug 2;11:616. Age-disparity, sexual connectedness and HIV infection in disadvantaged communities around Cape Town, South Africa: a study protocol. Delva W, Beauclair R, Welte A, Vansteelandt S, Hens N, Aerts M, du Toit E, Beyers N, Temmerman M. Abstract BACKGROUND: Crucial connections between sexual network structure and the distribution of HIV remain inadequately understood, especially in regard to the role of concurrency and age disparity in relationships, and how these network characteristics correlate with each other and other risk factors. Social desirability bias and inaccurate recall are obstacles to obtaining valid, detailed information about sexual behaviour and relationship histories. Therefore, this study aims to use novel research methods in order to determine whether HIV status is associated with age-disparity and sexual connectedness as well as establish the primary behavioural and socio-demographic predictors of the egocentric and community sexual network structures. METHOD/DESIGN: We will conduct a cross-sectional survey that uses a questionnaire exploring one-year sexual histories, with a focus on timing and age disparity of relationships, as well as other risk factors such as unprotected intercourse and the use of alcohol and recreational drugs. The questionnaire will be administered in a safe and confidential mobile interview space, using audio computer-assisted self-interview (ACASI) technology on touch screen computers. The ACASI features a choice of languages and visual feedback of temporal information. The survey will be administered in three peri-urban

ICRH Activity Report 2011

disadvantaged communities in the greater Cape Town area with a high burden of HIV. The study communities participated in a previous TB/HIV study, from which HIV test results will be anonymously linked to the survey dataset. Statistical analyses of the data will include descriptive statistics, linear mixed-effects models for the inter- and intra-subject variability in the age difference between sexual partners, survival analysis for correlated event times to model concurrency patterns, and logistic regression for association of HIV status with age disparity and sexual connectedness. DISCUSSION: This study design is intended to facilitate more accurate recall of sensitive sexual history data and has the potential to provide substantial insights into the relationship between key sexual network attributes and additional risk factors for HIV infection. This will help to inform the design of context-specific HIV prevention programmes. BMC Public Health. 2011 May 25;11:384. Use of AUDIT, and measures of drinking frequency and patterns to detect associations between alcohol and sexual behaviour in male sex workers in Kenya. Luchters S, Geibel S, Syengo M, Lango D, King’ola N, Temmerman M, Chersich MF. Abstract BACKGROUND: Previous research has linked alcohol use with an increased number of sexual partners, inconsistent condom use and a raised incidence of sexually transmitted infections (STIs). However, alcohol measures have been poorly standardised, with many ill-suited to eliciting, with adequate precision, the relationship between alcohol use and sexual risk behaviour. This study investigates which alcohol indicator--single-item measures of frequency and patterns of drinking ( > = 6 drinks on 1 occasion), or the Alcohol Use Disorders Identification Test (AUDIT)--can detect associations between alcohol use and unsafe sexual behaviour among male sex workers. METHODS: A cross-sectional survey in 2008 recruited male sex workers who sell sex to men from 65 venues in Mombasa district, Kenya, similar to a 2006 survey. Information was collected on socio-demographics, substance use, sexual behaviour, violence and STI symptoms. Multivariate models examined associations between the three measures of alcohol use and condom use, sexual violence, and penile or anal discharge. RESULTS: The 442 participants reported a median 2 clients/week (IQR = 1-3), with half using condoms consistently in the last 30 days. Of the approximately 70% of men who drink alcohol, half (50.5%) drink two or more times a week. Binge drinking was common (38.9%). As defined by AUDIT, 35% of participants who drink had hazardous drinking, 15% harmful drinking and 21% alcohol dependence. Compared with abstinence, alcohol dependence was associated with inconsistent condom use (AOR = 2.5, 95%CI = 1.3-4.6), penile or anal discharge (AOR = 1.9, 95%CI = 1.0-3.8), and two-fold higher odds of sexual violence (AOR = 2.0, 95%CI = 0.9-4.9). Frequent drinking was associated with inconsistent condom use (AOR = 1.8, 95%CI = 1.1-3.0) and partner number, while binge drinking was only linked with inconsistent condom use (AOR = 1.6, 95%CI = 1.0-2.5). CONCLUSIONS: Male sex workers have high levels of hazardous and harmful drinking, and require alcohol-reduction interventions. Compared with indicators of drinking frequency or pattern, the AUDIT measure has stronger associations with inconsistent condom use, STI symptoms and sexual violence. Increased use of the AUDIT tool in future studies may assist in delineating with greater precision the explanatory mechanisms which link alcohol use, drinking contexts, sexual behaviours and HIV transmission. Res Microbiol. 2011 Jun;162(5):499-505. Epub 2011 Comparison of culture with two different qPCR assays for detection of rectovaginal carriage of Streptococcus agalactiae (group B streptococci) in pregnant women. El Aila NA, Tency I, Claeys G, Verstraelen H, Deschaght P, Decat E, Lopes dos Santos Santiago G, Cools P, Temmerman M, Vaneechoutte M. Abstract Development of rapid and sensitive detection methods for group B streptococci (GBS) in pregnant women remains useful in order to adequately identify pregnant women at risk of transferring GBS to their neonate. This study compared the CDC recommended sampling and culture method with two qPCR methods for detecting GBS colonization. For a total of 100 pregnant women at 35-37 weeks of gestation, one rectovaginal ESwab each was collected. Eswab medium was inoculated into Lim broth, incubated for 24 h and plated onto chromID™ Strepto B agar (ChromAgar). DNA was extracted with the bioMérieux easyMAG platform, either directly from the rectovaginal ESwab or from Lim broth enrichment culture. Two different qPCR formats were compared, i.e. the hydrolysis probe format (Taqman, Roche) targeting the sip gene and the hybridization probe format (Hybprobe, Roche) targeting the cfb gene. Both qPCR techniques identified 33% of the women as GBS-positive. Only one culture-positive sample was qPCR-negative. QPCR directly on the sample significantly increased the number of women found to be GBS-positive (27%) compared to culture (22%). Moreover, the sensitivity of qPCR after Lim broth enrichment (33%) was again significantly higher than qPCR after DNA extracICRH Activity Report 2011

tion directly from the rectovaginal swabs (27%). In conclusion, for prenatal screening of GBS from rectovaginal samples of pregnant women, our results are in accordance with CDC guidelines, which suggest using qPCR after Lim broth enrichment in addition to conventional (culture-based) detection. qPCR after Lim broth enrichment further increased the percentage of GBS-positive women, as detected by direct qPCR, from 27 to 33%, although the bacterial inoculum was low for these subjects. Res Microbiol. 2011 Jun;162(5):506-13. Epub 2011 Apr 7. Strong correspondence in bacterial loads between the vagina and rectum of pregnant women. El Aila NA, Tency I, Saerens B, De Backer E, Cools P, dos Santos Santiago GL, Verstraelen H, Verhelst R, Temmerman M, Vaneechoutte M. Abstract We sampled the vagina and rectum in 71 pregnant women and bacterial loads of Lactobacillus crispatus, L. jensenii, L. gasseri, L. iners, Gardnerella vaginalis and Atopobium vaginae were determined by culture and quantitative PCR (qPCR). Culture and qPCR results differed substantially with regard to the evaluation of vaginal and rectal occurrence of the six species tested. The vaginal-rectal prevalence of L. crispatus, L. jensenii, L. gasseri, L. iners, G. vaginalis and A. vaginae as established by culture vs. PCR was 32.3 vs. 91.5%, 32.3 vs. 77.4%, 28.1 vs. 91.5%, 12.6 vs. 68.5%, 12.6 vs. 74.6% and 5.6 vs. 69.0%, respectively. Using qPCR, a significant positive correlation was found between vaginal and rectal loads of L. crispatus (p < 0.0001), L. jensenii (p < 0.0001), L. gasseri (p = 0.005), L. iners (p = 0.003) and A. vaginae (p = 0.002). In summary, significant correlations between quantities of vaginal and rectal lactobacilli and of Atopobium vaginae were established by means of qPCR, indicating strong correspondence of vaginal and rectal microflora, not only in the occurrence of certain species in both niches, but also of cell densities per bacterial species. Am J Obstet Gynecol. 2011 May;204(5):450.e1-7. Epub 2011 Mar 27. Gardnerella vaginalis comprises three distinct genotypes of which only two produce sialidase. Santiago GL, Deschaght P, El Aila N, Kiama TN, Verstraelen H, Jefferson KK, Temmerman M, Vaneechoutte M. Abstract OBJECTIVE: Sialidase and the presence of Gardnerella vaginalis have been proposed as biomarkers for bacterial vaginosis. Sialidase has been associated with adverse pregnancy outcome. We genotyped G vaginalis isolates, assessed the presence and diversity of sialidase-encoding genes, and determined the production of sialidase. STUDY DESIGN: One hundred thirty-four G vaginalis isolates were genotyped by random amplified polymorphic deoxyribonucleic acid (RAPD) and a selection of 29 isolates with amplified ribosomal deoxyribonucleic acid restriction analysis (ARDRA). A G vaginalis sialidase quantitative polymerase chain reaction was developed, and the sialidase production was assessed with the filter spot test. RESULTS: Three G vaginalis genotypes could be distinguished by both RAPD and ARDRA. Only 2 genotypes encoded and produced sialidase. CONCLUSION: Three genotypes exist among G vaginalis isolates, and there is a clear link between genotype and sialidase production. A possible link between sialidase production and (symptomatic) bacterial vaginosis and biofilm production can be hypothesized. Trop Doct. 2011 Apr;41(2):96-101. Results of infertility investigations and follow-up among 312 infertile women and their partners in Kigali, Rwanda. Dhont N, van de Wijgert J, Vyankandondera J, Busasa R, Gasarabwe A, Temmerman M. Erratum in Trop Doct. 2011 Jul;41(3):192. Abstract The objectives of this study were to assess the outcome of infertility investigations and an 18-month follow-up of 312 infertile women and their partners in Rwanda. Between November 2007 and May 2009, an infertility research clinic was opened. Infertile couples received basic infertility investigations, the available treatment was provided and couples were followed up over an 18-month period. The infertility remained unexplained in 3%, was due to a female factor in 31%, due to a male factor in 16% or due to a combination of male and female causes in 50% of fully investigated couples (n = 224). A tubal factor was found in 69% of women, a male factor in 64% of men. Predictors for tubal infertility in women included a history of high-risk sexual behaviour, HIV infection and a history of sexually transmitted infection (STI) symptoms in the male partner. After 12-18 months of follow-up, 40 pregnancies (16%) had occurred in 244 women.

ICRH Activity Report 2011

Our study shows high rates of tubal and male factor infertility in Rwanda. Pregnancy rates were low after conventional therapy. In order to provide effective and affordable treatment for infertility in resource-poor countries the development of low-cost assisted reproductive technologies are needed. Eur J Contracept Reprod Health Care. 2011 Jun;16(3):173-82. Epub 2011 Mar 17. Contraceptive needs of female sex workers in Kenya - a cross-sectional study. Sutherland EG, Alaii J, Tsui S, Luchters S, Okal J, King’ola N, Temmerman M, Janowitz B. Abstract BACKGROUND AND OBJECTIVES: Female sex workers (FSWs) are thought to be at heightened risk for unintended pregnancy, although sexual and reproductive health interventions reaching these populations are typically focused on the increased risk of sexually transmitted infections. The objective of this study of FSWs in Kenya is to document patterns of contraceptive use and unmet need for contraception. METHODS: This research surveys a large sample of female sex workers (N = 597) and also uses qualitative data from focus group discussions. RESULTS: The reported level of modern contraceptives in our setting was very high. However, like in other studies, we found a great reliance on male condoms, coupled with inconsistent use at last sex, which resulted in a higher potential for unmet need for contraception than the elevated levels of modern contraceptives might suggest. Dual method use was also frequently encountered in this population and the benefits of this practice were clearly outlined by focus group participants. CONCLUSION: These findings suggest that the promotion of dual methods among this population could help meet the broader reproductive health needs of FSWs. Furthermore, this research underscores the necessity of considering consistency of condom use when estimating the unmet or undermet contraceptive needs of this population. AIDS Care. 2011 May;23(5):612-8. Sexual and physical violence against female sex workers in Kenya: a qualitative enquiry. Okal J, Chersich MF, Tsui S, Sutherland E, Temmerman M, Luchters S. Abstract Few studies in Africa provide detailed descriptions of the vulnerabilities of female sex workers (FSW) to sexual and physical violence, and how this impacts on their HIV risk. This qualitative study documents FSW’s experiences of violence in Mombasa and Naivasha, Kenya. Eighty-one FSW who obtained clients from the streets, transportation depots, taverns, discos and residential areas were recruited through local sex workers trained as peer counsellors to participate in eight focus-group discussions. Analysis showed the pervasiveness of sexual and physical violence among FSW, commonly triggered by negotiation around condoms and payment. Pressing financial needs of FSW, gender-power differentials, illegality of trading in sex and cultural subscriptions to men’s entitlement for sex sans money underscore much of this violence. Sex workers with more experience had developed skills to avoid threats of violence by identifying potentially violent clients, finding safer working areas and minimising conflict with the police. Addressing violence and concomitant HIV risks and vulnerabilities faced by FSW should be included in Kenya’s national HIV/AIDS strategic plan. This study indicates the need for multilevel interventions, including legal reforms so that laws governing sex work promote the health and human rights of sex workers in Kenya. Lancet Infect Dis. 2011 Mar;11(3):171-80. Epub 2011 Jan 13. Triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis during pregnancy and breastfeeding for prevention of mother-to-child transmission of HIV-1 (Kesho Bora study): a randomised controlled trial. Kesho Bora Study Group, de Vincenzi I. Collaborators (71) Farley T, Gaillard P, Meda N, Rollins N, Luchters S, Nduati R, Newell ML, Read J, Dioulasso B, Faso B, Meda N, Fao P, KyZerbo O, Gouem C, Somda P, Hien H, Ouedraogo PE, Kania D, Sanou A, Kossiwavi IA, Sanogo B, Ouedraogo M, Siribie I, Valéa D, Ouedraogo S, Somé R, Rouet F, Rollins N, McFetridge L, Naidu K, Luchters S, Reyners M, Irungu E, Katingima C, Mwaura M, Ouattara G, Mandaliya K, Wambua S, Thiongo M, Nduati R, Kose J, Njagi E, Mwaura P, Newell ML, Mepham S, Viljoen J, Bland R, Mthethwa L, Bazin B, Rekacewicz C, Taylor A, Flowers N, Thigpen M, Fowler MG, Jamieson D, Read J, Bork K, Cames C, Cournil A, Claeys P, Temmerman M, Luchters S, Van de Perre P, Becquart P, Foulongne V, Segondy M, de Vincenzi I, Gaillard P, Farley T, Habib N, Landoulsi S. Erratum in Lancet Infect Dis. 2011 Mar;11(3):159. Read, Jennifer S [corrected to Read, Jennifer]. Abstract BACKGROUND: Breastfeeding is essential for child health and development in low-resource settings but carries a significant risk of ICRH Activity Report 2011

transmission of HIV-1, especially in late stages of maternal disease. We aimed to assess the efficacy and safety of triple antiretroviral compared with zidovudine and single-dose nevirapine prophylaxis in pregnant women infected with HIV. METHODS: Pregnant women with WHO stage 1, 2, or 3 HIV-1 infection who had CD4 cell counts of 200-500 cells per μL were enrolled at five study sites in Burkina Faso, Kenya, and South Africa to start study treatment at 28-36 weeks’ gestation. Women were randomly assigned (1:1) by a computer generated random sequence to either triple antiretroviral prophylaxis (a combination of 300 mg zidovudine, 150 mg lamivudine, and 400 mg lopinavir plus 100 mg ritonavir twice daily until cessation of breastfeeding to a maximum of 6•5 months post partum) or zidovudine and single-dose nevirapine (300 mg zidovudine twice daily until delivery and a dose of 600 mg zidovudine plus 200 mg nevirapine at the onset of labour and, after a protocol amendment in December, 2006, 1 week post-partum zidovudine 300 mg twice daily and lamivudine 150 mg twice daily). All infants received a 0•6 mL dose of nevirapine at birth and, from December, 2006, 4 mg/kg twice daily of zidovudine for 1 week after birth. Patients and investigators were not masked to treatment. The primary endpoints were HIV-free infant survival at 6 weeks and 12 months; HIV-free survival at 12 months in infants who were ever breastfed; AIDS-free survival in mothers at 18 months; and serious adverse events in mothers and babies. Analysis was by intention to treat. This trial is registered with Current Controlled Trials, ISRCTN71468401. FINDINGS: From June, 2005, to August, 2008, 882 women were enrolled, 824 of whom were randomised and gave birth to 805 singleton or first, liveborn infants. The cumulative rate of HIV transmission at 6 weeks was 3•3% (95% CI 1•9-5•6%) in the triple antiretroviral group compared with 5•0% (3•3-7•7%) in the zidovudine and single-dose nevirapine group, and at 12 months was 5•4% (3•6-8•1%) in the triple antiretroviral group compared with 9•5% (7•0-12•9%) in the zidovudine and single-dose nevirapine group (p=0•029). The cumulative rate of HIV transmission or death at 12 months was 10•2% (95% CI 7•6-13•6%) in the triple antiretroviral group compared with 16•0% (12•7-20•0%) in the zidovudine and single-dose nevirapine group (p=0•017). In infants whose mothers declared they intended to breastfeed, the cumulative rate of HIV transmission at 12 months was 5•6% (95% CI 3•4-8•9%) in the triple antiretroviral group compared with 10•7% (7•6-14•8%) in the zidovudine and single-dose nevirapine group (p=0•02). AIDS-free survival in mothers at 18 months will be reported in a different publication. The incidence of laboratory and clinical serious adverse events in both mothers and their babies was similar between groups. INTERPRETATION: Triple antiretroviral prophylaxis during pregnancy and breastfeeding is safe and reduces the risk of HIV transmission to infants. Revised WHO guidelines now recommend antiretroviral prophylaxis (either to the mother or to the baby) during breastfeeding if the mother is not already receiving antiretroviral treatment for her own health. FUNDING: Agence nationale de recherches sur le sida et les hépatites virales, Department for International Development, European and Developing Countries Clinical Trials Partnership, Thrasher Research Fund, Belgian Directorate General for International Cooperation, Centers for Disease Control and Prevention, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and UNDP/UNFPA/World Bank/WHO Special Programme of Research, Development and Research Training in Human Reproduction. PLoS One. 2011 Mar 8;6(3):e17591. A systematic review of African studies on intimate partner violence against pregnant women: prevalence and risk factors. Shamu S, Abrahams N, Temmerman M, Musekiwa A, Zarowsky C. Abstract BACKGROUND: Intimate partner violence (IPV) is very high in Africa. However, information obtained from the increasing number of African studies on IPV among pregnant women has not been scientifically analyzed. This paper presents a systematic review summing up the evidence from African studies on IPV prevalence and risk factors among pregnant women. METHODS: A key-word defined search of various electronic databases, specific journals and reference lists on IPV prevalence and risk factors during pregnancy resulted in 19 peer-reviewed journal articles which matched our inclusion criteria. Quantitative articles about pregnant women from Africa published in English between 2000 and 2010 were reviewed. At least two reviewers assessed each paper for quality and content. We conducted meta-analysis of prevalence data and reported odds ratios of risk factors. RESULTS: The prevalence of IPV during pregnancy ranges from 2% to 57% (n = 13 studies) with meta-analysis yielding an overall prevalence of 15.23% (95% CI: 14.38 to 16.08%). After adjustment for known confounders, five studies retained significant associations between HIV and IPV during pregnancy (OR1.48-3.10). Five studies demonstrated strong evidence that a history of violence is significantly associated with IPV in pregnancy and alcohol abuse by a partner also increases a woman’s chances of being abused during pregnancy (OR 2.89-11.60). Other risk factors include risky sexual behaviours, low socioeconomic status and young age.

ICRH Activity Report 2011

CONCLUSION: The prevalence of IPV among pregnant women in Africa is one of the highest reported globally. The major risk factors included HIV infection, history of violence and alcohol and drug use. This evidence points to the importance of further research to both better understand IPV during pregnancy and feed into interventions in reproductive health services to prevent and minimize the impact of such violence. Arch Gynecol Obstet. 2011 Jul;284(1):95-8. Epub 2011 Feb 19. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. Abstract PURPOSE: Vaginal infection with group A streptococci (GAS) is an established cause of vaginitis amongst prepubescent girls, but largely unrecognized in adult women and therefore often misdiagnosed as vulvovaginal candidosis. We sought to give an overview of the epidemiology, risk factors, symptoms, signs, and treatment of GAS vaginitis in adult women. METHODS: Systematic literature search. RESULTS: We identified nine case reports covering 12 patients with documented GAS vulvovaginitis. GAS vulvovaginitis in adult women is often associated with a predisposing factor: (1) household or personal history of dermal or respiratory infection due to GAS, (2) sexual contact, and (3) lactational or menopausal vaginal atrophy. Symptoms of GAS vulvovaginitis in adult women may include vaginal and/or vulvar pain, dyspareunia, burning sensation or irritation, and pruritus. In most cases, there is also profuse or copious vaginal discharge which may be watery, yellow, or even purulent. Whilst there are neither clinical trials nor treatment guidelines, treatment with oral penicillin or with vaginal clindamycin cream has been reported to result in rapid cure. In breast-feeding and postmenopausal women with vaginal atrophy, additional treatment with local estriol may be necessary to prevent recurrence. Finally, in case of recurrent GAS vulvovaginitis it will be necessary to assess the patientsâ&#x20AC;&#x2122; asymptomatic household members for pharyngeal and anal carriage and to treat them accordingly. CONCLUSION: Vaginal infection with GAS in adult women is a clearly defined entity and should be considered a diagnosis when more common causes of vaginitis have been ruled out. PLoS Med. 2011 Feb 15;8(2):e1000416. Intravaginal practices, bacterial vaginosis, and HIV infection in women: individual participant data meta-analysis. Low N, Chersich MF, Schmidlin K, Egger M, Francis SC, van de Wijgert JH, Hayes RJ, Baeten JM, Brown J, Delany-Moretlwe S, Kaul R, McGrath N, Morrison C, Myer L, Temmerman M, van der Straten A, Watson-Jones D, Zwahlen M, Hilber AM. Abstract BACKGROUND: Identifying modifiable factors that increase womenâ&#x20AC;&#x2122;s vulnerability to HIV is a critical step in developing effective femaleinitiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition. METHODS AND FINDINGS: We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I(2) values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p<0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p<0.001), respectively. CONCLUSIONS: This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been ICRH Activity Report 2011

demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidated. Please see later in the article for the Editors’ Summary. BMC Infect Dis. 2011 Jan 11;11:10. Bacterial vaginosis is associated with uterine cervical human papillomavirus infection: a meta-analysis. Gillet E, Meys JF, Verstraelen H, Bosire C, De Sutter P, Temmerman M, Broeck DV. Abstract BACKGROUND: Bacterial vaginosis (BV), an alteration of vaginal flora involving a decrease in Lactobacilli and predominance of anaerobic bacteria, is among the most common cause of vaginal complaints for women of childbearing age. It is well known that BV has an influence in acquisition of certain genital infections. However, association between BV and cervical human papillomavirus (HPV) infection has been inconsistent among studies. The objective of this meta-analysis of published studies is to clarify and summarize published literature on the extent to which BV is associated with cervical HPV infection. METHODS: Medline and Web of Science were systematically searched for eligible publications until December 2009. Articles were selected based on inclusion and exclusion criteria. After testing heterogeneity of studies, meta-analysis was performed using random effect model. RESULTS: Twelve eligible studies were selected to review the association between BV and HPV, including a total of 6,372 women. The pooled prevalence of BV was 32%. The overall estimated odds ratio (OR) showed a positive association between BV and cervical HPV infection (OR, 1.43; 95% confidence interval, 1.11-1.84). CONCLUSION: This meta-analysis of available literature resulted in a positive association between BV and uterine cervical HPV infection. Hum Reprod. 2011 Mar;26(3):623-9. Epub 2011 Jan 7. ‘Mama and papa nothing’: living with infertility among an urban population in Kigali, Rwanda. Dhont N, van de Wijgert J, Coene G, Gasarabwe A, Temmerman M. Abstract BACKGROUND: Not being able to procreate has severe social and economic repercussions in resource-poor countries. The purpose of this research was to explore the consequences of female and/or male factor infertility for men and women in Rwanda. METHODS: Both quantitative and qualitative methods were used. Couples presenting with female and/or male factor infertility problems at the infertility clinic of the Kigali University Teaching Hospital (n = 312), and fertile controls who recently delivered (n = 312), were surveyed about domestic violence, current and past relationships and sexual functioning. In addition, five focus group discussions were held with a subsample of survey participants, who were either patients diagnosed with female- or male-factor fertility or their partners. RESULTS: Domestic violence, union dissolutions and sexual dysfunction were reported more frequently in the survey by infertile than fertile couples. The psycho-social consequences suffered by infertile couples in Rwanda are severe and similar to those reported in other resource-poor countries. Although women carry the largest burden of suffering, the negative repercussions of infertility for men, especially at the level of the community, are considerable. Whether the infertility was caused by a female factor or male factor was an important determinant for the type of psycho-social consequences suffered. CONCLUSIONS: In Rwanda, as in other resource-poor countries, infertility causes severe suffering. There is an urgent need to recognize infertility as a serious reproductive health problem and to put infertility care on the public health agenda. Contemp Clin Trials. 2011 Jan;32(1):74-85. Epub 2010 Sep 17. Safety and effectiveness of antiretroviral drugs during pregnancy, delivery and breastfeeding for prevention of mother-to-child transmission of HIV-1: the Kesho Bora Multicentre Collaborative Study rationale, design, and implementation challenges. Kesho Bora Study Group. Collaborators (58) Meda N, Fao P, Ky-Zerbo O, Gouem C, Somda P, Hien H, Ouedraogo PE, Kania D, Sanou A, Kossiwavi IA, Sanogo B,

ICRH Activity Report 2011

Ouedraogo M, Siribie I, ValĂŠa D, Ouedraogo S, SomĂŠ R, Rouet F, Rollins N, McFetridg L, Naidu K, Luchters S, Reyners M, Irungu E, Katingima C, Mwaura M, Ouattara G, Mandaliya K, Thiongo M, Wambua S, Nduati R, Kose J, Njagi E, Mwaura P, Newell ML, Mepham S, Viljoen J, Bazin B, Rekacewicz C, Taylor A, Flowers N, Thigpen M, Fowler MG, Jamieson D, Read JS, Bork K, Cames C, Cournil A, Claeys P, Temmerman M, Van de Perre P, Becquart P, Foulongne V, Segondy M, de Vincenzi I, Gaillard P, Farley T, Habib N, Landoulsi S. Abstract To evaluate strategies to reduce HIV-1 transmission through breastfeeding, a multicentre study including a nested randomized controlled trial was implemented in five research sites in West, East and South Africa (The Kesho Bora Study). The aim was to optimize the use of antiretroviral (ARV) drugs during pregnancy, delivery and breastfeeding to prevent mother-to-child transmission of HIV-1 (PMTCT) and to preserve the health of the HIV-1-infected mother. The study included long-term ARV treatment for women with advanced disease, and short-course ARV prophylaxis stopped at delivery for women with early disease. Women with intermediate disease participated in a randomized controlled trial to compare safety and efficacy of triple-ARV prophylaxis prolonged during breastfeeding with short-course ARV prophylaxis stopped at delivery. Between January 2005 and August 2008 a total of 1140 women were enrolled. This paper describes the study design, interventions and protocol amendments introduced to adapt to evolving scientific knowledge, international guidelines and availability of ARV treatment. The paper highlights the successes and challenges during the conduct of the trial. The Kesho Bora Study included one of the few randomized controlled trials to assess safety and efficacy of ARV prophylaxis continued during breastfeeding and the only randomized trial to assess maternal prophylaxis started during pregnancy. The findings have been important for informing international and national guidelines on MTCT prevention in developing countries where, due to poverty, lack of reliable and affordable supply of replacement feed and stigma associated with HIV/AIDS, HIV-infected women have little or no option other than to breastfeed their infants. Eur J Contracept Reprod Health Care. 2011 Feb;16(1):26-35. Epub 2010 Dec 15. Determinants of unmet need for contraception among Chinese migrants: a worksite-based survey. Decat P, Zhang WH, Moyer E, Cheng Y, Wang ZJ, Lu CY, Wu SZ, Nadisauskiene RJ, Luchters S, Deveugele M, Temmerman M. Abstract BACKGROUND: Considerable sexual and reproductive health (SRH) challenges have been reported among rural-to-urban migrants in China. Predictors thereof are urgently needed to develop targeted interventions. STUDY DESIGN: A cross-sectional study assessed determinants of unmet need for contraception using semi-structured interviews in two cities in China: Guangzhou and Qingdao. RESULTS: Between July and September 2008, 4867 female rural-to-urban migrants aged 18-29 years participated in the study. Of these, 2264 were married or cohabiting. Among sexually-active women (n = 2513), unmet need for contraception was reported by 36.8% and 51.2% of respondents in Qingdao and Guangzhou, respectively; it was associated with being unmarried, having no children, less schooling, poor SRH knowledge, working in non-food industry, and not being covered by health insurance. A substantial proportion of unmarried migrants reported they had sexual intercourse (16.6 % in Qingdao and 21.4% in Guangzhou) contrary to current sexual standards in China. CONCLUSION: The study emphasises the importance of improving the response to the needs of rural-to-urban migrants and recommends strategies to address the unmet need for contraception. These should enhance open communication on sexuality, increase the availability of condoms, and improve health insurance coverage. Sex Transm Infect. 2011 Feb;87(1):28-34. Epub 2010 Sep 18. HIV infection and sexual behaviour in primary and secondary infertile relationships: a case-control study in Kigali, Rwanda. Dhont N, Muvunyi C, Luchters S, Vyankandondera J, De Naeyer L, Temmerman M, van de Wijgert J. Abstract OBJECTIVE: To compare the prevalence of sexually transmitted infections (STIs) (including HIV) and of high-risk sexual behaviour in the following three groups: primary infertile relationships, secondary infertile relationships and fertile relationships. Primary infertility is here defined as never having conceived before, secondary infertility as infertility subsequent to having conceived at least once. DESIGN: Unmatched case--control study. METHODS: Sexually active infertile women aged 21-45 years presenting at an infertility clinic of the Kigali Teaching Hospital, ICRH Activity Report 2011

Rwanda and their male partners were invited to participate. Fertile controls who had recently delivered were recruited from the community. In a face-to-face interview, participants were asked about sociodemographic characteristics and their sexual behaviours, and tested for HIV and STIs. RESULTS: Between November 2007 and May 2009, 312 women and 254 partners in infertile relationships and 312 women and 189 partners in fertile relationships were enrolled. Involvement in a secondary infertile relationship was associated with HIV infection after adjusting for sociodemographic covariates for women (adjusted OR (AOR) = 4.03, 95% CI 2.4 to 6.7) and for men (AOR = 3.3, 95% CI 1.8 to 6.4). Involvement in a primary infertile relationship, however, was not. Secondary infertile women were more likely to have engaged in risky sexual behaviour during their lifetime compared with primary infertile and fertile women. Men in primary and secondary infertile relationships more often reported multiple partners in the past year (AOR = 5.4, 95% CI 2.2 to 12.7; AOR = 7.1, 95% CI 3.2 to 15.8, respectively). CONCLUSIONS: Increased HIV prevalence and risky sexual behaviour among infertile couples is driven by secondary infertility. Infertile couples, and especially those with secondary infertility, should be targeted for HIV prevention programmes and their fertility problems should be addressed. Asia Pac J Public Health. 2011 Apr 28. Promoting Contraceptive Use More Effectively Among Unmarried Male Migrants in Construction Sites in China: A Pilot Intervention Trial. He D, Cheng YM, Wu SZ, Decat P, Wang ZJ, Minkauskiene M, Moyer E. Abstract Poor sexual and reproductive health status has been reported among rural-to-urban migrants in China. Therefore, some effective and feasible interventions are urgently needed. The authors developed a workplace-based intervention to compare 2 young labor migrant service packages (A and B) on the knowledge, attitude related to contraception, and contraceptive use among unmarried male migrants in Chengdu. Fourteen construction sites were randomly assigned to either of the 2 intervention packages. Interventions were completed in 3 months, and data were collected in 2 rounds independently (before and after interventions). After the intervention, the median scores for knowledge and attitude in migrants in package B were significantly higher than in migrants in package A. Although migrants in both packages increased use of condom, the increase was pronounced in migrants in package B, with odds ratio (OR) = 9.65 (95% confidence interval [CI] = 1.41-66.28). The rate of unwanted pregnancies was reduced more significantly in migrants in package B than in migrants in package A (OR = 0.16; 95%CI = 0.03-0.45). Unmarried male migrants who received the comprehensive intervention (package B) were more willing to use condoms and avoid unwanted pregnancies effectively.

4.2 OTHER ARTICLES Andries C, Buckley N, De Bal I, Roelens K, Studsrod I, Temmerman M, Van Parys AS, Voolma H, Willumsen E. Domestic Violence and Pregnancy: the challenge of framing a European-wide research question. International Journal of Community Based Research 2011;9:11-12. Claeys P, Van Braeckel D, Luchters S, Degomme O, Temmerman M. The International Centre for Reproductive Health (ICRH): an international multidisciplinary centre of excellence in the field of reproductive health. Facts Views & Visions in ObGyn 2011;3(2):71-4. Delporte F, Dhont M, Temmerman M. Medische aspecten van vrouwelijke genitale verminking. GunaĂŻkeia 2011;16(5):142-6. Dhont N, Temmerman M, Van de Wijgert J. Clinical, epidemiological and socio-cultural aspects of infertility in resourcepoor settings: Evidence from Rwanda. Facts Views & Visions in ObGyn 2011;3(2):77-88. Dhont N, Luchters S, Muvunyi, CM, Vyankandondera J, De Naeyer L, Temmerman M, Van de Wijgert J. The risk factor profile of women with secondary infertility: an unmatched case-control study in Kigali, Rwanda. BMC Womenâ&#x20AC;&#x2122;s Health 2011;11:32. Himpe E, Roelens K, Temmerman M. Evaluatie van het hymen bij prepuberale meisjes bij het vermoeden van seksueel kindermisbruik. Tijdschr Geneeskd 2011;67(16):751-5. Keygnaert I, El Mahi N, Van Egmond K, Temmerman M (2011) Verborgen Zorgen: Beeldessay- Tijdschrift voor Genderstudies n3, pp40-41.

ICRH Activity Report 2011

Keygnaert I, Deblonde J, Leye E, Temmerman M. Sexual Health of migrants in Europe: some pathways to improvement. Entre Nous 2011;72:20-1. Sabbe A., Implicaties van beleid in Europa op gedwongen huwelijken. Een analyse van cultuur, migratie en gender in het beleid ten aanzien van gedwongen huwelijken, Tijdschrift voor Genderstudies, 2011, 14(1), 21-33. Temmerman M, De Sutter P, Stevens L, Valcke L, Bauwelinck B. Draagmoederschap durven regelen. Samenlev Politiek 2011;18(5):50-9. Vercoutere A, Temmerman M, Leye E. Vrouwelijke genitale verminking, een ver-van-mijn-bedshow? Medische en ethicolegale aspecten van verminkte vrouwen in westerse landen. Tijdschr voor Geneeskd 2011;67(5):237-41.

4.3 CHAPTERS AND BOOKS Ryssaert L, Avonts D, Boeckxstaens P, Bracke P, Christiaens T, De Coninck L, Maes L, Matthijs K, Pattyn E, Schoenmaeckers J, Sunaert P, Temmerman M, Van Hal G, Verlinde E, Vyncke V, Willems S, De Maeseneer J. Gezondheid en Zorg in Vlaanderen, Europees gekaderd. In: De sociale staat van Vlaanderen 2011, edited by Noppe J, Vanderleyden L, Callens L. Studiedienst van de Vlaamse Regering, Brussel 2011, 165-216, D/2011/3241/155. Roelens K, Verstraelen H, Temmerman M. Partnergeweld en de visie van de gynaecoloog. In: Partnergeweld: als liefde een gevecht wordt, edited by Groenen A, Jaspaert E, Vervaeke G. Acco, Leuven en Den Haag 2011, 59-71, ISBN: 978-90334-7930-4. Galajdova L, Depypere H, Temmerman M. Seksualiteit van vrouwen na de overgang of menopause. In: Seksualiteit van ouderen, edited by Swinnen A. Amsterdam University Press 2011, 113-138, ISBN: 978 90 8964 182 3. Verhelst R, Verstraelen H, Cools P, Lopes Dos Santos Santiago G, Temmerman M, Vaneechoutte M. Gardnerella. In: Molecular detection of human bacterial pathogens, edited by Liu D. Taylor and Francis CRC Press, Boca Raton, 2011, 81-94, ISBN: 97 8143 981238 9.

4.4 PRESENTATIONS AND POSTERS Cools P, Verstraelen H, Vaneechoutte M and Verhelst R. Atopobium, In Dongyou Liu (ed) Molecular detection of human bacterial pathogens, pp. 31-43, Taylor and Francis CRC Press, Boca Raton, Florida, USA. Dazzo F, Liu J, Tang G, Gross C, Reddy C, Monosmith C, Zhu G, Wang J, Li M, Philips N, Baruti A, Leader I, Zamani S, Verhelst R, Radek C, Klemmer K, Farrell K, McCulhey J, Krasnov B, Zhou J, Smith P, Kneeshaw S, Ganesan I, McGarrell D, Leader-Wineland M, Hollingsworth R, Smucker A, Nakano S, Squartini A, Mateos P, Gantner S and Yanni Y. CMEIAS v3.1: Advanced computational tools of image analysis software designed to strengthen microscopy-based approaches for understanding microbial ecology at multiple spatial scales. Long-Term Ecological Research All Scientist Meeting, 15 April, 2011. Kellogg Biological Station, Hickory Corners, Michigan State University, US. Duysburgh E, Ye M, Williams A, Massawe S, Temmerman M Improving Quality of Maternal and Newborn Care in Selected Districts in 3 sub-Saharan Countries: Baseline Quality Assessment. 7th European Congress on Tropical Medicine and International Health, 3-6 October 2011, Barcelona, Spain. (oral presentation) Duysburgh E., Zhang W-H., Kerstens B., Temmerman M. ‘International Centre for Reproductive Health: Two Maternal Health Unit Projects in sub-Saharan Africa’, 5th Ghent Africa Platform Symposium, 2 December 2011, Ghent, Belgium. (poster presentation) Geelhoed D , Lafort Y , Candrinho B , Chissale E , Temmerman M , Degomme O. The effect of integrated mother-andchild health services on the follow-up of HIV exposed infants in Mozambique. 7th European Congress on Tropical Medicine and International Health, 3-6 October 2011, Barcelona, Spain. (poster presentation, abstract 2.2-003) Jespers V, Menten J, Verhelst R, Smet H , Poradosú S, Buvé A, Hardy L, Crucitti T. Quantifying Vaginal Flora Species with Real Time PCR for HIV prevention trials. Poster at the 20th ISSTDR Congress. July 2011. Quebec, Canada. Keygnaert I. Senperforto: determinants for effective prevention and response actions of SGBV perpetration and victimizaICRH Activity Report 2011

tion in the European asylum reception system », 7th European Congress on Tropical Medicine and International Health, 3-6 October 2011, Barcelona, Spain. Keygnaert I. Tips, hulpmiddelen en instrumenten voor seksuele gezondheidspromotie en preventie van seksueel geweld’, Studiedag Geestelijke Gezondheid van Niet-Begeleide Minderjarigen-Platform Kinderen op de Vlucht, 26 October 2011, De Factory, Brussels. Keygnaert I. How to deal with IPV according to the Ghent University Hospital violence protocol. Mini-symposium Ghent University Hospital Professionals, September 29th 2011, Ghent University Hospital. Keygnaert I., Anastasiou A., Camilleri K., Degomme O., Devile W., Dias S., Field CA., Kovats A., Vettenburg N. and Temmerman M. Senperforto : determinants for effective prevention and response actions of SGBV perpetration and victimization in the European asylum reception system. Tropical Medicine and International Health, 16 (SupplI), p 96 . Presented at 7th European Congress on Tropical Medicine and International Health, 3-6th October 2011, Barcelona, Spain. (oral presentation) Leye E. Vrouwelijke genital verminking: enkele knelpunten in de medische praktijk, 18e Doelencongress Infertility, Gynaecology and Obstetrics, 6-8 April 2011. Leye E, Sabbe A. ‘Female genitale mutilation & reproductive health: an intertwined relation’, Parliamentarians for Development Goals, Belgian Federal parliament, 15 June 2011. Leye E. Vaginal practices across cultures. American Association of Anthropologists Annual Meeting, Montréal 16-20 November, 2011. Mandaliya K, Mwaura M, Verhelst R, Vanden Broeck D, Temmerman M. Prevalence of human papilloma virus infection in HIV infected women during the third trimester of pregnancy. Sixth EDCTP Forum, 9-12 October 2011. Addis Ababa, Ethiopia. Merckx Mireille; Wildero – Van Wouwe Liesbeth; Meys Joris; Weyers Steven; Arbyn Marc; Temmerman Marleen; Vanden Broeck Davy. Transmission of carcinogenic HPV types from mother to child: a meta-analysis of published studies. Eurogin 2011, Lisbon 8-11 May 2011. Mwaura M, the Microbicide Safety Biomarkers Study Group. Prevalence of sexually transmitted infection (STIs) in groups of women targeted for microbicide trials: the Microbicide Safety Biomarkers Study in Kenya, Rwanda, and South Africa. Sixth EDCTP Forum, 9-12 October 2011. Addis Ababa, Ethiopia. Sabbe Alexia. Policies on Forced Marriage in Europe: at the Crossroads of Migration, Culture and Gender. International Conference ‘Negotiating Identity in Migration Processes’. 28 October 2011, Centro de Ciencias Humanas y Sociales, Madrid. (oral presentation) Van Decraen Els, Michielsen Kristien, Olawaiye Durotimi, Van Rossem Ronan, Herbots Sarah, Temmerman Marleen. (2011). Sexual coercion among young people in Rwanda: correlates of victimization and normative acceptance. “(R) Urban Africa, Gents Afrikaplatform, Gent, 2/12/2011. Vega B., Decat P (2011) Sexual and reproductive health of adolescents in Latin America: results of cross-sectional surveys in secondary schools in Latin America. 7th Be-cause Health annual seminar: Will our generation close the gap?: Comprehensive and Innovative strategies to address social determinants of health, 15-16 December, Brussels, Belgium. (oral presentation) Vega B., Decat P (2011) Bridging the worlds of research and policy: the CERCA experience in Ecuador. 7th Be-cause Health annual seminar: Will our generation close the gap?: Comprehensive and Innovative strategies to address social determinants of health, 15-16 December, Brussels, Belgium. (oral presentation) Wambua S, Verhelst R, Vanden Broeck D, Luchters S, Mandaliya K, Temmerman, M. EDCTP Capacity Building Achievements At The International Centre For Reproductive Health (ICRH) Clinical Research Laboratory In Mombasa, Kenya. Sixth EDCTP Forum, 9-12 October 2011. Addis Ababa, Ethiopia.

ICRH Activity Report 2011

“IF YOU CAN’T EXPLAIN SOMETHING SIMPLY, YOU DON’T UNDERSTAND IT WELL. MOST OF THE FUNDAMENTAL IDEAS OF SCIENCE ARE ESSENTIALLY SIMPLE, AND MAY, AS A RULE, BE EXPRESSED IN A LANGUAGE COMPREHENSIBLE TO EVERYONE. EVERYTHING SHOULD BE AS SIMPLE AS IT CAN BE, YET NO SIMPLER.” ALBERT EINSTEIN ICRH Activity Report 2011

HUM AN RESOURCE S

ICRH Activity Report 2011

ICRH WORKFORCE

onducting a state-of-the art HRM policy is far from easy given the strict regulations imposed by Ghent University and the fact that the vast majority of our staff depends on project funding and therefore can only be given contracts of limited duration. Nevertheless, within these limitations ICRH has taken measures aimed at creating an encouraging and comfortable working environment. These measures include: - flexible working hours; - a policy for working from home; - the introduction of evaluation and functioning talks for every staff member.

List of Employees in 2011 Enrica Bianco John-Paul Bogers Steven Callens Matthew Chersich Beatrice Crahay* Carla De Beule Jessika Deblonde Peter Decat Olivier Degomme* Ilse Delbaere** Wim Delva StĂŠphanie De Maesschalck* Sara Demeyer Nathalie Dhont** Lou Dierick Caroline Duprez* Els Duysburgh Diederike Geelhoed** Aurore Guieu* Dominique Godfroid* Laurence Hendrickx Li Jinke* Birgit Kerstens* Ines Keygnaert Olivier Koole* Yves Lafort Els Leye Stanley Luchters Sabine Mall** Kristien Michielsen Katherine Muylaert* Chen Qiju* Marlise Richter Alexia Sabbe Ellen Taets Marleen Temmerman Inge Tency Dirk Van Braeckel Davy Vandenbroeck An-Sophie Van Parijs Anke Van Vossole Lucas Verhaegen** Rita Verhelst Heleen Vermandere Bavo Verpoest ICRH Activity Report 2011

Intern Visiting Professor Senior Researcher Visiting Professor Volunteer Mozambique (and Country Director of ICRH Mozambique) Financial Assistant Researcher Researcher & Team Leader Health Systems Scientific Director Doctor-Assistant Visiting Professor Researcher & Family Physician Researcher PhD Fellow & Researcher Volunteer Kenya (and Director F&A ICRH Kenya) Administration and Support Researcher & Team Leader Maternal Health Volunteer Mozambique (and Tete Project Coordinator for ICRH Mozambique) Intern Secretariat Ghent Africa Platform (GAP) Permanent Expert in Mozambique Postdoc Fellow Consortium Project Administrator PhD Fellow & Researcher Volunteer Mozambique (and Deputy Country Director of ICRH Mozambique) Senior Project Coordinator & Team Leader HIV/STI Senior Project Coordinator & Senior Researcher & Team Leader GBV Visiting Professor Volunteer Kenya (and Research Director of ICRH Kenya) Phd Fellow & Researcher Administrative Project Manager Postdoc Fellow Phd Fellow & Researcher Phd Fellow & Researcher Administration and Support Director Researcher Director Administration & Finance Senior Researcher Phd Fellow & Researcher Project Coordinator Researcher Senior Researcher Phd Fellow & Researcher Project Collaborator

Liesbeth Wildero-Van Wouwe** Wei-Hong Zhang

Project Collaborator Senior Researcher & Senior Project Coordinator

* Joined ICRH in the course of 2011 or in the beginning of 2012. Welcome to the ICRH family! ** Left ICRH in the course of 2011. Thanks a lot for the work you have done with us, and good luck in your career!

ICRH Activity Report 2011

E NVI RO NMENT

ICRH Activity Report 2011

ICRH AND THE ENVIRONMENT

he impact of research activities on the environment is rather limited compared to other sectors such as industry or transportation. However, our environmental impacts are far from negligible, and as adherents of sustainable development and the millennium development goals, we hold ourselves responsible for striving to limit our environmental footprint as much as possible. Our main impacts stem from transportation, paper use and energy consumption. In each of these fields, we have taken measures to avoid excessive consumption of resources or emissions. 6.1 Transportation Commuting For reducing the impacts of commuting of ICRH employees, we benefit from the general stimulation measures of Ghent University: - Public transport commuting expenses are fully reimbursed, - Commuting by car is discouraged and related costs are not reimbursed, - Employees can rent a bicycle from the university at favourable conditions, and employees commuting by bicycle receive a financial compensation. Compensation of CO2 emissions

“IN NATURE THERE ARE NEITHER REWARDS NOR PUNISHMENTS — THERE ARE CONSEQUENCES.” ROBERT G. INGERSOLL ICRH Activity Report 2011

ICRH is involved in many international research projects and as a consequence ICRH staff has to travel frequently within Europe and to other continents. Of course we try to avoid as much as possible unnecessary flights, but even then there are still many flights left. Since July 2009, ICRH compensates the carbon emissions linked to its air miles through the specialized NGO CompenCO2. By doing so, we finance carbon emissions reduction in developing countries, up to the same volume of emissions that we have caused. Since the end of 2011, ICRH is investigating the possibilities of establishing, in cooperation with environmentalist groups, a platform that allows to compensate CO2 emissions through family planning projects. Indeed, by improving access to modern contraceptive methods and safe abortion, millions

of unwanted births can be avoided, with beneficial impacts on future CO2 emissions, but of course also on the human rights and the well-being of numerous women, men, children and communities. 6.2 Energy Consumption The non-transportation related energy consumption of ICRH is mostly limited to office heating and lighting. There is no separate tracking of energy consumption for the ICRH offices, but the age and the condition of the building in which the ICRH offices are housed suggest that consumption is relatively high. As a consequence, the best way to reduce energy consumption is through investment in renovation. We keep on insisting with the University Hospital (our landlord) on energy efficiency measures, and in the meantime we try to bring down our consumption by â&#x20AC;&#x2DC;good housekeeping measuresâ&#x20AC;&#x2122;, such as switching off the lights and turning down the heating whenever possible. 6.3 Waste Production ICRH produces almost exclusively office waste, such as paper and ink cartridges. In September 2010, ICRH has leased a new copier/scanner. Standard settings of the printer include black & white and recto/verso printing. Banner sheets are disabled. One-side printed paper is re-used in a special tray of the printer. ICRH is also gradually shifting towards electronic storage of documents as an alternative for printing and classifying paper copies. From 2009 on, ICRH is monitoring its paper consumption. The comparison between 2009 and 2010 is as follows: Oct. 2008Sept 2009*

Oct. 2009Sept. 2010

Oct. 2010Sept 2011

Black and white prints and copies

185989

140,495

139,992

Colour prints and copies

25,543

36,027

Total

185989

166,038

176,019

-10.3%

+6.0%

Difference compared to the previous year *Extrapolated from partial data

Compared to 2010, the number of photocopies and prints has increased, which is regrettable, but not surprising considering the increased number of staff and the increased project volume. If ICRH continues to grow, it will be difficult to cut paper consumption in absolute terms. However, we will continue to remind staff members and visitors of the printing and copying guidelines, and encourage the use of scans for archiving documents as opposed to hard copies. 6.4 The Ghent University Sustainability Pact In the course of 2011, Ghent University students, together with the universityâ&#x20AC;&#x2122;s environmental and communication departments, launched a university-wide initiative to reduce the environmental burden. Departments, laboratories and offices are requested to sign a sustainability pact, in which they commit to a number of very diverse environmental measures, ranging from energy saving actions like switching off lights, heating and computers, over applying environmental criteria to purchases, to encouraging environmentally friendly communing. ICRH was the first department within the Faculty of Medicine and Health Sciences to sign the Pact.

ICRH Activity Report 2011

“DON’T BLOW IT - GOOD PLANETS ARE HARD TO FIND.” ANONYMOUS

ICRH Activity Report 2011

I C RH GRO U P “THE TIME HAS NOW DEFINITELY COME WHEN EVERY INTELLIGENT INDIVIDUAL MUST LEARN TO THINK GLOBALLY, BEYOND THE HORIZON OF A NARROW NATIONALIST POINT OF VIEW.” ROBERT MAXWELL

ICRH Activity Report 2011

ICRH GROUP

he International Centre for Reproductive Health in Belgium works closely together with its sister organizations ICRH Kenya, based in Mombasa and Nairobi, and ICRH Mozambique, based in Maputo and Tete. In order to formalize the close ties between these organizations, and to facilitate coordination, an umbrella organization has been set up in 2009 under the name of ICRH Global. Below we give a brief outline of ICRH Global, ICRH Kenya and ICRH Mozambique.

ICRH Global

The Board of Directors of this not-for-profit organization consists of representatives from ICRH Belgium, ICRH Kenya, ICRH Mozambique, and the Ghent University, and vice versa, ICRH Global will appoint representatives in the management structures of the individual ICRHs. In addition to its coordination tasks, ICRH Global will organize networking and information activities in the field of sexual and reproductive health and rights. Organizations as well as individuals can become member of ICRH Global. In the course of 2011, ICRH Global focused started up a project on maternity waiting homes in Kenya and Mozambique, funded by the National Lottery Fund and by the Collibri Foundation for Education (see 3.3 Activities of the Maternal Health team) and co-organized a series of lectures on â&#x20AC;&#x2DC;Reproductive Health in Global Perspectiveâ&#x20AC;&#x2122; (see 3.6 Non teamrelated activities). In addition, regular dialogue and consultation among the three ICRHs took place. Contact: ICRH Global, Ghent University Hospital, De Pintelaan 185, P3, 9000 Ghent, Belgium, dirk.vanbraeckel@ugent.be ICRH Kenya

ICRH Kenya made steady and consistent progress with programme work throughout most of 2011, with four or five projects active at each stage of the pipeline of proposals. A number of studies reached their conclusion, and served to strengthen the mechanism of working in partnership at community level. As part of a nationwide exercise through the National AIDS and STI Control Programme, ICRH-K conducted the mapping of MARPS for HIV acquisition and transmission in Coast Province in order to identify locations of HIV risk activities and in turn, inform more meaningful interventions. ICRH Activity Report 2011

Similarly, the MOMI project, a multi-country study due to run for five years in four African countries, aims to improve maternal and new-born health, by adopting context-specific strategies and interventions to strengthen health care delivery and services at both facility and community level. The success of the Biomarkers study continued in 2011, and the final cohort of participants were enrolled between January and August. Final study visits are on-going and the last participants will be seen at the end of April 2012. The SGBV Recovery Clinic at Coast General hospital treated 642 survivors in 2011 which represented an increase of 5% on corresponding figures for 2010. A unique multimedia project entitled ‘Facing Violence – Unveiling Sexual and Gender Based Violence Issues in Kenya’ was published and told survivors stories in their own words. A new organizational structure based on five operational clusters was developed and proposed for ICRH-K, and is due to be implemented in early 2012. ICRH Mozambique

The year 2011 was a very successful one for ICRH Mozambique in terms of institutional development and in terms of project portfolio. At the programme level, ICRH Mozambique is currently implementing several projects in the area of maternal and child health with funding from UNICEF, DANIDA and the European Commission. The other main focus of the programme activities is HIV prevention with financial support from the Flemish Government, USAID and the European Commission. All projects have a research component which results are used at national level to facilitate policy dialogue on the development of new guidelines/policies. ICRH Mozambique also improved its institutional basis. Most importantly ICRH Mozambique was recognized as a national research institution by the Ministry of Sciences and Technology in December 2011. A national office was opened and a director recruited. The project staff increased also in Tete Province to support the provincial partners to develop and implement activities. Financial and administrative procedures were also strengthened, and there was an emphasis on recruiting skilled, qualified and dedicated administrative and finance staff.

ICRH Activity Report 2011

INTERNATIONAL CENTRE FOR REPRODUCTIVE HEALTH

CONTACT INFORMATION: ICRH Belgium: Ghent University, De Pintelaan 185 – P3, 9000 Ghent – Belgium Tel: +32 9 240 35 64 Fax: +32 9 240 38 67 e-mail: icrh@ugent.be

DONATIONS By supporting our projects and interventions, you are contributing to a better world for many women, vulnerable people and children. You can donate to: ICRH Belgium: Bank account Ghent University: 390-0965800-26 Bank address: ING Belgium - Business Centre Gent - Kouter 173 - 9000 Gent SWIFTCODE: BBRU BE BB 900 IBAN: BE59-3900-9658-0026 Please use reference ‘Gift G/00157/01’ Ghent University is a tax exempt charitable corporation. Donations are deductible from your federally-taxable income. If you don’t need a tax certificate, you can also donate to ICRH Global, the umbrella organisation of all ICRHs, on bank account 290-0205979-69 Bank address: BNP Paribas Fortis - Zwijnaardsesteenweg 674 - 9000 Gent IBAN: BE71 2900 2059 7969 Please use reference ‘Gift’.

www.icrh.org

ICRH Activity Report 2011

LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome AIGHD Amsterdam Institute for Global Health and Development AMC Academisch Medisch Centrum (University of Amsterdam) ANC Antenatal Care AOR Adjusted Odds Ratio ARL AIDS Reference Laboratory ART AntiRetroviral Therapy ASRH Adolescent Sexual and Reproductive Health AWEPA The Association of European Parliamentarians for Africa AZ Academisch Ziekenhuis (academic hospital) BIDENS Belgium, Iceland, Norway, Denmark, Estonia and Sweden BREACH Belgian AIDS and HIV Research Consortium BV Bacterial Vaginosis CA chromID Strepto B agar CBO community-based organization CD4 Cluster of Differentiation 4 CDC Centers for Disease Control and Prevention CERCA Community Embedded Reproductive Health Care for Adolescents CHIMACA China Maternal Health Care CHUK Centre Hospitalier Universitaire de Kigali CHW Community health workers CIN2 Cervical intraepithelial neoplasia Phase 2 CNA Colistin and Naladixic Acid CPDP Center for poverty-related communicable diseases CRF Circulating Recombinant Form Danida Danish Ministry of foreign Affairs DBS Dried Blood Spots DIFFER Diagonal Interventions t Fast Forward Enhanced Reproductive Health DNA Desoxyribo Nucleic Acid DOVE Domestic Violence Against Women/men in Europe DRC Democratic Republic Congo DSS Demographic Surveillance System DV Domestic Violence ECHO European Commission Humanitarian Aid Office EDCTP European and Developing Countries Clinical Trials Partnership ELISA Enzyme Linked Immuno-Sorbent Assay EMA European Medicines Agency ESA East and Southern Africa ESC European Society of Contraception and Reproductive Health EU European Union FGD Focus Group Discussions FGM Female Genital Mutilation FIFA Fédération Internationale de Football Association FOHCUS Focal Point on Harmful Cultural Practices FSW Female Sex Workers FWO Fonds Wetenschappelijk Onderzoek (Research Foundation Flanders) GBS Group B streptococcus GBV Gender-based violence GBSDA Group B Streptococcus Differential Agar HAART Highly Active Antiretroviral Therapy HCP Harmful Cultural Practices HIV Human Immunodeficiency Virus HPV Human Papilloma Virus HSV Herpes simplex virus ICDP International Conference on Population and Development ICRH International Centre of Reproductive Health IGVM Instituut voor Gelijkheid van Mannen en Vrouwen (Institute for the Equality of Women and Men) IPM International Partnership for Microbicides IQR Inter-Quartile Range ISPOR International Society For Pharmacoeconomics and Outcomes Research ITM Institute of Tropical Medicine IUC Institutional University Cooperation IWT Institute for Innovation through Science and Technology KAP Knowledge – Attitude - Practice

ICRH Activity Report 2011

LDD Long-Distance truck Drivers LSHTM London School of Hygiene & Tropical Medicine MARP Most-At-Risk Populations MDG Millennium Development Goals m-DOT modified-Directly Observed Therapy MITU Mwanza Intervention Trials Unit MOSAFC Modelo de Salud Familiar y Comunitaria MRC-CTU Medical Research Council - Clinical Trials Unit MSM Men having Sex with Men MTCT Mother-To-Child Transmission MYSA Mathare Youth Sport Association NGO Non-governmental organization NIMR National Institute for Medical Research NRF National Research Foundation NTNU Norwegian University of Science and Technology Faculty of Medicine OLV Onze Lieve Vrouw Ziekenhuis (Hospital Aalst) PAC Post-Abortion Contraception PAF Population Attributable Fraction PAFP Post Abortion Family Planning services PAHO Pan American Health Organization PASER PharmAccess African Studies to Evaluate Resistance PCR Polymerase Chain Reaction PMTCT Prevention of Mother to Child Transmission QC/QA Quality Control / Quality Assurance QUALMAT Quality of Maternal and Prenatal Care: Bridging the Know-Do Gap RCT Randomized Controlled Trial RHEA Centrum voor Gender en Diversiteit RHRU Reproductive Health and HIV Research Unit RNA Ribonucleic acid RTI Reproductive Tract Infections SACEMA South African Centre for Epidemiological Modelling and Analysis SAM Sub-Saharan African Migrants SD Standard deviation SED sexually enhanced disease SGBV Sexual and Gender Based Violence SLPI Secretory Leukocyte Protease Inhibitor SRHR Sexual and Reproductive Health and Rights SSA Sub-Saharan Africa STD Sexually transmitted disease STI Sexually Transmitted Infections SWEAT Sex Workers Education and Advocacy Taskforce TB Tuberculosis TcP Treatment-centred Prevention UEM University Eduardo Mondlane UNFPA United Nations Populations Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund USAID United States Agency for International Development UZA Universitair Ziekenhuis Antwerpen (University Hospital Antwerp) VLIR Vlaamse Interuniversitaire Raad (Flemish Interuniversity Council) VLIR-UOS Vlaamse Interuniversitaire Raad - University Development Cooperation VUB Vrije Universiteit Brussel WHI Women's Health Initiative WHO World Health Organisation WRHI Wits Reproductive health and HIV Institute Y-SAV Youth Sexual Aggression and Victimization YOLAMI Young Labour Migrants in China ZNA Ziekenhuis Netwerk Antwerpen (Antwerp Network of hospitals)

ICRH Activity Report 2011

Photography Credits Free Digital Photos - www.freedigitalphotos.net Ghent University - www.ugent.be ICRH Belgium - www.icrh.org ICRH Kenya - www.icrhk.org Jan Coenen Liesbet Christiaen Nadia El Mahi Tineke Dhaese Design & Layout Mshenga Mwacharo - mwacharo@icrhk.org

ICRH Activity Report 2011

International Centre for Reproductive Health Ghent University, De Pintelaan 185 – P3, 9000 Ghent – Belgium Tel: +32 9 240 35 64 Fax: +32 9 240 38 67 e-mail: icrh@ugent.be Website www.icrh.org