A randomized controlled trial to promote long-term contraceptive use among HIV-serodiscordant and concordant positive couples in Zambia

Comparing Repeated (Annual) Couples HIV Testing and Counseling to Individual HIV Testing and Counseling Among Male Couples at High Risk of HIV Infection: Protocol for a Randomized Control Trial

BACKGROUND

Couples HIV testing and counseling (CHTC) is now a standard of care prevention strategy recommended by the Centers for Disease Control and Prevention for sexual minority men (SMM) in relationships. Despite standard recommendations that couples complete CHTC every 6-12 months, no study has empirically evaluated the effects associated with CHTC retesting.

OBJECTIVE

This study aims to understand the benefits associated with continued dyadic engagement in the HIV prevention continuum through routine CHTC retesting, which is of particular importance for emerging-adult SMM in relationships who use drugs.

METHODS

Eligible couples for this CHTC retesting trial must already be enrolled in the 4Us trial, where they completed a CHTC session after their baseline survey. The purpose of the original 4Us trial was to test the efficacy of 2 intervention components for CHTC: a communication skills training video and a substance use module. Couples were eligible for the original 4Us trial if they identified as cisgender male, were in a relationship for 3 months or longer, were aged 17 years or older, and communicated in English. At least 1 partner had to be aged 17-29 years, report HIV negative or unknown serostatus, report use of at least 1 drug (cannabis, cocaine or crack, crystal methamphetamine, ketamine, gamma-hydroxybuterate [GHB], psychedelics, ecstasy, prescription medication misuse, opiates, and nitrates) use, and engage in condomless anal sex (CAS) acts with a casual partner or have a main partner who is nonmonogamous or serodiscordant. Those who complete the 4Us 12-month follow-up and remain in a relationship with the partner they participated in 4Us with are offered the opportunity to participate in this CHTC retesting trial. Those consenting are randomized to either CHTC retesting or individual HIV testing. Follow-up assessments are conducted 3 and 6 months after randomization to evaluate the effects of repeat CHTC on 2 primary outcomes: (1) CAS with a casual partner in the absence of preexposure prophylaxis (PrEP), and (2) CAS with a serodiscordant main partner who is not virally suppressed or concurrent CAS between main and casual partners in the absence of PrEP.

RESULTS

The CHTC retesting trial launched in January 2023, and enrollment is ongoing. As of February 2024, the study had enrolled 106 eligible participants (n=53 couples).

CONCLUSIONS

Findings from this CHTC retesting study will contribute to knowledge about the benefits associated with regular (repeated) CHTC testing versus routine individual HIV testing for SMM in relationships. The results of this trial will inform CHTC retesting guidance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05833074; htps://www.clinicaltrials.gov/study/NCT05833074.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53023.

A strategic analysis of health behaviour change initiatives in Africa

BACKGROUND

Changed health behaviours can contribute significantly to improved health. Consequently, significant investments have been channelled towards health behaviour change initiatives in Africa. Health behaviour change initiatives that address social, economic and environmental levers for behaviour change can create more sustained impact.

OBJECTIVES

Through a scoping study of the literature, we explored the literature on behaviour change initiatives in Africa, to assess their typologies. We explored whether the availability of initiatives reflected country demographic characteristics, namely life expectancy, gross domestic product (GDP), and population sizes. Finally, we assessed topical themes of interventions relative to frequent causes of mortality.

METHODS

We used the Behaviour Change Wheel intervention categories to categorise each paper into a typology of initiatives. Using Pearson's correlation coefficient, we explored whether there was a correlation between the number of initiatives implemented in a country in the specified period, and socio-demographic indicators, namely, GDP per capita, total GDP, population size, and life expectancy.

RESULTS

Almost 64% of African countries were represented in the identified initiatives. One in five initiatives was implemented in South Africa, while there was a dearth of literature from Central Africa and western parts of North Africa. There was a positive correlation between the number of initiatives and GDP per capita. Most initiatives focused on addressing sexually transmitted infections and were short-term trials and/or pilots. Most initiatives were downstream focused e.g. with education and training components, while upstream intervention types such as the use of incentives were under-explored.

CONCLUSION

We call for more emphasis on initiatives that address contextual facilitators and barriers, integrate considerations for sustainable development, and consider intra-regional deprivation.

Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low- and middle-income countries

Background

Involving men and boys as both users and supporters of Family Planning (FP) is now considered essential for optimising maternal and child health outcomes. Evidence on how to engage men and boys to meet FP needs is therefore important.

Objectives

The main objective of this review was to assess the strength of evidence in the area and uncover the effective components and critical process- and system-level characteristics of successful interventions.

Search Methods

We searched nine electronic databases, seven grey literature databases, organisational websites, and the reference lists of systematic reviews relating to FP. To identify process evaluations and qualitative papers associated with the included experimental studies, we used Connected Papers and hand searches of reference lists.

Selection Criteria

Experimental and quasi-experimental studies of behavioural and service-level interventions involving males aged 10 years or over in low- and middle-income countries to increase uptake of FP methods were included in this review.

Data Collection and Analysis

Methodology was a causal chain analysis involving the development and testing of a logic model of intervention components based on stakeholder consultation and prior research. Qualitative and quantitative data relating to the evaluation studies and interventions were extracted based on the principles of 'effectiveness-plus' reviews. Quantitative analysis was undertaken using r with robust variance estimation (RVE), meta-analysis and meta-regression. Qualitative analysis involved 'best fit' framework synthesis.

Results

We identified 8885 potentially relevant records and included 127 in the review. Fifty-nine (46%) of these were randomised trials, the remainder were quasi-experimental studies with a comparison group. Fifty-four percent of the included studies were assessed as having a high risk of bias. A meta-analysis of 72 studies (k = 265) showed that the included group of interventions had statistically significantly higher odds of improving contraceptive use when compared to comparison groups (odds ratio = 1.38, confidence interval = 1.21 to 1.57, prediction interval = 0.36 to 5.31, p < 0.0001), but there were substantial variations in the effect sizes of the studies (Q = 40,647, df = 264, p < 0.0001; I 2 = 98%) and 73% was within cluster/study. Multi-variate meta-regression revealed several significant intervention delivery characteristics that moderate contraceptive use. These included community-based educational FP interventions, interventions delivered to women as well as men and interventions delivered by trained facilitators, professionals, or peers in community, home and community, or school settings. None of the eight identified intervention components or 33 combinations of components were significant moderators of effects on contraceptive use. Qualitative analysis highlighted some of the barriers and facilitators of effective models of FP that should be considered in future practice and research.

Authors' Conclusions

FP interventions that involve men and boys alongside women and girls are effective in improving uptake and use of contraceptives. The evidence suggests that policy should continue to promote the involvement of men and boys in FP in ways that also promote gender equality. Recommendations for research include the need for evaluations during conflict and disease outbreaks, and evaluation of gender transformative interventions which engage men and boys as contraceptive users and supporters in helping to achieve desired family size, fertility promotion, safe conception, as well as promoting equitable family planning decision-making for women and girls.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Implementing HIV Prevention in Sub-Saharan Africa: A Systematic Review of Interventions Targeting Systems, Communities, and Individuals

HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the nature of the interventions and vulnerability of the intervention during implementation. This systematic review of 51 studies synthesizes data on the implementation and evaluation of evidence-based HIV prevention interventions across Sub-Saharan Africa. Studies were included if they occurred between January 1, 2008, and December 31, 2019, inclusive in Sub-Saharan Africa, were written in English, implemented an HIV prevention intervention in the field, and had reportable results. Using a modified social-ecological model for HIV prevention, we divided studies into three categories: interventions targeting health systems (n = 16), communities (n = 8), and individuals (n = 27). Across all categories, the data emphasized preventing mother-to-child transmission (PMTCT), medical interventions, and psychosocial interventions. The most successful programs bundled several interventions that were integrated into the health system. There is a notable lack of interventions targeting key populations and there are significant rates of loss to follow up (LTFU) across many studies. This review provides insight into the prioritization of evidence-based HIV prevention interventions across Sub-Saharan Africa.

Intimate Partner Violence and Unmet Need for Family Planning in Selected South Asian Countries

This article analyzes the relationship between various forms of intimate partner violence (IPV) and unmet need for family planning (FP) in South Asia. The data were obtained from the latest wave of the Demographic and Health Survey in Afghanistan, India, Maldives, Nepal, and Pakistan. Binary logistic regression analyses show mixed results, with a significant association between at least one type of IPV and unmet need for FP in all countries under study, except Maldives. There were also contrasting findings on the IPV-unmet need nexus, with a positive sign in some but negative sign in others. Women who experienced physical violence were associated with a higher odds of having an unmet need in Pakistan, but the opposite was true in Afghanistan and Nepal. The odds of having an unmet need were higher among Indian women who experienced IPV (sexual and emotional). In Afghanistan, women who experienced IPV (physical and emotional) have lower odds of having an unmet need. However, the interaction analysis of IPV (physical and sexual) and partners' controlling behavior showed a positive association with unmet need. Policymakers need to develop policies and strategies to prevent IPV and reduce unmet need for FP, in line with the Sustainable Development Goals.

Partners' Consensus About Joint Effort and COVID-19 Prevention Among Sexual Minority Men

The current study examined the relevance of relationship functioning to partners' agreement or consensus about joint effort surrounding COVID-19 prevention. Interdependence theory has been widely used to understand how relationship partners influence health behavior, including how sexual minority male (SMM) couples regulate HIV risk. Couples with better relationship functioning tend to be more successful at negotiating joint (shared) goals and subsequently accomplishing them. The study recruited 134 cis-male, SARS-CoV-2 negative adults in relationships with cis-male partners from phone-based social networking applications. Participants completed an online survey assessing relationship functioning (Perceived Relationship Components Questionnaire), COVID-19 prevention behaviors, and risk perceptions. Partners' consensus around joint COVID-19 prevention effort was assessed using an adapted version of the Preferences for Sexual Health Outcomes scale. Path analyses indicated that consensus for joint prevention effort predicted social distancing (B = 0.23; p = .001) and the number of other COVID-19 prevention behaviors engaged in (B = 0.17; p = .003) above and beyond perceived risk and relationship functioning. Relationship satisfaction predicted higher levels of consensus for joint COVID-19 prevention effort (B = 0.40; p = .029). Findings suggest that the theoretical foundations of successful HIV prevention interventions that utilize joint goal formation may generalize to the prediction of COVID-19 prevention behavior and may be leveraged to mitigate the risk of SARS-CoV-2 infection among SMM in relationships. Interventions that overlook the potential for dyadic regulation of health behavior may miss opportunities to capitalize on shared coping resources and fail to address relational barriers to prevention.

Cross-sectional assessment of government health center needs to implement long-acting reversible contraception services in rural Rwanda

BACKGROUND

There is unmet need for family planning in Rwanda. We previously developed an evidence-based couples' family planning counseling (C)FPC program in the capital city that combines: (1) fertility goal-based family planning counseling with a focus on long-acting reversible contraceptive (LARC) for couples wishing to delay pregnancy; (2) health center capacity building for provision of LARC methods, and (3) LARC promotion by community health workers (CHW) trained in community-based provision of oral and injectable contraception. From 2015 to 2016, this service was integrated into eight government health centers in Kigali, reaching 6072 clients and resulting in 5743 LARC insertions.

METHODS

From May to July 2016, we conducted cross-sectional health center needs assessments in 30 rural health centers using surveys, key informant interviews, logbook extraction, and structured observations. The assessment focused on the infrastructure, materials, and human resources needed for LARC demand creation and provision.

RESULTS

Few nurses had received training in LARC insertion [41% implant, 27% intrauterine device (IUD)]. All health centers reported working with CHW, but none trained in LARC promotion. Health centers had limited numbers of IUDs (median 10), implants (median 39), functional gynecological exam tables (median 2), and lamps for viewing the cervix (median 0). Many did not have backup power supplies (40%). Most health centers reported no funding partners for family planning assistance (60%). Per national guidelines, couples' voluntary HIV counseling and testing (CVCT) was provided at the first antenatal visit at all clinics, reaching over 80% of pregnant women and their partners. However, only 10% of health centers had integrated family planning and HIV services.

CONCLUSIONS

To successfully implement (C)FPC and LARC services in rural health centers across Rwanda, material and human resource capacity for LARC provision will need to be greatly strengthened through equipment (gynecological exam tables, sterilization capacity, lamps, and backup power supplies), provider trainings and follow-up supervision, and new funding partnerships. Simultaneously, awareness of LARC methods will need to be increased among couples through education and promotion to ensure that demand and supply scale up together. The potential for integrating (C)FPC with ongoing CVCT in antenatal clinics is unique in Africa and should be pursued.

Motivational interviewing to promote long-acting reversible contraception among Rwandan couples wishing to prevent or delay pregnancy

BACKGROUND

Few family-planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change.

OBJECTIVES

We evaluate a couples-focused joint family-planning and HIV counseling intervention using motivational interviewing to enhance uptake of long-acting reversible contraception (Paragard copper intrauterine device or Jadelle hormonal implant) among Rwandan couples.

STUDY DESIGN

In this experimental study, couples receiving care at 8 government health clinics in Kigali, the capital city, were referred from a parent study of couples who did not want more children or wanted to wait at least 2 years for their next pregnancy. Long-acting reversible contraception methods were offered on site following joint HIV testing and family-planning counseling. At the first follow-up visit 1 month after enrollment in the parent study, couples who had not yet chosen a long-acting reversible contraception method were interviewed separately using motivational interviewing and then brought together and again offered long-acting reversible contraception.

RESULTS

Following motivational interviewing, 78 of 229 couples (34%) requested a long-acting reversible contraception method (68 implant and 10 intrauterine device). Long-acting reversible contraception uptake after motivational interviewing was associated with the woman being Catholic (vs Protestant/Muslim/other, adjusted odds ratio, 2.87, 95% confidence interval, 1.19-6.96, P = .019) or having an income (vs no income, adjusted odds ratio, 2.54, 95% confidence interval, 1.12-5.73, P = .025); the couple having previously discussed long-acting reversible contraception (adjusted odds ratio, 8.38, 95% confidence interval, 2.54-27.59, P = .0005); either partner believing that unplanned pregnancy was likely with their current method (adjusted odds ratio, 6.67, 95% confidence interval, 2.77-16.11, P < .0001); or that they might forget to take or make an appointment for their current method (adjusted odds ratio, 4.04, 95% confidence interval, 1.32-12.34, P = .014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection was associated with long-acting reversible contraception uptake (adjusted odds ratio, 2.86, 95% confidence interval, 1.17-7.03, P = .022), as was the woman citing long-term duration of action of the implant as an advantage (adjusted odds ratio, 5.41, 95% confidence interval, 1.86-15.76, P = .002). The woman not listing any side effects or disadvantages of implants was associated with long-acting reversible contraception uptake (adjusted odds ratio, 5.42, 95% confidence interval, 2.33-12.59, P < .0001). Clinic location (rural vs urban), couple HIV status, and concerns about negative economic effects of an unplanned pregnancy were significant in bivariate but not multivariate analysis.

CONCLUSION

Encouraging couples to reflect on the benefits and disadvantages of long-acting reversible contraception methods, the likelihood of unplanned pregnancy with their current contraception, and the impact of an unplanned pregnancy is an effective motivational interviewing technique in family-planning counseling. One third of couples who did not want a pregnancy for at least 2 years but had not chosen a long-acting reversible contraception method when provided with standard family-planning counseling did so after motivational interviewing. Involving the male partner in family-planning discussions facilitates joint decision making about fertility goals and contraceptive choice. Combining family planning and joint HIV testing for couples allows targeted focus on dual-method use with discordant couples, who are advised to use condoms for HIV/sexually transmitted infection prevention along with a more effective contraceptive for added protection against unplanned pregnancy.

Fertility intentions and long-acting reversible contraceptive use among HIV-negative single mothers in Zambia

BACKGROUND

Integrating family planning interventions with HIV studies in developing countries has been shown to prevent mother-to-child HIV transmission and simultaneously reduce HIV and unintended pregnancy in high-risk populations. As part of a prospective cohort study on HIV incidence and risk factors in Zambian women having unprotected sex, we also offered family planning counseling and immediate access to long-acting reversible contraceptives. Although long-acting reversible contraceptives are the most effective form of contraception, many Zambian women are limited to oral or injectable methods because of a lack of knowledge or method availability. This project offers to single mothers who are enrolled in a cohort study information about and access to long-acting reversible contraceptives at enrollment and at each follow-up visit.

OBJECTIVE

This study evaluates how fertility intentions affect long-acting reversible contraceptive use in HIV-negative single mothers in Zambia. Our primary outcome was long-acting reversible contraceptive use throughout the study participation. We also estimated rates of long-acting reversible contraceptive uptake and discontinuation. We specifically studied single mothers because they are at high risk for unintended pregnancy, which can have significant negative ramifications on their financial, social, and psychologic circumstances.

STUDY DESIGN

From 2012-2017, Zambia Emory HIV Research Project recruited 521 HIV-negative single mothers ages 18-45 years from government clinics in Lusaka and Ndola, Zambia's 2 largest cities. Participants were followed every 3 months for up to 5 years. At each visit, we discussed fertility goals and contraceptive options and offered a long-acting reversible method to any woman who was not pregnant or who already was using a long-acting reversible or permanent contraceptive method. Data were collected on demographic factors, sexual behavior, and reproductive history. Multivariable logistic regression was used to model baseline fertility intentions with long-acting reversible contraceptive use.

RESULTS

We enrolled 518 women; 57 women did not return for any follow-up visits. There was a significant increase in long-acting reversible contraceptive use during the study. At baseline, 93 of 518 women (18%) were using a long-acting reversible method, and 151 of 461 women (33%) used a long-acting reversible method at the end of follow-up period (P<.0001). Four women chose an intrauterine device, and 91 women chose an implant for their first uptake event. After we adjusted the data for other confounders, we found that women in Ndola who did not desire any more children were more likely to use a long-acting reversible contraceptive (adjusted prevalence ratio, 2.02; 95% confidence interval, 1.88-3.42). During follow up, 37 of 183 long-acting reversible contraceptive users (20%) discontinued their method; women who desired future children at baseline were more likely to discontinue earlier (P=.016).

CONCLUSION

This study demonstrates that integrated family planning services can increase long-acting reversible contraceptive use successfully among Zambian single mothers, who are a vulnerable population that disproportionately is affected by unintended pregnancy. A steady increase in use over time confirms the importance of repeated messaging about these unfamiliar methods. Thus, it is imperative that family planning interventions target single mothers in developing countries to promote effective contraceptive use.

Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia

OBJECTIVE

To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis.

METHODS

Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest.

RESULTS

There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54-0.95), candidiasis (aHR 0.75, 95% CI 0.57-1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25-0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65-0.97).

CONCLUSION

We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.

Motivational interviewing with male couples to reduce substance use and HIV risk: Manifestations of partner discord and strategies for facilitating dyadic functioning

The efficacy of motivational interviewing (MI) to reduce substance use is well established; however, its use with couples has met with mixed results. The development of such interventions is particularly relevant for male couples, as rates of substance use in this population are comparatively high and use is associated with aspects of sexual relationship functioning. One challenge noted in conducting MI with couples is how to respond to situations in which partners disagree with one another or argue against change. Guided by the couples interdependence theory, we conceptualized conflicts within session as failures in the accommodation process. We used qualitative analysis to examine manifestations of conflict in session and to identify effective provider response strategies. The sample included 14 cis-male couples with at least 1 partner was aged 18-29 years, reported substance use, and was HIV negative. All couples completed 3 MI sessions lasting 60-75 min each. Manifestations of conflict included conflation of thoughts/feelings, vague or indirect communication, and inaccurate assumptions. Effective provider responses included correcting assumptions, shifting focus, relationship repair, "common ground" reflections, and relationship affirmations. Observed conflicts aligned with conceptualizations of destructive resolutions to the accommodation process (i.e., exit and neglect). Effective provider responses to conflict facilitated dyadic functioning and catalyzed constructive accommodation. These results provide an initial compendium of provider skills and strategies that may be particularly relevant in work with sexual minority male couples, for whom achieving accommodation around drug use and sexual health goals is often viewed as a key mechanism of intervention. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Single Mothers and Female Sex Workers in Zambia Have Similar Risk Profiles

The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers (FSWs) and single mothers (SMs) in Zambia's two largest cities, Lusaka and Ndola. FSWs were invited from known community hot spots, and sexually active HIV- SMs were referred from infant vaccination services for free and anonymous screening and treatment for HIV and other sexually transmitted infections (STIs) and long acting reversible contraception. A subset completed an interviewer-administered survey. From 2012 to 2016, 1,893 women (1,377 FSWs and 516 HIV- SMs) responded to referrals. HIV prevalence was 50% in Lusaka and 33% in Ndola FSWs. Positive syphilis serology (rapid plasmin reagin) was found in 29%-31% of HIV+ FSWs and 9%-12% of HIV- FSWs and SMs. Trichomonas was more common in Ndola (11%-12%), compared with Lusaka (3%-7%). Antiretroviral therapy (ART) use among HIV+ FSWs was 9%-15%. In all groups, consistent condom use (8%-11%) and modern contraceptive use (35%-65%) were low. Low literacy and reported coercion at first sexual intercourse were common in both FSWs and SMs, as was alcohol use during sex among FSWs. Zambian FSWs and SMs have low condom use and high HIV/STI and unplanned pregnancy risk. Many FSWs and half of SMs are ≥25 years of age, and thus too old for HIV prevention services targeting "adolescent girls and young women" (aged 15-24). Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women.

A Pilot Randomized Trial of Intervention Components Addressing Drug Use in Couples HIV Testing and Counseling (CHTC) with Male Couples

Men who have sex with men (MSM) experience high rates of substance use and HIV infection. Main partners are the source of many (35-68%) of these new HIV infections. This study developed and examined the efficacy of two adjunct components to couples HIV testing and counseling (CHTC)-communication training (CT) videos and a substance use module (SUM)-to reduce drug use and sexual HIV transmission risk in MSM couples. Participants included 70 male couples randomized into one of four conditions: CHTC, CHTC + CT videos, CHTC + SUM, and CHTC + CT videos + SUM. Participants completed a survey pre-intervention and 1-, 3-, and 6-months later. Completion of the SUM in the absence of CT videos was associated with significant immediate decreases in drug use and related problems; however, at 3- and 6-month follow ups, the SUM was only associated with reductions in drug use and related problems among men who also viewed the CT videos. There were no between-condition differences in sexual behavior. CHTC may serve as a vehicle for the delivery of brief substance use intervention for MSM couples.ClinicalTrails.gov NCT # 03125915.

Electronic interventions for changing knowledge, attitudes or practices regarding contraception: a systematic review

OBJECTIVES

We conducted a systematic review of the effectiveness of electronic health education tools designed to improve knowledge, attitudes or practices related to contraception.

METHODS

Eligible studies consisted of English-language reports published after 1990 that quantified the effects of an electronic intervention on any of the following outcomes: contraceptive knowledge, attitude toward contraceptives, contraceptive method choice, contraceptive use or pregnancy. We conducted a systematic search of multiple electronic databases including MEDLINE, Global Health, Academic Search Complete, Cochrane Library and Grey Literature Report. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for reporting.

RESULTS

Of 143 full-text reports assessed for eligibility, 13 studies described in 16 reports were eligible for inclusion. Of six studies that evaluated video interventions, all were randomized controlled trials, and four reported any statistically significant difference between intervention groups on knowledge, method choice or pregnancy. Of seven studies of interactive computer applications, five were randomized controlled trials, and two were nonrandomized comparison studies. Four of these seven studies found statistically significant difference between study arms in contraceptive knowledge, attitudes or contraceptive use. While most differences favored the intervention, effects were generally limited with respect to clinical relevance and the number of outcomes impacted.

CONCLUSIONS

Published assessments of electronic interventions for improving contraception-related outcomes are limited. Formal evaluations of interventions and publication of results are needed to determine the efficacy of electronic tools for contraceptive education and guide development of new interventions.

Contraceptive counseling lectures do not influence decision making in family planning services

Family planning services should provide women and men with information on contraceptive methods. This study aimed to evaluate the impact of multidisciplinary contraceptive counseling lectures related to the efficacy and individual choices of contraceptive methods. Sociodemographic variables, preferred methods and opinion about the efficacy of contraceptive methods of 101 participants were analyzed. After the lecture, a lower percentage of men declared that they did not know which contraceptive method was more efficacious (24.3% versus 0.0%; p=0.006). Also, a lower percentage of women (12.7% versus 1.8%; p=0.020) and men (25.5% versus 7.7%; p=0.003) reported that they did not know which contraceptive method was less efficacious. Number of children increased the likelihood of choosing an irreversible method in a 30.87-fold (95%CI, 5.503 to 173.168, p<0.001). The choice of irreversible methods did not change after the counseling lecture (p>0.05). The lecture impacted on participants' opinions about the efficacy of contraceptive methods, making them have more informed choices. However, it did not influence their choice of contraception. Number of children was the most determining factor in choosing irreversible methods.

Community-based integrated approach to changing women's family planning behaviour in Pakistan, 2014-2016

Setting: Karachi, Pakistan. Objective: To assess the effectiveness of a community-based integrated approach in changing women's behaviour regarding contraceptive use. Design: The Sukh Initiative is a multipronged approach with door-to-door services using community health workers to provide quality family planning/reproductive health services at both public and private facilities and a 24/7 family planning helpline service that provides youth skill-based education. Methods: Retrospective pre- and post-intervention data using samples of 5140 and 3810 women, respectively. Results: The contraceptive prevalence rate increased by 10.7%, from 42.3% at baseline to 53.0% mid-intervention, with an increase in use of modern contraceptive methods of 9.2%. A significant association was found between door-to-door counselling and the use of contraceptive methods (OR 3.4, 95%CL 2.9-4.1) and access to public and private facilities for modern contraceptives (OR 2.4, 95%CL 2.0-3.0). However, support group meetings and 24/7 helpline use did not show any association with use of contraceptive method. Conclusion: The study helped to increase access to and choice of family planning services through a community-based approach that successfully reduced unmet needs and improved continuity in contraceptive use.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Bacterial vaginosis modifies the association between hormonal contraception and HIV acquisition

Objective:

To examine bacterial vaginosis as an effect modifier for the association between hormonal contraception and incident HIV infection.

Design:

Serodiscordant couples enrolled in an open longitudinal cohort in Lusaka, Zambia from 1994 to 2012. This analysis was restricted to couples with an HIV-positive man enrolled between1994 and 2002 when a quarterly genital tract examination and HIV testing was performed.

Methods:

Multivariate Cox models evaluated the association between contraceptive method and HIV-acquisition, stratified by time-varying bacterial vaginosis status.

Results:

Among 564 couples contributing 1137.2 couple-years of observation, bacterial vaginosis was detected at 15.5% of study visits. Twenty-two of 106 seroconversions occurred during intervals after bacterial vaginosis was detected [12 on no method/nonhormonal method (nonhormonal contraception), two on injectables, eight on oral contraceptive pills (OCPs)]. Unadjusted seroincidence rates per 100 couple-years for nonhormonal contraception, injectable, and OCP users, respectively, during intervals with bacterial vaginosis were 8.3, 20.8, and 31.0 and during intervals without bacterial vaginosis were 8.2, 9.7, and 12.3. In the bacterial vaginosis-positive model, there was a significant increase in incident HIV among those using injectables (adjusted hazard ratio, aHR 6.55, 95% CI 1.14–37.77) and OCPs (aHR 5.20, 95% CI 1.68–16.06) compared with nonhormonal contraception. Hormonal contraception did not increase the hazard of HIV acquisition in bacterial vaginosis-negative models. These findings persisted in sensitivity analyses whenever all covariates from the nonstratified model previously published were included, whenever other genital tract findings were excluded from the model and with the addition of condom-less sex and sperm on wet-prep.

Conclusion:

Future research should consider a potential interaction with bacterial vaginosis whenever evaluating the impact of hormonal contraception on HIV acquisition.

Determinants of facility readiness for integration of family planning with HIV testing and counseling services: evidence from the Tanzania service provision assessment survey, 2014-2015

BACKGROUND

Global policy reports, national frameworks, and programmatic tools and guidance emphasize the integration of family planning and HIV testing and counseling services to ensure universal access to reproductive health care and HIV prevention. However, the status of integration between these two services in Tanzanian health facilities is unclear. This study examined determinants of facility readiness for integration of family planning with HIV testing and counseling services in Tanzania.

METHODS

Data from the 2014-2015 Tanzania Service Provision Assessment Survey were analyzed. Facilities were considered ready for integration of family planning with HIV testing and counseling services if they scored ≥ 50% on both family planning and HIV testing and counseling service readiness indices as identified by the World Health Organization. All analyses were adjusted for clustering effects, and estimates were weighted to correct for non-responses and disproportionate sampling. Descriptive, bivariate, and multivariate logistic regression analyses were performed.

RESULTS

A total of 1188 health facilities were included in the study. Of all of the health facilities, 915 (77%) reported offering both family planning and HIV testing and counseling services, while only 536 (45%) were considered ready to integrate these two services. Significant determinants of facility readiness for integrating these two services were being government owned [AOR = 3.2; 95%CI, 1.9-5.6], having routine management meetings [AOR = 1.9; 95%CI, 1.1-3.3], availability of guidelines [AOR = 3.8; 95%CI, 2.4-5.8], in-service training of staff [AOR = 2.6; 95%CI, 1.3-5.2], and availability of laboratories for HIV testing [AOR = 17.1; 95%CI, 8.2-35.6].

CONCLUSION

The proportion of facility readiness for the integration of family planning with HIV testing and counseling in Tanzania is unsatisfactory. The Ministry of Health should distribute and ensure constant availability of guidelines, availability of rapid diagnostic tests for HIV testing, and the provision of refresher training to health providers, as these were among the determinants of facility readiness.

HIV Incidence and Predictors of HIV Acquisition From an Outside Partner in Serodiscordant Couples in Lusaka, Zambia

OBJECTIVE

Evaluate the incidence and predictors of HIV acquisition from outside partners in serodiscordant couples.

METHODS

Demographic, behavioral, and clinical exposures were measured quarterly in a cohort of serodiscordant cohabiting couples in Zambia from 1995 to 2012 (n = 3049). Genetic analysis classified incident infections as those acquired from the study partner (linked) or acquired from an outside partner (unlinked). Factors associated with time to unlinked HIV infection were evaluated using multivariable Cox proportional hazards regression stratified by sex.

RESULTS

There were 100 unlinked infections in couples followed for a median of 806 days. Forty-five infections occurred in women [1.85/100 couple-years; 95% confidence interval (CI): 1.35 to 2.47]. Risk of female unlinked infection (vs. nonseroconverting females) was associated with reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline [adjusted hazard ratio (aHR) = 5.44; 95% CI: 1.03 to 28.73], genital ulcers (aHR = 6.09; 95% CI: 2.72 to 13.64), or genital inflammation (aHR = 11.92; 95% CI: 5.60 to 25.37) during follow-up adjusting for age, years cohabiting, income, contraceptive use, previous pregnancies, history of sexually transmitted infections, and condomless sex with study partner. Fifty-five infections occurred in men (1.82/100 couple-years; 95% CI: 1.37 to 2.37). Risk of male unlinked infection was associated with genital inflammation (aHR = 8.52; 95% CI: 3.82 to 19.03) or genital ulceration (aHR = 2.31; 95% CI: 2.05 to 8.89), reporting ≥1 outside sexual partner (aHR = 3.86; 95% CI: 0.98 to 15.17) during follow-up, and reporting being drunk weekly/daily vs. moderate/nondrinkers at baseline (aHR = 3.84; 95% CI: 1.28 to 11.55), controlling for age, income, circumcision status, and history of sexually transmitted infection.

CONCLUSIONS

Predictors of unlinked infection in serodiscordant relationships were alcohol use, genital inflammation, and ulceration. Causes of genital inflammation and ulceration should be screened for and treated in HIV-negative individuals. Counseling on risk of alcohol use and sex with outside partners should be discussed with couples where 1 or both are HIV-negative, including in counseling on use of pre-exposure prophylaxis to prevent HIV acquisition in the HIV-negative partner (when feasible and affordable).

Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care

INTRODUCTION

We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda.

METHODS

We recruited HIV-positive men and women on antiretroviral therapy (ART) ('index') from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner ('partner'), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis.

RESULTS

11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner's HIV status. Similarly, the partner's HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner's desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes.

CONCLUSIONS

Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.

Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples

BACKGROUND

Dual method use, which combines condoms with a more effective modern contraceptive to optimize prevention of HIV and unplanned pregnancy, is underutilized in high-risk heterosexual couples.

MATERIALS AND METHODS

Heterosexual HIV-discordant Zambian couples were enrolled from couples' voluntary HIV counseling and testing services into an open cohort with 3-monthly follow-up (1994-2012). Relative to dual method use, defined as consistent condom use plus modern contraception, we examine predictors of (1) condom-only use (suboptimal pregnancy prevention) or (2) modern contraceptive use with inconsistent condom use (effective pregnancy prevention and suboptimal HIV prevention).

RESULTS

Among 3,049 couples, dual method use occurred in 28% of intervals in M+F- and 23% in M-F+, p < 0.01; condom-only use in 56% in M+F- and 61% in M-F+, p < 0.01; and modern contraceptive use with inconsistent condom use in 16% regardless of serostatus. Predictors (p < 0.05) of condom-only use included the man being HIV+ (adjusted hazard ratio, aHR = 1.15); baseline oral contraceptive pill (aHR = 0.76), injectable (aHR = 0.48), or implant (aHR = 0.60) use; woman's age (aHR = 1.04 per 5 years) and lifetime number of sex partners (aHR = 1.01); postpartum periods (aHR = 1.25); and HIV stage of the index partner III/IV versus I (aHR = 1.10). Predictors (p < 0.05) of modern contraceptive use with inconsistent condom use included woman's age (aHR = 0.94 per 5 years) and HIV+ male circumcision (aHR = 1.51), while time-varying implant use was associated with more consistent condom use (aHR = 0.80).

CONCLUSIONS

Three-quarters of follow-up intervals did not include dual method use. This highlights the need for counseling to reduce unintended pregnancy and HIV transmission and enable safer conception.

The promotion of intrauterine contraception in low- and middle-income countries: a narrative review

CONTEXT

The contribution of copper-bearing intrauterine devices (IUDs) to overall contraceptive protection has declined in many countries, despite their well-known advantages. In response, initiatives to promote this method have been undertaken.

OBJECTIVE

To review and interpret the experience of interventions to promote use of IUDs in low- and middle-income countries in order to provide strategic guidance for policies and programs.

METHODS

We conducted a systematic search of Medline, Popline, Embase and Global Health electronic databases for relevant journal papers, reports and gray literature since 2010. Telephone interviews were held with two donors and six international family planning organizations.

RESULTS

We identified a total of 31 publications. Four reported the results of randomized control trials and three were derived from quasi-experiments. The majority were based on service statistics. Eight publications concerned interventions for HIV-positive women or couples, nine for postpartum or postabortion cases and 14 for general populations. Intervention approaches included vouchers, franchising of private practitioners, mobile outreach services, placement of dedicated staff in high-volume facilities and demand creation. Most publications adduced evidence of a positive impact and some reported impressively large numbers of IUD insertions. Results to date on the uptake of IUDs in postpartum interventions are modest. There is also almost no evidence of effects on IUD use at national levels. Implant uptake generally exceeded IUD uptake when both were offered.

CONCLUSION

The evidence base is weak and offers few lessons on what strategies are most effective. The overall impression is that IUD use can be increased in a variety of ways but that progress is hampered by persistent adverse perceptions by both providers and potential clients. Provider enthusiasm is a key to success. The lack of a population impact stems in part from the fact that nearly all interventions are initiated by international organizations, with limited national reach except in small countries, rather than by government agencies.

Accessibility of long-term family planning methods: a comparison study between Output Based Approach (OBA) clients verses non-OBA clients in the voucher supported facilities in Kenya

Background

The study seeks to evaluate the difference in access of long-term family planning (LTFP) methods among the output based approach (OBA) and non-OBA clients within the OBA facility.

Methods

The study utilises a quasi experimental design. A two tailed unpaired t-test with unequal variance is used to test for the significance variation in the mean access. The difference in difference (DiD) estimates of program effect on long term family planning methods is done to estimate the causal effect by exploiting the group level difference on two or more dimensions. The study also uses a linear regression model to evaluate the predictors of choice of long-term family planning methods. Data was analysed using SPSS version 17.

Results

All the methods (Bilateral tubal ligation-BTL, Vasectomy, intrauterine contraceptive device -IUCD, Implants, and Total or combined long-term family planning methods -LTFP) showed a statistical significant difference in the mean utilization between OBA versus non-OBA clients. The difference in difference estimates reveal that the difference in access between OBA and non OBA clients can significantly be attributed to the implementation of the OBA program for intrauterine contraceptive device (p = 0.002), Implants (p = 0.004), and total or combined long-term family planning methods (p = 0.001). The county of residence is a significant determinant of access to all long-term family planning methods except vasectomy and the year of registration is a significant determinant of access especially for implants and total or combined long-term family planning methods. The management level and facility type does not play a role in determining the type of long-term family planning method preferred; however, non-governmental organisations (NGOs) as management level influences the choice of all methods (Bilateral tubal ligation, intrauterine contraceptive device, Implants, and combined methods) except vasectomy. The adjusted R² value, representing the percentage of the variance explained by various models, is larger than 18% for implants and total or combined long-term family planning.

Conclusion

The study showed that the voucher services in Kenya has been effective in providing long-term family planning services and improving access of care provided to women of reproductive age. Therefore, voucher scheme can be used as a tool for bridging the gap of unmet needs of family planning in Kenya and could potentially be more effective if rolled out to other counties.

Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania

AIM

To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa.

DESIGN

Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression.

RESULTS

Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use.

CONCLUSIONS

There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.

Behavioral interventions for improving contraceptive use among women living with HIV

BACKGROUND

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling or education, can help women choose and use an appropriate contraceptive method.

OBJECTIVES

We systematically reviewed studies of behavioral interventions for HIV-positive women intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.

SEARCH METHODS

Until 2 August 2016, we searched MEDLINE, CENTRAL, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP. For the initial review, we examined reference lists and unpublished project reports, and we contacted investigators in the field.

SELECTION CRITERIA

Studies evaluated a behavioral intervention for improving contraceptive use for family planning (FP). The comparison could have been another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive versus HIV-negative women. We included non-randomized studies as well as randomized controlled trials (RCTs).Primary outcomes were pregnancy and contraception use, e.g. uptake of a new method or improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception or a specific contraceptive method.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. We evaluated RCTs according to recommended principles. For non-randomized studies, we examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Given the need to control for confounding factors in non-randomized studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs and interventions, we did not conduct meta-analysis.

MAIN RESULTS

With three new reports, 10 studies from seven African countries met our eligibility criteria. Eight non-randomized studies included 8980 participants. Two cluster RCTs had 7136 participants across 36 sites. Three studies compared a special FP intervention versus usual care, three examined FP services integrated with HIV services, and four compared outcomes for HIV-positive and HIV-negative women.In four studies with high or moderate quality evidence, the special intervention was associated with contraceptive use or pregnancy. A study from Nigeria compared enhanced versus basic FP services. All sites had integrated FP and HIV services. Women with enhanced services were more likely to use a modern contraceptive method versus women with basic services (OR 2.48, 95% CI 1.31 to 4.72). A cluster RCT conducted in Kenya compared integrated FP and HIV services versus standard referral to a separate FP clinic. Women with integrated services were more likely to use more effective contraception (adjusted OR 1.81, 95% CI 1.24 to 2.63). Another cluster RCT compared an HIV prevention and FP intervention versus usual care in Kenya, Namibia, and Tanzania. Women at the special intervention sites in Tanzania were more likely to use highly effective contraception (adjusted OR 2.25, 95% CI 1.24 to 4.10). They were less likely to report unprotected sex (no condom use) at last intercourse (adjusted OR 0.23, 95% CI 0.14 to 0.40). Across the three countries, women at the special intervention sites were less likely to report any unprotected sex in the past two weeks (adjusted OR 0.56, 95% CI 0.32 to 0.99). A study in Côte d'Ivoire integrated HIV and FP services. HIV-positive women had a lower incidence of undesired pregnancy, but not overall pregnancy, compared with HIV-negative women (1.07 versus 2.38; reported P = 0.023).

AUTHORS' CONCLUSIONS

The studies since 2009 focused on using modern or more effective methods of contraception. In those later reports, training on FP methods and counseling was more common, which may strengthen the intervention and improve the ability to meet clients' needs. The quality of evidence was moderate from the more recent studies and low for those from the 1990s.Comparative research involving contraceptive counseling for HIV-positive women is limited. The FP field needs better ways to help women choose an appropriate contraceptive and continue using that method. Improved counseling methods are especially needed for limited resource settings, such as clinics focusing on people living with HIV.

Hormonal Contraception, Pregnancy, Breastfeeding, and Risk of HIV Disease Progression Among Zambian Women

Background:

Some studies suggest that hormonal contraception, pregnancy, and/or breastfeeding may influence rates of HIV disease progression.

Methods:

From 1994 to 2012, HIV discordant couples recruited at couples' voluntary HIV counseling and testing centers in Lusaka were followed 3-monthly. Multivariate survival analyses explored associations between time-varying contraception, pregnancy, and breastfeeding and 2 outcomes among HIV-positive women: (1) time to death and (2) time to antiretroviral treatment (ART) initiation.

Results:

Among 1656 female seropositive, male seronegative couples followed for 3359 person-years (PY), 224 women died [6.7/100 PY; 95% confidence interval (CI): 5.8 to 7.6]. After 2003, 290 women initiated ART (14.5/100 PY; 95% CI: 12.9 to 16.2). In a multivariate model of time to death, hormonal implant [adjusted hazard ratio (aHR) = 0.30; 95% CI: 0.10 to 0.98] and injectable (aHR = 0.59; 95% CI: 0.36 to 0.97) were significantly protective relative to nonhormonal method use, whereas oral contraceptive pill (OCP) use was not (aHR = 1.08; 95% CI: 0.74 to 1.57) controlling for baseline HIV disease stage, time-varying pregnancy, time-varying breastfeeding, and year of enrollment. In a multivariate model of time-to-ART initiation, implant was significantly protective (aHR = 0.54; 95% CI: 0.31 to 0.95), whereas OCP (aHR = 0.70; 95% CI: 0.44 to 1.10) and injectable (aHR = 0.85; 95% CI: 0.55 to 1.32) were not relative to nonhormonal method use controlling for variables above, woman's age, and literacy. Pregnancy was not significantly associated with death (aHR = 1.07; 95% CI: 0.68 to 1.66) or ART initiation (aHR = 1.24; 95% CI: 0.83 to 1.86), whereas breastfeeding was protective for death (aHR = 0.34; 95% CI: 0.19 to 0.62) and ART initiation (aHR = 0.49; 95% CI: 0.29 to 0.85).

Conclusions:

Hormonal implants and injectables significantly predicted lower mortality; implants were protective for ART initiation. OCPs and pregnancy were not associated with death or ART initiation, whereas breastfeeding was protective for both. Findings from this 18-year cohort study suggest that (1) HIV-positive women desiring pregnancy can be counseled to do so and breastfeed and (2) all effective contraceptive methods, including injectables and implants, should be promoted to prevent unintended pregnancy.

Integrating Routine HIV Testing into Family Planning Clinics That Treat Adolescents and Young Adults

OBJECTIVE

Adolescents and young adults remain at high risk for new HIV infections and for unknowingly transmitting the virus to others. Yet, they have demonstrated low rates of testing due to barriers such as stigma and difficulty accessing testing services. Few existing programs have successfully integrated family planning and HIV care services to improve testing and diagnosis rates among young adults and adolescents, particularly those of minority groups. This study describes the process of implementing HIV services into family planning clinics and how to train staff in routine, opt-out testing.

METHODS

This study used HIV screening data from 10 family planning clinics serving adolescents and young adults in Houston, Texas. A total of 34,299 patients were tested for HIV during a 48-month study period, from January 2010 through December 2014.

RESULTS

Patients tested included minors <18 years of age (25.5%), males (22.8%), and individuals who had missed opportunities for HIV testing at other health-care settings. From the opt-in period (2006-2007) to the routine, opt-out period (2008-2010), the yearly average number of tests administered more than doubled; the yearly average increased again by 50% from the routine, opt-out period to the routine, rapid period (2011-2014). Eighty-eight (0.3%) patients were diagnosed with HIV, a higher seropositivity rate than CDC's recommended threshold of 0.1% for settings where routine screening is warranted.

CONCLUSION

Routine, opt-out HIV testing integrated into family planning clinics increased rates of testing acceptance, receipt of test results, and HIV-positive diagnoses among adolescents and young adults.

Personalized contraceptive counseling: helping women make the right choice

Unintended pregnancy is a significant problem with medical, social, and economic consequences. Half of unintended pregnancies are a result of no contraceptive use; while the other half results from contraceptive inconsistencies, or method failure. Women have an array of contraceptive options to choose from, each of which differs significantly in terms of usage, efficacy, side effects, risks, and noncontraceptive benefits. Determining the best tool for communication is a challenge. In addition, the choice of contraceptive method differs among women with medical problems. Not all contraceptive methods are suitable for women with certain medical problems. In this review, we discuss different methods of counseling and the tools available for sharing contraception information.

Evaluation of a male engagement intervention to transform gender norms and improve family planning and HIV service uptake in Kabale, Uganda

Men's limited understanding of family planning (FP) and harmful cultural gender norms pose obstacles to women's FP use. Thirty-two model men called 'Emanzis' were recruited from the community in Kabale, Uganda to lead men from their peer group through a 10-session curriculum designed to transform gender norms and motivate men to engage in FP and HIV services. Cross-sectional surveys were conducted before (n = 1251) and after (n = 1122) implementation. The Gender Equitable Men (GEM) Scale was used to assess the effect on gender attitudes. The intervention achieved negligible changes in responses to GEM items. Improvements in some gender-influenced health-seeking behaviours and practices in men were noted, specifically in visiting health facilities, HIV testing, and condom use. For future application, the intervention should be adapted to require higher peer educator qualifications, longer intervention duration, and more frequent supervision. Practical guidance is needed on where to direct investments in gender-transformative approaches for maximum impact.

Intrauterine Contraception Among Women Living With Human Immunodeficiency Virus: A Randomized Controlled Trial

OBJECTIVE

To compare discontinuation rates of the levonorgestrel and copper intrauterine devices (IUDs) among women with human immunodeficiency virus.

METHODS

A double-masked randomized trial was conducted at Mulago Hospital, Uganda. Women received either a copper or levonorgestrel IUD. The primary outcome was discontinuation of intrauterine contraception within 1 year of placement. The secondary outcomes were incidence of side effects and severe adverse events. To discern a difference of 10% from a copper IUD discontinuation rate of 18%, power of 80%, and 95% confidence interval (CI), a sample size of 351 per arm was estimated. Analysis of the primary outcome was by intension-to-treat principle.

RESULTS

From September 2013 to December 2014, 979 were screened and 703 randomized as follows: 349 to the copper group and 354 to the levonorgestrel group. In total, 8.6% (29/338) women in the copper group compared with 8.1% (27/334) in the levonorgestrel group discontinued intrauterine conception within 1 year of placement (incidence rate ratio 1.1 [95% CI 0.64-1.96]). Overall, the incidence of heavy bleeding was higher in the copper group (37% [125/338]) than in the levonorgestrel group (19.5% [65/334]). However, the incidence of amenorrhea, which occurred in 3.3% (11/338) of women, was lower in the copper group than the 19.8% (66/334) of women who reported amenorrhea in the levonorgestrel group.

CONCLUSION

There was no difference in discontinuation rates between the copper and levonorgestrel devices. Women in the levonorgestrel group had reduced incidence of heavy bleeding and a higher incidence of amenorrhea compared with those in the copper group.

CLINICAL TRIAL REGISTRATION

Pan African Clinical Trial Registry, www.pactr.org, PACTR 201308000561212.

LEVEL OF EVIDENCE

I.

Behaviour change techniques and contraceptive use in low and middle income countries: a review

We aimed to identify effective behaviour change techniques to increase modern contraceptive use in low and middle income countries (LMICs). Literature was identified in Global Health, Web of Science, MEDLINE, PsycINFO and Popline, as well as peer reviewed journals. Articles were included if they were written in English, had an outcome evaluation of contraceptive use, modern contraceptive use, contraceptive initiation/uptake, contraceptive adherence or continuation of contraception, were a systematic review or randomised controlled trial, and were conducted in a low or middle income country. We assessed the behaviour change techniques used in each intervention and included a new category of male partner involvement. We identified six studies meeting the inclusion criteria. The most effective interventions were those that involve male partner involvement in the decision to initiate contraceptive use. The findings also suggest that providing access to contraceptives in the community promotes their use. The interventions that had positive effects on contraceptive use used a combination of behaviour change techniques. Performance techniques were not used in any of the interventions. The use of social support techniques, which are meant to improve wider social acceptability, did not appear except in two of the interventions. Our findings suggest that when information and contraceptives are provided, contraceptive use improves. Recommendations include reporting of behaviour change studies to include more details of the intervention and techniques employed. There is also a need for further research to understand which techniques are especially effective.

Integrating prevention interventions for people living with HIV into care and treatment programs: a systematic review of the evidence

INTRODUCTION

This review assesses the impact of prevention interventions for people living with HIV on HIV-related mortality, morbidity, retention in care, quality of life, and prevention of ongoing HIV transmission in resource-limited settings (RLSs).

METHODS

We conducted a systematic review of studies reporting the results of prevention interventions for people living with HIV in RLS published between January 2000 and August 2014. Standardized methods of searching and data abstraction were used.

RESULTS

Ninety-two studies met the eligibility criteria: 24 articles related to adherence counseling and support, 13 on risk reduction education and condom provision, 19 on partner HIV testing and counseling, 14 on provision of family planning services, and 22 on assessment and treatment of other sexually transmitted infections. Findings indicate good evidence that adherence counseling and sexually transmitted infection treatment can have a high impact on morbidity, whereas risk reduction education, partner HIV testing and counseling, and family planning counseling can prevent transmission of HIV. More limited evidence was found to support the impact of these interventions on retention in care and quality of life. Most studies did not report cost information, making it difficult to draw conclusions about the cost-effectiveness of these interventions.

CONCLUSIONS

This evidence suggests that these prevention interventions, if brought to sufficient scale and coverage, can help support and optimize the impact of core treatment and prevention interventions in RLS. Further operational research with more rigorous study designs, and ideally with biomarkers and costing information, is needed to determine the best model for providing these interventions in RLS.

Unmet need for family planning: implication for under-five mortality in Nigeria

There are gaps in evidence on whether unmet need for family planning has any implication for under-five mortality in Nigeria. This study utilized 2008 Nigeria Demographic and Health Survey data to examine the effect of unmet need on under-five mortality. Cox regression analysis was performed on 28,647 children born by a nationally-representative sample of 18,028 women within the five years preceding the survey. Findings indicated elevated risks of under-five death for children whose mothers had unmet need for spacing [Hazard ratio (HR): 1.60, confidence interval (CI) 1.37-1.86, p<0.001] and children whose mothers had unmet need for limiting (HR: 1.78, CI 1.48-2.15, p<0.001) compared to children whose mothers had met need. These findings were consistent after adjusting for the effects of factors that could confound the association. Findings of this study underscore the need to address the present level of unmet need for family planning in Nigeria, if the country would achieve meaningful reduction in under-five mortality.

Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery

BACKGROUND

Eliminating family planning (FP) unmet need among HIV-infected individuals (PLHIV) is critical to elimination of mother-to-child HIV transmission. We assessed FP unmet need among PLHIV attending two clinics with differing models of FP services. Nsambya Home Care provided only FP information while Mulago HIV clinic provided information and contraceptives onsite.

METHODS

In a cross-sectional study conducted between February-June 2011, we documented pregnancies, fertility desires, and contraceptive use among 797 HIV-infected men and women (408 in Mulago and 389 in Nsambya). FP unmet need was calculated among women who were married, unmarried but had sex within the past month, did not desire the last or future pregnancy at all or wished to postpone for ≥ two years and were not using contraceptives. Multivariable analyses for correlates of FP unmet need were computed for each clinic.

RESULTS

Overall, 40% (315) had been pregnant since HIV diagnosis; 58% desired the pregnancies. Of those who were not pregnant, 49% (366) did not desire more children at all; 15.7% wanted children then and 35.3% later. The unmet need for FP in Nsambya (45.1%) was significantly higher than that in Mulago at 30.9% (p = 0.008). Age 40+ compared to 18-29 years (OR = 6.05; 95% CI: 1.69, 21.62 in Mulago and OR = 0.21; 95% CI: 0.05, 0.90 in Nsambya), other Christian denominations (Pentecostal and Seventh Day Adventists) compared to Catholics (OR = 7.18; 95% CI: 2.14, 24.13 in Mulago and OR = 0.23; 95% CI: 0.06, 0.80 in Nsambya), and monthly expenditure > USD 200 compared to < USD40 in Nsambya (OR = 0.17; 95% CI: 0.03, 0.90) were associated with FP unmet need.

CONCLUSIONS

More than half of the pregnancies in this population were desired. Unmet need for FP was very high at both clinics and especially at the clinic which did not have contraceptives onsite. Lower income and younger women were most affected by the lack of contraceptives onsite. Comprehensive and aggressive FP programs are required for fertility support and elimination of FP unmet need among PLHIV, even with integration of FP information and supplies into HIV clinics.

Risk reduction among HIV-seroconcordant and -discordant couples: the Zambia NOW2 intervention

Heterosexual HIV transmission remains the leading cause of HIV incidence in adult men and women in sub-Saharan Africa. This study assessed whether an HIV risk-reduction intervention would be more likely to increase sexual barrier acceptability and decrease risk behavior when delivered to couples in gender concordant groups or in an individual format. This study also examined the mutual impact of couple members as a source of influence on acceptability, and assessed whether product acceptability, intimate partner violence (IPV), and/or partner communication predicted sexual barrier use. HIV seroconcordant and serodiscordant couples (n=216) were recruited in Lusaka, Zambia, and randomized to a four session gender-concordant intervention. Participants were assessed at baseline, 6, and 12 months. Willingness to use barriers (p=0.012), acceptability (p<0.001), and barrier use (p<0.001) increased over time in both conditions, and were influenced by gender preferences. IPV decreased (p=0.040) and positive communication increased (p<0.001) in both conditions. Individual and gender concordant group sessions achieved similar increases in sexual barrier use following the intervention. Results highlight the influence of partners as well as product acceptability as predictors of sexual barrier use among couples in sub-Saharan Africa. Future prevention studies should consider both product acceptability and partner influence to achieve optimal sexual risk behavior outcomes.

The role of family planning in elimination of new pediatric HIV infection

PURPOSE OF REVIEW

We reviewed recent literature on the role of family planning in eliminating new pediatric HIV infections.

RECENT FINDINGS

Global commitments to eliminate new pediatric HIV infections recognize that preventing unintended pregnancies among women with HIV is essential to achieving this goal. However, substantial shortcomings exist in translating this policy support into widespread practice. Programs to prevent mother-to-child transmission of HIV continue to be implemented and evaluated as a narrow set of interventions that typically begins in antenatal care, after a woman is already pregnant. In addition, data suggest that women living with HIV experience high rates of unmet need for family planning and unintended pregnancies. Evidence is growing that integrating family planning and HIV services is an effective strategy for increasing access to contraception among women with HIV who do not wish to become pregnant. A number of health system obstacles must be resolved to achieve effective, sustained delivery of integrated services at scale.

SUMMARY

Prevention of unintended pregnancies among women with HIV must be elevated as a programmatic priority. By strengthening family planning programs for all women, and better integrating family planning and HIV services, progress toward ending new pediatric HIV infections will be accelerated.

Expanding contraceptive options for PMTCT clients: a mixed methods implementation study in Cape Town, South Africa

BACKGROUND

Clients of prevention of mother-to-child transmission (PMTCT) services in South Africa who use contraception following childbirth rely primarily on short-acting methods like condoms, pills, and injectables, even when they desire no future pregnancies. Evidence is needed on strategies for expanding contraceptive options for postpartum PMTCT clients to include long-acting and permanent methods.

METHODS

We examined the process of expanding contraceptive options in five health centers in Cape Town providing services to HIV-positive women. Maternal/child health service providers received training and coaching to strengthen contraceptive counseling for postpartum women, including PMTCT clients. Training and supplies were introduced to strengthen intrauterine device (IUD) services, and referral mechanisms for female sterilization were reinforced. We conducted interviews with separate samples of postpartum PMTCT clients (265 pre-intervention and 266 post-intervention) to assess knowledge and behaviors regarding postpartum contraception. The process of implementing the intervention was evaluated through systematic documentation and interpretation using an intervention tracking tool. In-depth interviews with providers who participated in study-sponsored training were conducted to assess their attitudes toward and experiences with promoting voluntary contraceptive services to HIV-positive clients.

RESULTS

Following the intervention, 6% of interviewed PMTCT clients had the desired knowledge about the IUD and 23% had the desired knowledge about female sterilization. At both pre- and post-intervention, 7% of clients were sterilized and IUD use was negligible; by comparison, 75% of clients used injectables. Intervention tracking and in-depth interviews with providers revealed intervention shortcomings and health system constraints explaining the failure to produce intended effects.

CONCLUSIONS

The intervention failed to improve PMTCT clients' knowledge about the IUD and sterilization or to increase use of those methods. To address the family planning needs of postpartum PMTCT clients in a way that is consistent with their fertility desires, services must expand the range of contraceptive options to include long-acting and permanent methods. In turn, to ensure consistent access to high quality family planning services that are effectively linked to HIV services, attention must also be focused on resolving underlying health system constraints weakening health service delivery more generally.

Family planning counseling for women living with HIV: a systematic review of the evidence of effectiveness on contraceptive uptake and pregnancy incidence, 1990 to 2011

BACKGROUND

Family planning is an important public health intervention with numerous potential health benefits for all women. One of those key benefits is the prevention of mother-to-child transmission of HIV, through the prevention of unintended pregnancies among women living with HIV.

METHODS

We conducted a systematic review of the effectiveness of family planning counseling interventions for HIV infected women in low- and middle-income countries.

RESULTS

We found nine articles which met the inclusion criteria for this review, all from Africa. Though these studies varied in the specifics of the interventions provided, research designs and measures of outcomes, key features were discernible. Providing concerted information and support for family planning use, coupled with ready access to a wide range of contraceptive methods, seemed most effective in increasing use. Effects on pregnancy overall were difficult to measure, however: no studies assessed the effect on unintended pregnancy.

CONCLUSIONS

Though these results are far from definitive, they do highlight the need for strengthened efforts to integrate family planning counseling and access to services into HIV prevention, and for greater consistency of effort over time. Studies which specifically investigate fertility intentions and desires of women living with HIV, contraception use following interventions to increase knowledge, awareness, motivation and access to the means to act on those intentions and unintended pregnancies would be valuable to help clinic personnel, programme planners and policy makers guide the development of the integrated services they offer.

Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia

OBJECTIVE

To describe predictors of contraceptive method discontinuation and switching behaviours among HIV-positive couples receiving couples' voluntary HIV counselling and testing services in Lusaka, Zambia.

DESIGN

Couples were randomized in a factorial design to two-family planning educational intervention videos, received comprehensive family planning services and were assessed every 3 months for contraceptive initiation, discontinuation and switching.

METHODS

We modelled factors associated with contraceptive method upgrading and downgrading via multivariate Andersen-Gill models.

RESULTS

Most women continued the initial method selected after randomization. The highest rates of discontinuation/switching were observed for injectable contraceptive and intrauterine device users. Time to discontinuing the more effective contraceptive methods or downgrading to oral contraceptives or condoms was associated with the women's younger age, desire for more children within the next year, heavy menstrual bleeding, bleeding between periods and cystitis/dysuria. Health concerns among women about contraceptive implants and male partners not wanting more children were associated with upgrading from oral contraceptives or condoms. HIV status of the woman or the couple was not predictive of switching or stopping.

CONCLUSION

We found complicated patterns of contraceptive use. The predictors of contraception switching indicate that interventions targeted to younger couples that address common contraception-related misconceptions could improve effective family planning utilization. We recommend these findings be used to increase the uptake and continuation of contraception, especially long-acting reversible contraceptive (LARC) methods, and that fertility goal based, LARC-focused family planning be offered as an integral part of HIV prevention services.

Integration of family planning into HIV services: a synthesis of recent evidence

INTRODUCTION

Increasing access to contraception among women who enter the health system for HIV care is crucial to help them achieve their fertility intentions and reduce vertical transmission of HIV. Identifying intervention strategies that contribute to effective family planning/HIV service integration and synthesizing lessons for future integration programming and research is important to move the field forward.

METHODS

Using a standard review methodology, we searched for articles in the peer-reviewed literature published between January 2008 and August 2013 that addressed the integration of family planning interventions into HIV service settings. Eligible studies were assessed in terms of methodological rigor; documented outcomes; and reported process and cost data.

RESULTS

Twelve studies met our inclusion criteria. Eight studies documented significant increases in contraceptive use by HIV service clients, and three reported significant increases in completed referrals from HIV services to family planning clinics. The outcomes of the seven studies implemented in public sector facilities were more modest than the five studies embedded in clinical trials. Process evaluation measures for some of the studies indicated weak implementation of the intervention as intended. The average rigor score was low, 3.4 out of 9.

CONCLUSION

Our review reveals an expanding evidence base for integrated family planning/HIV service delivery innovations. However, the modest observed effect under typical settings and the evidence of weak intervention implementation emphasize the need for stronger programmatic efforts and implementation research to address the health system obstacles to integrating these two essential services.

Unintended pregnancy among HIV positive couples receiving integrated HIV counseling, testing, and family planning services in Zambia

Objective

We describe rates of unintended pregnancy among HIV positive couples in Lusaka, Zambia. We also identify factors associated with unintended pregnancy among oral contraceptive pill (OCP) using couples in this cohort.

Design

Data were analyzed from couples randomized in a factorial design to two family planning intervention videos.

Methods

Rates of unintended pregnancy were stratified by contraceptive method used at time of pregnancy. Predictors of time to unintended pregnancy among OCP users were determined via multivariate Cox modeling.

Results

The highest rates of unintended pregnancy were observed among couples requesting condoms only (26.4/100CY) or OCPs (20.7/100CY); these rates were not significantly different. OCP users accounted for 37% of the couple-years (CY) observed and 87% of unintended pregnancies. Rates of unintended pregnancy for injectable (0.7/100CY) and intrauterine device (1.6/100CY) users were significantly lower relative to condom only users. No pregnancies occurred among contraceptive implant users or after tubal ligation. Factors associated (p<0.05) with time to unintended pregnancy among OCP users in multivariate analysis included the man wanting more children, the woman being HIV negative versus having stage IV HIV disease, and the woman reporting: younger age, no previous OCP use, missed OCPs, or sex without a condom.

Conclusions

Long-acting reversible contraceptive methods were effective in the context of integrated couples HIV prevention and contraceptive services. Injectable methods were also effective in this context. Given the high user failure rate of OCPs, family planning efforts should promote longer-acting methods among OCP users wishing to avoid pregnancy. Where other methods are not available or acceptable, OCP adherence counseling is needed, especially among younger and new OCP users.

Trial registration

ClinicalTrials.gov NCT00067522

Longitudinal study of correlates of modern contraceptive use and impact of HIV care programmes among HIV concordant and serodiscordant couples in Rakai, Uganda

Objective

To assess trends and determinants of family planning use and impact of HIV serostatus among couples.

Methods

Couples’ data were retrospectively linked from cohort surveys in Rakai, Uganda between 1999 and 2011, and were classified by HIV status as concordant (M+F+/M−F−) or serodiscordant (M−F+/M+F−). HIV care (HIVC) was grouped into three periods, pre-antiretroviral therapy (pre-HIVC) (<2004), HIVC roll-out (2005–2007) and HIVC scale-up (≥2008). Trends in couple contraceptive use were assessed by chi-square test (χ²) for trend, and multinomial logistic regression was used to estimate adjusted odds ratios (ORs) of predictors of contraceptive use.

Results

A toal of 6139 couples contributed 13 709 observations. Hormonal contraception (HC) use increased over time from 22.9% to 33.9%, p<0.001), with significant increases among M−F− (23.2% to 34.8%, p<0.0001) and M+F+ (20.8% to 32.2%, p=0.0005), but not serodiscordant couples. Condom use significantly increased among M+F+ (30.3% to 48.0%, p<0.001) and serodiscordant couples (24.2% to 48.7%, p<0.001), but not among M−F− couples. Dual use of HC and condoms increased over time, irrespective of HIV status. Factors associated with increases in contraceptive use were: higher education, co-resident children, male non-marital relationship and scaled-up HIVC phase. Enrolment into HIVC was associated with increased HC and condom use among HIV+ concordant [adjusted OR (adjOR)=3.03; 95% confidence interval (CI) 1.69–5.44 and adjOR=4.46, 95% CI 2.53–7.86, respectively], and serodiscordant couples (adjOR=2.21; 95% CI 1.25–3.92 and adjOR=4.75; 95% CI 2.89–7.82, respectively).

Conclusions

Use of modern contraception and dual method use increased over time, particularly after enrolment into HIVC. Integration of HIV and reproductive health services is critical for prevention of unwanted pregnancies and HIV infection.

Dual Protection and Dual Methods in Women Living with HIV: The Brazilian Context

The cooccurrence of HIV and unintended pregnancy has prompted a body of work on dual protection, the simultaneous protection against HIV and unintended pregnancy. This study examines dual protection and dual methods as a risk-reduction strategy for women living with HIV. Data are from a cross-sectional sample of HIV-positive women attended in Specialized STI/AIDS Public Health Service Clinics in 13 municipalities from all five regions of Brazil 2003-2004 (N = 834). Descriptive techniques and logistic regression were used to examine dual protection among women living with HIV. We expand the definition of dual protection to include consistent condom use and reversible/irreversible contraceptive methods, we test the dual methods hypothesis that women who use dual methods will use condoms less consistently than women who use only condoms, and we identify predictors of dual protection. Dual protection is common in our sample. Women who use dual methods have lower odds of consistent condom use than women who only use condoms. Among dual method users, we find that women who use an irreversible method use condoms more consistently than women who use a reversible method. Women on ART and with an HIV-serodiscordant partner have greater odds of consistent condom use than their counterparts.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Impact of long-term contraceptive promotion on incident pregnancy: a randomized controlled trial among HIV-positive couples in Lusaka, Zambia

OBJECTIVES

To evaluate the impact of family planning promotion on incident pregnancy in a combined effort to address Prongs 1 and 2 of prevention of mother-to-child transmission of HIV.

DESIGN

We conducted a factorial randomized controlled trial of 2 video-based interventions.

METHODS

"Methods" and "Motivational" messages promoted long-term contraceptive use among 1060 couples with HIV in Lusaka, Zambia.

RESULTS

Among couples not using contraception before randomization (n = 782), the video interventions had no impact on incident pregnancy. Among baseline contraceptive users, viewing the "Methods video" which focused on the intrauterine device and contraceptive implant was associated with a significantly lower pregnancy incidence [hazard ratio (HR) = 0.38; 95% confidence interval (CI): 0.19 to 0.75] relative to those viewing control and/or motivational videos. The effect was strongest in concordant positive couples (HR = 0.22; 95% CI: 0.08 to 0.58) and couples with HIV-positive women (HR = 0.23; 95% CI: 0.09 to 0.55).

CONCLUSIONS

The "Methods video" intervention was previously shown to increase uptake of long-acting contraception and to prompt a shift from daily oral contraceptives to quarterly injectables and long-acting methods such as the intrauterine device and implant. Follow-up confirms sustained intervention impact on pregnancy incidence among baseline contraceptive users, in particular couples with HIV-positive women. Further work is needed to identify effective interventions to promote long-acting contraception among couples who have not yet adopted modern methods.

Strategies for communicating contraceptive effectiveness

BACKGROUND

Knowledge of contraceptive effectiveness is crucial to making an informed choice. The consumer has to comprehend the pros and cons of the contraceptive methods being considered. Choice may be influenced by understanding the likelihood of pregnancy with each method and factors that influence effectiveness.

OBJECTIVES

To review all randomized controlled trials comparing strategies for communicating to consumers the effectiveness of contraceptives in preventing pregnancy.

SEARCH METHODS

Through February 2013, we searched the computerized databases of MEDLINE, POPLINE, CENTRAL, PsycINFO and CINAHL, ClinicalTrials.gov, and ICTRP. Previous searches also included EMBASE. We also examined references lists of relevant articles. For the initial review, we wrote to known investigators for information about other published or unpublished trials.

SELECTION CRITERIA

We included randomized controlled trials that compared methods for communicating contraceptive effectiveness to consumers. The comparison could be usual practice or an alternative to the experimental intervention.Outcome measures were knowledge of contraceptive effectiveness, attitude about contraception or toward any particular contraceptive, and choice or use of contraceptive method.

DATA COLLECTION AND ANALYSIS

For the initial review, two authors independently extracted the data. One author entered the data into RevMan, and a second author verified accuracy. For the update, an author and a research associate extracted, entered, and checked the data.For dichotomous variables, we calculated the Mantel-Haenszel odds ratio with 95% confidence intervals (CI). For continuous variables, we computed the mean difference (MD) with 95% CI.

MAIN RESULTS

Seven trials met the inclusion criteria and had a total of 4526 women. Five were multi-site studies. Four trials were conducted in the USA, while Nigeria and Zambia were represented by one study each, and one trial was done in both Jamaica and India.Two trials provided multiple sessions for participants. In one study that examined contraceptive choice, women in the expanded program were more likely to choose sterilization (OR 4.26; 95% CI 2.46 to 7.37) or use a modern contraceptive method (OR 2.35; 95% CI 1.82 to 3.03), i.e., sterilization, pills, injectable, intrauterine device or barrier method. For the other study, the groups received educational interventions with differing format and intensity. Both groups reportedly had increases in contraceptive use, but they did not differ significantly by six months in consistent use of an effective contraceptive, i.e., sterilization, IUD, injectable, implant, and consistent use of oral contraceptives, diaphragm, or male condoms.Five trials provided one session and focused on testing educational material or media. In one study, knowledge gain favored a slide-and-sound presentation versus a physician's oral presentation (MD -19.00; 95% CI -27.52 to -10.48). In another trial, a table with contraceptive effectiveness categories led to more correct answers than a table based on pregnancy numbers [ORs were 2.42 (95% CI 1.43 to 4.12) and 2.19 (95% CI 1.21 to 3.97)] or a table with effectiveness categories and pregnancy numbers [ORs were 2.58 (95% CI 1.5 to 4.42) and 2.03 (95% CI 1.13 to 3.64)]. Still another trial provided structured counseling with a flipchart on contraceptive methods. The intervention and usual-care groups did not differ significantly in choice of contraceptive method (by effectiveness category) or in continuation of the chosen method at three months. Lastly, a study with couples used videos to communicate contraceptive information (control, motivational, contraceptive methods, and both motivational and methods videos). The analyses showed no significant difference between the groups in the types of contraceptives chosen.

AUTHORS' CONCLUSIONS

These trials varied greatly in the types of participants and interventions to communicate contraceptive effectiveness. Therefore, we cannot say overall what would help consumers choose an appropriate contraceptive method. For presenting pregnancy risk data, one trial showed that effectiveness categories were better than pregnancy numbers. In another trial, audiovisual aids worked better than the usual oral presentation. Strategies should be tested in clinical settings and measured for their effect on contraceptive choice. More detailed reporting of intervention content would help in interpreting results. Reports could also include whether the instruments used to assess knowledge or attitudes were tested for validity or reliability. Follow-up should be incorporated to assess retention of knowledge over time. The overall quality of evidence was considered to be low for this review, given that five of the seven studies provided low or very low quality evidence.