Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland

Exploring the accuracy of self-reported maternal and newborn care in select studies from low and middle-income country settings: do respondent and facility characteristics affect measurement?

BACKGROUND

Accurate data on the receipt of essential maternal and newborn health interventions is necessary to interpret and address gaps in effective coverage. Validation results of commonly used content and quality of care indicators routinely implemented in international survey programs vary across settings. We assessed how respondent and facility characteristics influenced the accuracy of women's recall of interventions received in the antenatal and postnatal periods.

METHODS

We synthesized reporting accuracy using data from a known sample of validation studies conducted in Sub-Saharan Africa and Southeast Asia, which assessed the validity of women's self-report of received antenatal care (ANC) (N = 3 studies, 3,169 participants) and postnatal care (PNC) (N = 5 studies, 2,462 participants) compared to direct observation. For each study, indicator sensitivity and specificity are presented with 95% confidence intervals. Univariate fixed effects and bivariate random effects models were used to examine whether respondent characteristics (e.g., age group, parity, education level), facility quality, or intervention coverage level influenced the accuracy of women's recall of whether interventions were received.

RESULTS

Intervention coverage was associated with reporting accuracy across studies for the majority (9 of 12) of PNC indicators. Increasing intervention coverage was associated with poorer specificity for 8 indicators and improved sensitivity for 6 indicators. Reporting accuracy for ANC or PNC indicators did not consistently differ by any other respondent or facility characteristic.

CONCLUSIONS

High intervention coverage may contribute to higher false positive reporting (poorer specificity) among women who receive facility-based maternal and newborn care while low intervention coverage may contribute to false negative reporting (lower sensitivity). While replication in other country and facility settings is warranted, results suggest that monitoring efforts should consider the context of care when interpreting national estimates of intervention coverage.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

The practice of pilot/feasibility studies in informing the conduct of HIV related clinical trials in sub-Saharan Africa: A scoping review

Introduction

Pilot/feasibility studies represent a fundamental phase of the research process and play a vital role in the preliminary planning of a full size HIV clinical trial. Published HIV clinical trial protocols were reviewed to establish the extent to which the proposed HIV clinical trials are informed by a prior pilot/feasibility study.

Methods

The JBI methodology for scoping reviews was followed. Six databases were systematically searched to identify articles for inclusion.

Results

Thirty two (32) published HIV study protocols were included. Articles were in the English language and were published in the past 10 years (2011-2020). The review results showed that the majority of HIV-related clinical trials in sub-Saharan Africa were not informed by pilot/feasibility studies. The results further indicated that the number of HIV clinical trials informed by a pilot/feasibility study have been on the increase in the 8 years' period since 2012, a trend that indicates positive uptake of pilot studies in HIV related studies. A few select countries (South Africa, Uganda, Zimbabwe, Malawi and Kenya) comprised more than 70% of all clinical trials that were informed by a pilot/feasibility study, conducted in sub Saharan Africa.

Conclusions

Although there is an increasing interest among researchers to integrate pilot/feasibility studies in HIV related research, limited countries in sub-Saharan Africa appear to have embraced this trend. Strategies that can motivate researchers to engage in a culture of incorporating pilot/feasibility studies in HIV related research should be implemented.

Design, adaptation, and diffusion of an innovative tool to support contraceptive decision-making: Balanced Counseling Strategy Plus

Contraceptive decision-making is highly complex, and family planning (FP) clients choose methods according to a host of personal, interpersonal, and context-specific considerations. These include concerns about side effects, confidence in their ability to adhere to daily or monthly use, efficacy of methods, partner support, and HIV vulnerability. FP decision support tools can support FP clients and providers to engage in a joint decision-making process to ensure clients make informed choices about contraception. For more than two decades, the Balanced Counseling Strategy (BCS) and Balanced Counseling Strategy Plus (BCS+) decision support tools have been used in lower- and middle-income countries, informed by implementation science research and iterative updates and refinements to reflect new developments in contraceptive technology and HIV prevention strategies. To inform the development and scale-up of future FP decision support tools, this article describes the development, evaluation, and proliferation of BCS and BCS+.

Design, adaptation, and diffusion of an innovative tool to promote shared contraceptive decision-making: Balanced Counseling Strategy Plus

Contraceptive decision-making is highly complex, and family planning (FP) clients choose methods according to a host of personal, interpersonal, and context-specific considerations. These include concerns about side effects, confidence in their ability to adhere to daily or monthly use, efficacy of methods, partner support, and HIV vulnerability. FP decision support tools can support FP clients and providers to engage in a joint decision-making process to ensure clients make informed choices about contraception. For more than two decades, the Balanced Counseling Strategy (BCS) and Balanced Counseling Strategy Plus (BCS+) decision support tools have been used in lower- and middle-income countries, informed by implementation science research and iterative updates and refinements to reflect new developments in contraceptive technology and HIV prevention strategies. To inform the development and scale-up of future FP decision support tools, as well as share lessons from translating implementation science results to practice, this article describes the development, evaluation, and proliferation of BCS and BCS+.

Integration of HIV testing services into family planning services: a systematic review

BACKGROUND

Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously.

METHODS

We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017.

RESULTS

Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes.

CONCLUSIONS

Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.

Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya

Introduction

Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya.

Methods

Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009–2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling.

Results

Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care.

Conclusions

These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time.

Trial registration number

NCT01694862

Women's recall of maternal and newborn interventions received in the postnatal period: a validity study in Kenya and Swaziland

Background

Despite the concentration of maternal and infant deaths in the early postnatal period, information on the content and quality of postnatal care interventions is not routinely collected in most low and middle-income countries. At present, data on the coverage of postnatal care interventions mostly rely on women’s reports collected in household surveys, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), which collect limited information. We assessed the validity of a set of postnatal care indicators that reflect a range of recommended interventions for both mother and newborn and have potential to be included in household surveys for monitoring of population-level coverage.

Methods

We compared women’s reports in exit interviews on the content of postnatal care received in health facilities located in Kenya and Swaziland against a gold standard of direct observation by a trained third party. We calculated sensitivity, specificity and the area under the receiver operating curve (AUC) to assess individual-level reporting accuracy and the inflation factor (IF) to assess population-level accuracy. We also examined whether women’s reporting accuracy varied significantly by her sociodemographic characteristics.

Results

18 indicators in Kenya and 19 in Swaziland had sufficient sample size for analysis. Of these, 12 indicators in Kenya and five in Swaziland met criteria for acceptable individual and population-level reporting accuracy. Two indicators met acceptability criteria in both Kenya and Swaziland: whether the provider performed a breast exam or an abdominal exam. There was no significant association between women’s characteristics and reporting accuracy, across indicators.

Conclusion

Women are able to accurately report on multiple aspects of care received during a postnatal visit. Findings inform the recommendation of indicators for tracking progress of critical postnatal care interventions for mothers and newborns. Improved measurement of the coverage of maternal and newborn postnatal care is warranted to monitor progress in maternal and newborn care globally.

Ambivalence in pregnancy intentions: The effect of quality of care and context among a cohort of women attending family planning clinics in Kenya

Context

Ambivalence in pregnancy intentions is well-documented in sub-Saharan African (SSA) settings and has been associated with inconsistent use of contraception, thereby exposing women using contraception to the possibility of unintended pregnancies. A better understanding of the potential role for client counseling interventions in enabling women to achieve their pregnancy intentions is essential for aiding program efforts to reduce unintended pregnancies.

Objective

To measure ambivalence in pregnancy intentions longitudinally and determine its association with the quality of care received, controlling for demographic, socio-economic and contextual factors among a cohort of family planning (FP) clients in Kenya.

Methods

This paper uses data drawn from a prospective cohort study of FP clients to investigate the relationship between the quality of care received during FP service delivery and the decisiveness of their pregnancy intentions over time. The study tests the hypothesis that higher quality of care enables women to be less ambivalent about their pregnancy intentions. Binary logistic regression with random effects and multinomial logistic regression were used to assess the predictive effect of the quality of care received by a woman on the decisiveness or ambivalence of her pregnancy intentions, and on any shifts in ambivalence over time, controlling for background characteristics. The study recruited 1,957 women aged 15–49 years attending twelve family planning clinics in four counties in Central Kenya; of these, 1,053 women were observed for four rounds of data collection over a period of 24 months and form the sample for analysis.

Findings

A substantial proportion (43%) of women expressed ambivalence about their intentions to become pregnant at some point during the study period, while over half (57%) remained unequivocal throughout the study. Almost one third of women (31%) shifted from being unequivocal to ambivalent and 12% shifted from ambivalence to being unequivocal. Women experiencing higher quality of care have lower odds of ever expressing ambivalence and higher odds of remaining unequivocal over time, net of other factors. Quality of care was not associated with a shift in ambivalence over time.

Conclusion

FP programs offering higher quality of care are likely to support women to be more decisive in their pregnancy intentions. Improving the quality of care can contribute to reduced ambivalence and consequently reduced likelihood of unintended pregnancy among contraceptive users. This study provides further evidence of the benefits gained through providing high quality services.

Trial registration

ClinicalTrials.gov NCT01694862

Does service integration improve technical quality of care in low-resource settings? An evaluation of a model integrating HIV care into family planning services in Kenya

The aim of this study was to investigate association between HIV and family planning integration and technical quality of care. The study focused on technical quality of client-provider consultation sessions. The cross-sectional study observed 366 client-provider consultation sessions and interviewed 37 health care providers in 12 public health facilities in Kenya. Multilevel random intercept and linear regression models were fitted to the matched data to investigate relationships between service integration and technical quality of care as well as associations between facility-level structural and provider factors and technical quality of care. A sensitivity analysis was performed to test for hidden bias. After adjusting for facility-level structural factors, HIV/family planning integration was found to have significant positive effect on technical quality of the consultation session, with average treatment effect 0.44 (95% CI: 0.63-0.82). Three of the 12 structural factors were significantly positively associated with technical quality of consultation session including: availability of family planning commodities (9.64; 95% CI: 5.07-14.21), adequate infrastructure (5.29; 95% CI: 2.89-7.69) and reagents (1.48; 95% CI: 1.02-1.93). Three of the nine provider factors were significantly positively associated with technical quality of consultation session: appropriate provider clinical knowledge (3.14; 95% CI: 1.92-4.36), job satisfaction (2.02; 95% CI: 1.21-2.83) and supervision (1.01; 95% CI: 0.35-1.68), while workload (-0.88; 95% CI: -1.75 to - 0.01) was negatively associated. Technical quality of the client-provider consultation session was also determined by duration of the consultation and type of clinic visit and appeared to depend on whether the clinic visit occurred early or later in the week. Integration of HIV care into family planning services can improve the technical quality of client-provider consultation sessions as measured by both health facility structural and provider factors.

Impact of integration of sexual and reproductive health services on consultation duration times: results from the Integra Initiative

The lack of human resources is a key challenge in scaling up of HIV services in Africa's health care system. Integrating HIV services could potentially increase their effectiveness and optimize the use of limited resources and clinical staff time. We examined the impact of integration of provider initiated HIV counselling and testing (PITC) and family planning (FP counselling and FP provision) services on duration of consultation to assess the impact of PITC and FP integration on staff workload. This study was conducted in 24 health facilities in Kenya under the Integra Initiative, a non-randomized, pre/post intervention trial to evaluate the impact of integrated HIV and sexual and reproductive health services on health and service outcomes. We compared the time spent providing PITC-only services, FP-only services and integrated PITC/FP services. We used log-linear regression to assess the impact of plausible determinants on the duration of clients' consultation times. Median consultation duration times were highest for PITC-only services (30 min), followed by integrated services (10 min) and FP-only services (8 min). Times for PITC-only and FP-only services were 69.7% higher (95% Confidence Intervals (CIs) 35.8-112.0) and 43.9% lower (95% CIs -55.4 to - 29.6) than times spent on these services when delivered as an integrated service, respectively. The reduction in consultation times with integration suggests a potential reduction in workload. The higher consultation time for PITC-only could be because more pre- and post-counselling is provided at these stand-alone services. In integrated PITC/FP services, the duration of the visit fell below that required by HIV testing guidelines, and service mix between counselling and testing substantially changed. Integration of HIV with FP services may compromise the quality of services delivered and care must be taken to clearly specify and monitor appropriate consultation duration times and procedures during the process of integrating HIV and FP services.

Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya

Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more.

How to Integrate HIV and Sexual and Reproductive Health Services in Namibia, the Epako Clinic Case Study

INTRODUCTION

During the past two decades, HIV and Sexual and Reproductive Health services in Namibia have been provided in silos, with high fragmentation. As a consequence of this, quality and efficiency of services in Primary Health Care has been compromised.

METHODS

We conducted an operational research (observational pre-post study) in a public health facility in Namibia. A health facility assessment was conducted before and after the integration of health services. A person-centred integrated model was implemented to integrate all health services provided at the health facility in addition to HIV and Sexual and Reproductive Health services. Comprehensive services are provided by each health worker to the same patients over time (longitudinality), on a daily basis (accessibility) and with a good external referral system (coordination). Prevalence rates of time flows and productivity were done.

RESULTS

Integrated services improved accessibility, stigma and quality of antenatal care services by improving the provider-patient communication, reducing the time that patients stay in the clinic in 16% and reducing the waiting times in 14%. In addition, nurse productivity improved 85% and the expected time in the health facility was reduced 24% without compromising the uptake of TB, HIV, outpatient, antenatal care or first visit family planning services. Given the success on many indicators resulting from integration of services, the goal of this paper was to describe "how" health services have been integrated, the "process" followed and presenting some "results" from the integrated clinic.

CONCLUSIONS

Our study shows that HIV and SRH services can be effectively integrated by following the person-centred integrated model. Based on the Namibian experience on "how" to integrate health services and the "process" to achieve it, other African countries can replicate the model to move away from the silo approach and contribute to the achievement of Universal Health Coverage.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

BACKGROUND

Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

METHODS

Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

RESULTS

Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

CONCLUSIONS

WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

TRIAL REGISTRATION

Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services

Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.

Impact of Integrated Services on HIV Testing: A Nonrandomized Trial among Kenyan Family Planning Clients

The impact of integrated reproductive health and HIV services on HIV testing and counseling (HTC) uptake was assessed among 882 Kenyan family planning clients using a nonrandomized cohort design within six intervention and six "comparison" facilities. The effect of integration on HTC goals (two tests over two years) was assessed using conditional logistic regression to test four "integration" exposures: a training and reorganization intervention; receipt of reproductive health and HIV services at recruitment; a functional measure of facility integration at recruitment; and a woman's cumulative exposure to functionally integrated care across different facilities over time. While recent receipt of HTC increased rapidly at intervention facilities, achievement of HTC goals was higher at comparison facilities. Only high cumulative exposure to integrated care over two years had a significant effect on HTC goals after adjustment (aOR 2.94, 95%CI 1.73-4.98), and programs should therefore make efforts to roll out integrated services to ensure repeated contact over time.

Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document

OBJECTIVES

Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies.

METHODS

An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts.

RESULTS

The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice.

CONCLUSIONS

Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice.

Utilization of integrated HIV and sexual and reproductive health services among women in Uganda

BACKGROUND

While the rationale for integration of HIV and sexual and reproductive health (HIV and SRH) services is strong, there is paucity of information on which population groups most utilize these services. Such studies would inform policy and programs on integration of services. The overall objective of this assessment is to provide information to researchers, planners and policy makers on the best practices for integrated services in order to maximize feasibility of scaling up. Specifically, this research paper identifies demographic and socioeconomic factors that are most related to utilization of integrated services in Uganda.

METHODS

This manuscript uses data from a sample of 9,691 women interviewed during the Uganda AIDS Indicator Survey (UAIS) of 2011. The selection criteria of the study respondents for this paper included women of reproductive age 15 - 49 years. The dependent variable is whether the respondent utilized integrated HIV and SRH services during pregnancy and delivery of the last child, while independent variables include; region of residence, age-group of woman, marital status, rural-urban residence, wealth indicator and educational level attainment. In the main analysis, a binary logistic regression model was fitted to the data.

RESULTS

Log-odds of utilizing integrated services were significantly higher among those women with a primary education (OR = 1.2, 95 % CI = 1.0-1.4, p < 0.05) compared to those with no education. Women from the Central part of Uganda were more likely to utilize integrated HIV and SRH services (OR = 1.3, 95 % CI = 1.0-1.7, p < 0.05), further the log-odds of utilizing integrated HIV and SRH services were significantly higher among women residing in Northern region (OR = 1.6, 95 % CI = 1.2-2.2, p < 0.01). The odds of utilization of integrated HIV and SRH services were higher for currently married women (OR = 6.6, 95 % CI = 5.5-8.0, p < 0.01) and the formerly married (OR = 3.4, 95 % CI = 2.7-4.2, p < 0.01), compared to the never married group. The odds of utilizing integrated HIV and SRH services were higher for younger women of ages less than 35 years compared to older women aged 40 - 49 years.

CONCLUSIONS

Utilization of integrated HIV and SRH services in Uganda is influenced greatly by demographic and socioeconomic characteristics. This study contributes to the current debate as it shows the on how best ways to improve HIV and SRH service delivery to the people.

Perceptions and Experiences of Integrated Service Delivery Among Women Living with HIV Attending Reproductive Health Services in Kenya: A Mixed Methods Study

This is one of the few studies that explores preferences of and experiences with integrated sexual and reproductive health (SRH)-HIV care among users of mainstream family planning and postnatal care services who are women living with HIV (WLWH). This paper reports on the quantitative data from 179 clients attending public sector clinics and from 30 qualitative in-depth interviews with WLHIV in Kenya. Quantitative data show that integration is happening for the vast majority of these clients at their last HIV visit. However, qualitative data show that very often the care received by WLWH is fragmented as providers do not offer multiple same-day appointments for FP and ARV refills. Our study has shown factors that could either prevent or enable receipt of integrated SRH and HIV care for WLWH. To address these factors, management systems need to be able to support providers to make flexible decisions and facilitate better coordination and communication across clinics within facilities.

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.

The risks of partner violence following HIV status disclosure, and health service responses: narratives of women attending reproductive health services in Kenya

Introduction

For many women living with HIV (WLWH), the disclosure of positive status can lead to either an extension of former violence or new conflict specifically associated with HIV status disclosure. This study aims to explore the following about WLWH: 1. the women's experiences of intimate partner violence (IPV) risks following disclosure to their partners; 2. an analysis of the women's views on the role of health providers in preventing and addressing IPV, especially following HIV disclosure.

Methods

Thirty qualitative interviews were conducted with purposively selected WLWH attending clinics in Kenya. Data were coded using NVivo 9 and analyzed thematically.

Results

Nearly one third of the respondents reported experiencing physical and/or emotional violence inflicted by their partners following the sero-disclosure, suggesting that HIV status disclosure can be a period of heightened risk for partner stigma and abuse, and financial withdrawal, and thus should be handled with caution. Sero-concordance was protective for emotional and verbal abuse once the partner knew his positive status, or knew the woman knew his status. Our results show acceptance of the role of the health services in helping prevent and reduce anticipated fear of partner stigma and violence as barriers to HIV disclosure. Some of the approaches suggested by our respondents included couple counselling, separate counselling sessions for men, and facilitated disclosure. The women's narratives illustrate the importance of integrating discussions on risks for partner violence and fear of disclosure into HIV counselling and testing, helping women develop communication skills in how to disclose their status, and reducing fear about marital separation and break-up. Women in our study also confirmed the key role of preventive health services in reducing blame for HIV transmission and raising awareness on HIV as a chronic disease. However, several women reported receiving no counselling on safe disclosure of HIV status.

Conclusion

Integration of partner violence identification and care into sexual, reproductive and HIV services for WLWH could be a way forward. The health sector can play a preventive role by sensitizing providers to the potential risks for partner violence following disclosure and ensuring that the women's decision to disclose is fully informed and voluntary.

Innovation in Evaluating the Impact of Integrated Service-Delivery: The Integra Indexes of HIV and Reproductive Health Integration

BACKGROUND

The body of knowledge on evaluating complex interventions for integrated healthcare lacks both common definitions of 'integrated service delivery' and standard measures of impact. Using multiple data sources in combination with statistical modelling the aim of this study is to develop a measure of HIV-reproductive health (HIV-RH) service integration that can be used to assess the degree of service integration, and the degree to which integration may have health benefits to clients, or reduce service costs.

METHODS AND FINDINGS

Data were drawn from the Integra Initiative's client flow (8,263 clients in Swaziland and 25,539 in Kenya) and costing tools implemented between 2008-2012 in 40 clinics providing RH services in Kenya and Swaziland. We used latent variable measurement models to derive dimensions of HIV-RH integration using these data, which quantified the extent and type of integration between HIV and RH services in Kenya and Swaziland. The modelling produced two clear and uncorrelated dimensions of integration at facility level leading to the development of two sub-indexes: a Structural Integration Index (integrated physical and human resource infrastructure) and a Functional Integration Index (integrated delivery of services to clients). The findings highlight the importance of multi-dimensional assessments of integration, suggesting that structural integration is not sufficient to achieve the integrated delivery of care to clients--i.e. "functional integration".

CONCLUSIONS

These Indexes are an important methodological contribution for evaluating complex multi-service interventions. They help address the need to broaden traditional evaluations of integrated HIV-RH care through the incorporation of a functional integration measure, to avoid misleading conclusions on its 'impact' on health outcomes. This is particularly important for decision-makers seeking to promote integration in resource constrained environments.

Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? An application of a two-stage semi parametric approach incorporating quality measures

Theoretically, integration of vertically organized services is seen as an important approach to improving the efficiency of health service delivery. However, there is a dearth of evidence on the effect of integration on the technical efficiency of health service delivery. Furthermore, where technical efficiency has been assessed, there have been few attempts to incorporate quality measures within efficiency measurement models particularly in sub-Saharan African settings. This paper investigates the technical efficiency and the determinants of technical efficiency of integrated HIV and sexual and reproductive health (SRH) services using data collected from 40 health facilities in Kenya and Swaziland for 2008/2009 and 2010/2011. Incorporating a measure of quality, we estimate the technical efficiency of health facilities and explore the effect of integration and other environmental factors on technical efficiency using a two-stage semi-parametric double bootstrap approach. The empirical results reveal a high degree of inefficiency in the health facilities studied. The mean bias corrected technical efficiency scores taking quality into consideration varied between 22% and 65% depending on the data envelopment analysis (DEA) model specification. The number of additional HIV services in the maternal and child health unit, public ownership and facility type, have a positive and significant effect on technical efficiency. However, number of additional HIV and STI services provided in the same clinical room, proportion of clinical staff to overall staff, proportion of HIV services provided, and rural location had a negative and significant effect on technical efficiency. The low estimates of technical efficiency and mixed effects of the measures of integration on efficiency challenge the notion that integration of HIV and SRH services may substantially improve the technical efficiency of health facilities. The analysis of quality and efficiency as separate dimensions of performance suggest that efficiency may be achieved without sacrificing quality.

Use of HIV counseling and testing and family planning services among postpartum women in Kenya: a multicentre, non-randomised trial

BACKGROUND

Addressing the postnatal needs of new mothers is a neglected area of care throughout sub-Saharan Africa. The study compares the effectiveness of integrating HIV and family planning (FP) services into postnatal care (PNC) with stand-alone services on postpartum women's use of HIV counseling and testing and FP services in public health facilities in Kenya.

METHODS

Data were derived from samples of women who had been assigned to intervention or comparison groups, had given birth within the previous 0-10 weeks and were receiving postnatal care, at baseline and 15 months later. Descriptive statistics describe the characteristics of the sample and multivariate logistic regression models assess the effect of the integrated model of care on use of provider-initiated testing and counseling (PITC) and FP services.

RESULTS

At the 15-month follow-up interviews, more women in the intervention than comparison sites used implants (15 % vs. 3 %; p < 0.001), while injectables were the most used short-term method by women in both sites. Women who wanted to wait until later to have children (OR = 1.3; p < 0.01; 95 % CI: 1.1-1.5), women with secondary education (OR = 1.2; p < 0.05; 95 % CI: 1.0-1.4), women aged 25-34 years (OR = 1.2; p < 0.01; 95 % CI: 1.1-1.4) and women from poor households (OR = 1.6; p < 0.001; 95 % CI: 1.4-1.9) were associated with FP use. Nearly half (47 %) and about one-third (30 %) of mothers in the intervention and comparison sites, respectively, were offered PITC. Significant predictors of uptake of PITC were seeking care in a health center/dispensary relative to a hospital, having a partner who has tested for HIV and being poor.

CONCLUSIONS

An integrated delivery approach of postnatal services is beneficial in increasing the uptake of PITC and long-acting FP services among postpartum women. Also, interventions aimed at increasing male partners HIV testing have a positive effect on the uptake of PITC and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01694862.

Does integration of HIV and SRH services achieve economies of scale and scope in practice? A cost function analysis of the Integra Initiative

OBJECTIVE

Policy-makers have long argued about the potential efficiency gains and cost savings from integrating HIV and sexual reproductive health (SRH) services, particularly in resource-constrained settings with generalised HIV epidemics. However, until now, little empirical evidence exists on whether the hypothesised efficiency gains associated with such integration can be achieved in practice.

METHODS

We estimated a quadratic cost function using data obtained from 40 health facilities, over a 2-year-period, in Kenya and Swaziland. The quadratic specification enables us to determine the existence of economies of scale and scope.

FINDINGS

The empirical results reveal that at the current output levels, only HIV counselling and testing services are characterised by service-specific economies of scale. However, no overall economies of scale exist as all outputs are increased. The results also indicate cost complementarities between cervical cancer screening and HIV care; post-natal care and HIV care and family planning and sexually transmitted infection treatment combinations only.

CONCLUSIONS

The results from this analysis reveal that contrary to expectation, efficiency gains from the integration of HIV and SRH services, if any, are likely to be modest. Efficiency gains are likely to be most achievable in settings that are currently delivering HIV and SRH services at a low scale with high levels of fixed costs. The presence of cost complementarities for only three service combinations implies that careful consideration of setting-specific clinical practices and the extent to which they can be combined should be made when deciding which services to integrate.

TRIAL REGISTRATION NUMBER

NCT01694862.

Family planning use and fertility desires among women living with HIV in Kenya

Background

Enabling women living with HIV to effectively plan whether and when to become pregnant is an essential right; effective prevention of unintended pregnancies is also critical to reduce maternal morbidity and mortality as well as vertical transmission of HIV. The objective of this study is to examine the use of family planning (FP) services by HIV-positive and HIV-negative women in Kenya and their ability to achieve their fertility desires.

Methods

Data are derived from a random sample of women seeking family planning services in public health facilities in Kenya who had declared their HIV status (1887 at baseline and 1224 at endline) and who participated in a longitudinal study (the INTEGRA Initiative) that measured the benefits/costs of integrating HIV and sexual/reproductive health services in public health facilities. The dependent variables were FP use in the last 12 months and fertility desires (whether a woman wants more children or not). The key independent variable was HIV status (positive and negative). Descriptive statistics and multivariate logistic regression analysis were used to describe the women’s characteristics and to examine the relationship between FP use, fertility desires and HIV status.

Results

At baseline, 13 % of the women sampled were HIV-positive. A slightly higher proportion of HIV-positive women were significantly associated with the use of FP in the last 12 months and dual use of FP compared to HIV-negative women. Regardless of HIV status, short-acting contraceptives were the most commonly used FP methods. A higher proportion of HIV-positive women were more likely to be associated with unintended (both mistimed and unwanted) pregnancies and a desire not to have more children. After adjusting for confounding factors, the multivariate results showed that HIV-positive women were significantly more likely to be associated with dual use of FP (OR = 3.2; p < 0.05). Type of health facility, marital status and household wealth status were factors associated with FP use. Factors associated with fertility desires were age, education level and household wealth status.

Conclusions

The findings highlight important gaps related to utilization of FP among WLHIV. Despite having a greater likelihood of reported use of FP, HIV-positive women were more likely to have had an unintended pregnancy compared to HIV-negative women. This calls for need to strengthen family planning services for WLHIV to ensure they have better access to a wide range of FP methods. There is need to encourage the use of long-acting reversible contraceptive (LARC) to reduce the risk of unintended pregnancy and prevention of vertical transmission of HIV. However, such policies should be based on respect for women’s right to informed reproductive choice in the context of HIV/AIDS.

Trial registration

NCT01694862

Exploring the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained.

Exploring risk of experiencing intimate partner violence after HIV infection: a qualitative study among women with HIV attending postnatal services in Swaziland

OBJECTIVE

To explore risks of experiencing intimate partner violence (IPV) after HIV infection among women with HIV in a postnatal care setting in Swaziland.

DESIGN

A qualitative semistructured in-depth interview study, using thematic analysis with deductive and inductive coding, of IPV experiences after HIV infection extracted from service-integration interview transcripts.

SETTING

Swaziland.

PARTICIPANTS

19 women with HIV, aged 18-44, were purposively sampled for an in-depth interview about their experiences of services, HIV and IPV from a quantitative postnatal cohort participating in an evaluation of HIV and reproductive health services integration in Swaziland.

RESULTS

Results indicated that women were at risk of experiencing IPV after HIV infection, with 9 of 19 disclosing experiences of physical violence and/or coercive control post-HIV. IPV was initiated through two key pathways: (1) acute interpersonal triggers (eg, status disclosure, mother-to-child transmission of HIV) and (2) chronic normative tensions (eg, fertility intentions, initiating contraceptives).

CONCLUSIONS

The results highlight a need to mitigate the risk of IPV for women with HIV in shorter and longer terms in Swaziland. While broader changes are needed to resolve gender disparities, practical steps can be institutionalised within health facilities to reduce, or avoid increasing, IPV pathways for women with HIV. These might include mutual disclosure between partners, greater engagement of Swazi males with HIV services, and promoting positive masculinities that support and protect women.

TRIAL REGISTRATION NUMBER

NCT01694862.

The Costs of Delivering Integrated HIV and Sexual Reproductive Health Services in Limited Resource Settings

OBJECTIVE

To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services.

DESIGN

A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland.

METHODS

Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider's perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars.

RESULTS

The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity.

CONCLUSION

For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements.

The importance of context in implementation research

This article describes the pertinence of context in HIV/AIDS implementation research. Without attending to context and how it interacts with interventions, national protocols for HIV/AIDS interventions are likely to fail or underperform. With its focus on what works, for whom, under what contextual circumstances, and whether interventions are scalable, implementation research yields context-sensitive designs and enhances the likelihood of scale-up for equitable outcomes. A framework for implementation science is presented alongside a review of published HIV/AIDS protocols for complex interventions. A case study of the South African Prevention of Mother-to-Child Transmission of HIV program highlights the application of complex system improvement principles in developing adaptive and context-sensitive scale-up designs. Preliminary recommendations are provided that can be used to characterize context when reporting interventions and describing how context can be accounted for in implementation strategies.

Health systems integration of sexual and reproductive health and HIV services in sub-Saharan Africa: a scoping study

OBJECTIVE

Both sexual and reproductive health (SRH) services and HIV programs in sub-Saharan Africa are typically delivered vertically, operating parallel to national health systems. The objective of this study was to map the evidence on national and international strategies for integration of SRH and HIV services in sub-Saharan Africa and to develop a research agenda for future health systems integration.

METHODS

We examined the literature on national and international strategies to integrate SRH and HIV services using a scoping study methodology. Current policy frameworks, national HIV strategies and research, and gray literature on integration were mapped. Five countries in sub-Saharan Africa with experience of integrating SRH and HIV services were purposively sampled for detailed thematic analysis, according to the health systems functions of governance, policy and planning, financing, health workforce organization, service organization, and monitoring and evaluation.

RESULTS

The major international health policies and donor guidance now support integration. Most integration research has focused on linkages of SRH and HIV front-line services. Yet, the common problems with implementation are related to delayed or incomplete integration of higher level health systems functions: lack of coordinated leadership and unified national integration policies; separate financing streams for SRH and HIV services and inadequate health worker training, supervision and retention.

CONCLUSIONS

Rigorous health systems research on the integration of SRH and HIV services is urgently needed. Priority research areas include integration impact, performance, and economic evaluation to inform the planning, financing, and coordination of integrated service delivery.

Strategies for improving postpartum contraceptive use: evidence from non-randomized studies

BACKGROUND

Nearly two-thirds of women in their first postpartum year have an unmet need for family planning. Adolescents often have repeat pregnancies within a year of giving birth. Women may receive counseling on family planning both antepartum and postpartum. Decisions about contraceptive use made right after counseling may differ considerably from actual postpartum use. In earlier work, we found limited evidence of effectiveness from randomized trials on postpartum contraceptive counseling. For educational interventions, non-randomized studies may be conducted more often than randomized trials.

OBJECTIVES

We reviewed non-randomized studies of educational strategies to improve postpartum contraceptive use. Our intent was to examine associations between specific interventions and postpartum contraceptive use or subsequent pregnancy.

SEARCH METHODS

We searched for eligible non-randomized studies until 3 November 2014. Sources included CENTRAL, PubMed, POPLINE, and Web of Science. We also sought current trials via ClinicalTrials.gov and ICTRP. For additional citations, we examined reference lists of relevant reports and reviews.

SELECTION CRITERIA

The studies had to be comparative, i.e., have intervention and comparison groups. The educational component could be counseling or another behavioral strategy to improve contraceptive use among postpartum women. The intervention had to include contact within six weeks postpartum. The comparison condition could be another behavioral strategy to improve contraceptive use, usual care, other health education, or no intervention. Our primary outcomes were postpartum contraceptive use and subsequent pregnancy.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. We computed the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous measures, both with 95% Confidence Intervals (CI). Where studies used adjusted analyses for continuous outcomes, we presented the results as reported by the investigators. Due to differences in interventions and outcome measures, we did not conduct meta-analysis. To assess the evidence quality, we used the Newcastle-Ottawa Quality Assessment Scale.

MAIN RESULTS

Six studies met our inclusion criteria and included a total of 5143 women. Of three studies with self-reported pregnancy data, two showed pregnancy to be less likely in the experimental group than in the comparison group (OR 0.48, 95% CI 0.27 to 0.87) (OR 0.60, 95% CI 0.41 to 0.87). The interventions included a clinic-based counseling program and a community-based communication project.All studies showed some association of the intervention with contraceptive use. Two showed that treatment-group women were more likely to use a modern method than the control group: ORs were 1.77 (95% CI 1.08 to 2.89) and 3.08 (95% CI 2.36 to 4.02). In another study, treatment-group women were more likely than control-group women to use pills (OR 1.78, 95% CI 1.26 to 2.50) or an intrauterine device (IUD) (OR 3.72, 95% CI 1.27 to 10.86) but less likely to use and injectable method (OR 0.23, 95% CI 0.05 to 1.00). One study used a score for method effectiveness. The methods of the special-intervention group scored higher than those of the comparison group at three months (MD 13.26, 95% CI 3.16 to 23.36). A study emphasizing IUDs showed women in the intervention group were more likely to use an IUD (OR 1.79, 95% CI 1.20 to 2.69) and less likely to use no method (OR 0.48, 95% CI 0.31 to 0.75). In another study, contraceptive use was more likely among women in a health service intervention compared to women in a community awareness program at four months (OR 1.79, 95% CI 1.40 to 2.30) or women receiving standard care at 10 to 12 months (OR 2.08, 95% CI 1.58 to 2.74). That study was the only one with a specific component on the lactational amenorrhea method (LAM) that had sufficient data on LAM use. Women in the health service group were more likely than those in the community awareness group to use LAM (OR 41.36, 95% CI 10.11 to 169.20).

AUTHORS' CONCLUSIONS

We considered the quality of evidence to be very low. The studies had limitations in design, analysis, or reporting. Three did not adjust for potential confounding and only two had sufficient information on intervention fidelity. Outcomes were self reported and definitions varied for contraceptive use. All studies had adequate follow-up periods but most had high losses, as often occurs in contraception studies.

Experiences of stigma among women living with HIV attending sexual and reproductive health services in Kenya: a qualitative study

Background

Researchers have widely documented the pervasiveness of HIV stigma and discrimination, and its impact on people living with HIV. Only a few studies, however, have analysed the perceptions of women living with HIV accessing sexual and reproductive health (SRH) services. This study explores the experiences of stigma of HIV-positive clients attending family planning and post-natal services and implications for service use and antiretroviral therapy (ART) adherence. Our aim was to gain a better understanding of the impact of various dimensions of stigma on service use and ART adherence among HIV clients in order to inform the response of integrated SRH services.

Methods

In-depth interviews were conducted with 48 women living with HIV attending SRH services in two districts in Kenya. Data were coded using Nvivo 8 and analysed using a thematic analysis approach.

Results

Findings show that many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Many women feared desertion following disclosure of their positive status to partners. Consequently some women preferred to hide their status and adhere to HIV treatment in secret. However, the majority of study participants attending postnatal care (PNC) services also revealed that anticipated stigma does not adversely affect their HIV drug uptake and ART adherence, as their drive to live outweighs their fear of stigma. Our findings also seem to suggest a preference for specialist HIV services by some family planning (FP) clients because of better confidentiality and reduced opportunities for unwanted disclosure that could lead to stigma.

Conclusions

The findings highlight that anticipated stigma leading to low disclosure is widespread and sometimes reinforced by health providers’ actions and facility layout (contributing to enacted stigma). However, the motivation to stay healthy and look after the children appears in many cases to override fears of stigma related to ART adherence in our client-based sample.

The impact of HIV/SRH service integration on workload: analysis from the Integra Initiative in two African settings

BACKGROUND

There is growing interest in integration of HIV and sexual and reproductive health (SRH) services as a way to improve the efficiency of human resources (HR) for health in low- and middle-income countries. Although this is supported by a wealth of evidence on the acceptability and clinical effectiveness of service integration, there is little evidence on whether staff in general health services can easily absorb HIV services.

METHODS

We conducted a descriptive analysis of HR integration through task shifting/sharing and staff workload in the context of the Integra Initiative - a large-scale five-year evaluation of HIV/SRH integration. We describe the level, characteristics and changes in HR integration in the context of wider efforts to integrate HIV/SRH, and explore the impact of HR integration on staff workload.

RESULTS

Improvements in the range of services provided by staff (HR integration) were more likely to be achieved in facilities which also improved other elements of integration. While there was no overall relationship between integration and workload at the facility level, HIV/SRH integration may be most influential on staff workload for provider-initiated HIV testing and counselling (PITC) and postnatal care (PNC) services, particularly where HIV care and treatment services are being supported with extra SRH/HIV staffing. Our findings therefore suggest that there may be potential for further efficiency gains through integration, but overall the pace of improvement is slow.

CONCLUSIONS

This descriptive analysis explores the effect of HIV/SRH integration on staff workload through economies of scale and scope in high- and medium-HIV prevalence settings. We find some evidence to suggest that there is potential to improve productivity through integration, but, at the same time, significant challenges are being faced, with the pace of productivity gain slow. We recommend that efforts to implement integration are assessed in the broader context of HR planning to ensure that neither staff nor patients are negatively impacted by integration policy.

Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic

Objectives

To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use.

Methods

Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically.

Results

64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears.

Conclusions

Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.

Integration of HIV and maternal healthcare in a high HIV-prevalence setting: analysis of client flow data over time in Swaziland

OBJECTIVE

Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland.

DESIGN

In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites.

PARTICIPANTS

8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012.

INTERVENTION

Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009-2010.

MAIN OUTCOME MEASURES

The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling.

RESULTS

Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)-the most common reasons for women's attendance-and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities.

CONCLUSIONS

Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC.

TRIAL REGISTRATION NUMBER

Current Controlled Trials NCT01694862.

Exploring experiences in peer mentoring as a strategy for capacity building in sexual reproductive health and HIV service integration in Kenya

Background

The Integra Initiative designed, tested, and adapted protocols for peer mentorship in order to improve service providers’ skills, knowledge, and capacity to provide quality integrated HIV and sexual and reproductive health (SRH) services. This paper describes providers’ experiences in mentoring as a method of capacity building. Service providers who were skilled in the provision of FP or PNC services were selected to undergo a mentorship training program and to subsequently build the capacity of their peers in SRH-HIV integration.

Methods

A qualitative assessment was conducted to assess provider experiences and perceptions about peer mentoring. In-depth interviews were conducted with twelve mentors and twenty-three mentees who were trained in SRH and HIV integration. Interviews were recorded, transcribed, and imported to NVivo 9 for analysis. Thematic analysis methods were used to develop a coding framework from the research questions and other emerging themes.

Results

Mentorship was perceived as a feasible and acceptable method of training among mentors and mentees. Both mentors and mentees agreed that the success of peer mentoring largely depended on cordial relationship and consensus to work together to achieve a specific set of skills. Mentees reported improved knowledge, skills, self-confidence, and team work in delivering integrated SRH and HIV services as benefits associated with mentoring. They also associated mentoring with an increase in the range of services available and the number of clients seeking those services. Successful mentorship was conditional upon facility management support, sufficient supplies and commodities, a positive work environment, and mentors selection.

Conclusion

Mentoring was perceived by both mentors and mentees as a sustainable method for capacity building, which increased providers’ ability to offer a wide range of and improved access to integrated SRH and HIV services.

Family planning practices and pregnancy intentions among HIV-positive and HIV-negative postpartum women in Swaziland: a cross sectional survey

Background

In settings where sexually transmitted infection (STI) and HIV prevalence is high, the postpartum period is a time of increased biological susceptibility to pregnancy related sepsis. Enabling women living with HIV to avoid unintended pregnancies during the postpartum period can reduce vertical transmission and maternal mortality associated with HIV infection. We describe family planning (FP) practices and fertility desires of HIV-positive and HIV-negative postpartum women in Swaziland.

Methods

Data are drawn from a baseline survey of a four-year multi country prospective cohort study under the Integra Initiative, which is measuring the benefits and costs of providing integrated HIV and sexual and reproductive health (SRH) services in Kenya and Swaziland. We compare data from 386 HIV-positive women and 483 HIV-negative women recruited in Swaziland between February and August 2010. Data was collected on hand-held personal digital assistants (PDAs) covering fertility desires, mistimed or unwanted pregnancies and contraceptive use prior to their most recent pregnancy. Data were analysed using Stata 10.0. Descriptive statistics were conducted using the chi square test for categorical variables. Measures of effect were assessed using multivariate fixed effects logistic regression model accounting for clustering at facility level and the results are presented as adjusted odds ratios.

Results

Majority (69.2%) of postpartum women reported that their most recent pregnancy was unintended with no differences between HIV-positive and HIV-negative women: OR: 0.96 (95% CI) (0.70, 1.32). Although, there were significant differences between HIV-positive and HIV-negative women who reported that their previous pregnancy was unwanted, (20.7% vs. 13.5%, p = 0.004), when adjusted this was not significant OR: 1.43 (0.92, 1.91). 47.2% of HIV-positive women said it was mistimed compared to 52.5%, OR: 0.79 (0.59, 1.06). 37.9% of all women said they do not want another child. Younger women were more likely to have unwanted pregnancies: OR: 1.12 (1.07, 1.12), while they were less likely to have mistimed births; OR: 0.82 (0.70, 0.97). Those with tertiary education were less likely to have unwanted or mistimed pregnancies OR: 0.30 (0.11, 0.86). Half of HIV-positive women and more than a third of HIV-negative women reported that they had been using a FP method when they became pregnant with no differences between the groups: OR: 1.61 (0.82,3.41). Only short-acting methods were available to these women before the most recent pregnancy; and available during the postpartum visit. One fifth of all women received an FP method during the current visit. Among the four fifths who did not receive a method 17.3% reported they were already using a method or were breastfeeding. HIV-positive women were more likely to have already started a method than HIV-negative women (20% vs. 15%, p = 0.089).

Conclusion

There are few differences overall between the experiences of both HIV-positive and negative women in terms of FP experiences, unintended pregnancy and services received during the early postpartum period in Swaziland. Women attending postpartum facilities are receiving satisfactory care. Access to a wider range of effective methods is urgently needed if high levels of unintended pregnancy are to be reduced among HIV-positive and HIV-negative women living in Swaziland.

Accelerators/decelerators of achieving universal access to sexual and reproductive health services: a case study of Iranian health system

Background

At the 1994 International Conference on Population and Development (ICPD), held in Cairo, the global community agreed to the goal of achieving universal access to sexual and reproductive health (SRH) and rights by 2015. This research explores the accelerators and decelerators of achieving universal access to the sexual and reproductive health targets and accordingly makes some suggestions.

Method

We have critically reviewed the latest national reports and extracted the background data on each SRH indicator. The key stakeholders, both national and international, were visited and interviewed at two sites. A total of 55 in-depth interviews were conducted with religious leaders, policy-makers, senior managers, senior academics, and health care managers. Six focus-group discussions were also held among health care providers. The study was qualitative in nature.

Results

Obstacles on the road to achieving universal access to SRH can be viewed from two perspectives. One gap exists between current achievements and the targets. The other gap arises due to age, marital status, and residency status. The most recently observed trends in the indicators of the universal access to SRH shows that the achievements in the “unmet need for family planning” have been poor. Unmet need for family planning could directly be translated to unwanted pregnancies and unwanted childbirths; the former calls for sexual education to underserved people, including adolescents; and the latter calls for access to safe abortion. Local religious leaders have not actively attended international goal-setting programs. Therefore, they usually do not presume a positive attitude towards these goals. Such negative attitudes seem to be the most important factors hindering the progress towards universal access to SRH. Lack of international donors to fund for SRH programs is also another barrier. In national levels both state and the society are interactively playing their roles. We have used a cascade model for presenting the barriers at the state levels from the strategic planning to implementation. Social factors are to be considered as a background for other factors at all stages.

Conclusion

Accelerating universal access to SRH requires adequate funding, firm political commitment, creative programming, and the involvement of diverse actors, including faith-based, civil society, and private sector partners.

Are integrated HIV services less stigmatizing than stand-alone models of care? A comparative case study from Swaziland

Introduction

Integrating HIV with primary health services has the potential to reduce HIV-related stigma through delivering care in settings disassociated with HIV. This study investigated the relationship between integrated care and felt stigma. The study design was a comparative case study of four models of HIV care in Swaziland, ranging from fully integrated to fully stand-alone HIV care.

Methods

An exit survey (N=602) measured differences in felt stigma across model of care; the primary outcome “perception of HIV status exposure through clinic attendance” was analyzed using multivariable logistic regression. In-depth interviews (N=22) explored whether and how measured differences in stigma experiences were related to service integration.

Results

There were significant differences in perceived status exposure across models of care. After adjustment for potential confounding between sites, those at a partially integrated site and a partially stand-alone site had greater odds of perceived status exposure than those at the fully stand-alone site (aOR 3.33, 95% CI 1.98–5.60; and aOR 11.84, 95% CI 6.89–20.36, respectively). There was no difference between the fully stand-alone and the fully integrated clinic. Qualitative data suggested that many clients at HIV-only sites felt greater confidentiality knowing that those around them were positive, and support was gained from other HIV care clients. Confidentiality was maintained in various ways, even in stand-alone sites, through separate waiting areas for HIV testing and HIV treatment, and careful clinic and room labelling.

Conclusions

The relationship between model of care and stigma was complex, and the hypothesis that stigma is higher at stand-alone sites did not hold true in this high prevalence setting. Policy-makers should ensure that service integration does not increase stigma, in particular within partially integrated models of care.