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Mkwashapi D, Renju J, Mahande M, Wringe A, Changalucha J, Urassa M, Todd J. Unmet need for modern contraception by HIV status: findings from community-based studies implemented before and after earlier ART initiation program in rural Tanzania. Reprod Health 2023; 20:153. [PMID: 37845687 PMCID: PMC10577981 DOI: 10.1186/s12978-023-01695-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Tanzania Health policy insists on the need to provide all women access to contraception despite HIV status. We used data from two HIV epidemiologic serological surveys carried out at different periods of ART provision in rural Tanzania to assess the level of unmet need for modern contraception by HIV status and associated factors. METHODS We performed secondary data analysis of two surveys conducted at the Magu Health and Demographic Surveillance System site, in Mwanza, Tanzania. Information on unmet need for modern contraception was derived from fertility desire and contraception use. Unmet need, HIV status, and socioeconomic and demographic variables were analysed. The percentage of women with unmet needs for modern contraception by HIV status is presented for the 2012 and 2017 surveys. Bivariate and multivariate analyses using logistic regression were used to investigate associated factors showing adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS Data from 3352 and 3196 women aged 15-49 years collected in the 2012 and 2017 surveys, respectively, were analysed. The percentages of women with unmet needs for modern contraception in the 2012 and 2017 surveys were 30.9% (95% CI 29.4-32.6) and 31.6% (95% CI 30.0-33.3), respectively. The unmet need for modern contraception was 26% lower in HIV-uninfected women in 2012 (aOR = 0.74; 95% CI 0.569-0.973); p = 0.031). Risk factors for unmet need for modern contraception in 2012 were HIV uninfected (adjusted OR = 0.74; 95% CI 0.569-0.973); p = 0.031), married marital status (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), higher education (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), and taking alcohol (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001). Only two factors were associated with unmet need for modern contraception in 2017: married marital status (adjusted OR = 0.46; 95% CI 0.305-0.722); p = 0.001) and women who earned for their families (aOR = 0.66; 95% CI 0.494-0.887); p = 0.006). DISCUSSION Nearly one-third of women had an unmet need for modern contraception, which was lower in HIV-uninfected women than in WLHIV-infected women. The study has identified women whose demand for contraception has not been met: WLHIV, post marital women, women with low education and women who were reported to earn money for their families. Family planning interventions should be tailored to these groups of women.
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Affiliation(s)
- Denna Mkwashapi
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza, United Republic of Tanzania.
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania.
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Michael Mahande
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Alison Wringe
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - John Changalucha
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Mark Urassa
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Jim Todd
- Department of Sexual and Reproductive Health, National Institute for Medical Research, Mwanza, United Republic of Tanzania
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
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Tounkara MS, Ingabire R, Comeau DL, Karita E, Allen S, Nyombayire J, Parker R, Haddad LB, Da Costa V, Tichacek A, Mazzei A, Mukamuyango J, Wall KM. A mixed-methods study of factors influencing postpartum intrauterine device uptake after family planning counseling among women in Kigali, Rwanda. PLoS One 2022; 17:e0276193. [PMID: 36327214 PMCID: PMC9632907 DOI: 10.1371/journal.pone.0276193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Rwanda has high unmet need for family planning (FP), especially in the postpartum period when women are advised to space pregnancies at least two years for improved maternal-child health. Despite interest in the copper intrauterine device (IUD), a highly cost-effective method, access and uptake remain low. This study aimed to determine factors associated with postpartum IUD (PPIUD) uptake after postpartum family planning (PPFP) counseling as well as provider perceptions of facilitators and barriers to clients’ PPIUD uptake. Methods Postpartum women who received PPFP counseling and were less than 6 weeks postpartum were recruited for a case-control study in Kigali, Rwanda in 2018. We recruited n = 74 women who had accepted and n = 91 women who had declined the PPIUD. Multivariate logistic regression analyses evaluated associations between women’s socio-demographics, FP knowledge and decision-making, and the outcome of PPIUD uptake. Six focus groups (FGs) were conducted with FP providers (n = 24) and community health workers (n = 17) trained to deliver PPFP counseling to assess perceptions of PPFP counseling and facilitators and barriers to PPIUD uptake. FG discussions were recorded, translated, and analyzed for themes. Results Factors associated (P<0.1) with PPIUD uptake included citing its non-hormonal nature, effectiveness, and duration of protection against pregnancy as advantages. Exclusive male partner control over FP decisions (relative to women’s control or joint decision-making) was associated with non-use. Overall, limited knowledge about some aspects of the PPIUD persisted among clients even after counseling. Provider FGs highlighted client concerns, inconsistent FP messaging, and lack of male partner involvement as factors influencing non-use. Conclusions Knowledge of the IUD and its benefits was associated with PPIUD uptake. There is need to refine PPFP counseling messages to address remaining knowledge gaps and concerns. Additionally, male partner involvement in FP counseling and decisions with their partners could be a key strategy to increase both PPIUD and FP uptake in Rwanda.
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Affiliation(s)
- Mariama S. Tounkara
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Rosine Ingabire
- Projet San Francisco, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Kigali, Rwanda
| | - Dawn L. Comeau
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Etienne Karita
- Projet San Francisco, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Kigali, Rwanda
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Julien Nyombayire
- Projet San Francisco, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Kigali, Rwanda
| | - Rachel Parker
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Lisa B. Haddad
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Vanessa Da Costa
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Amelia Mazzei
- Projet San Francisco, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Kigali, Rwanda
| | - Jeannine Mukamuyango
- Projet San Francisco, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Kigali, Rwanda
| | - Kristin M. Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America,* E-mail:
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Magadi MA. HIV and Unintended Fertility in Sub-Saharan Africa: Multilevel Predictors of Mistimed and Unwanted Fertility Among HIV-Positive Women. Popul Res Policy Rev 2020. [DOI: 10.1007/s11113-020-09620-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nabirye J, Matovu JKB, Bwanika JB, Makumbi F, Wanyenze RK. Missed opportunities for family planning counselling among HIV-positive women receiving HIV Care in Uganda. BMC Womens Health 2020; 20:91. [PMID: 32370797 PMCID: PMC7201557 DOI: 10.1186/s12905-020-00942-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 04/12/2020] [Indexed: 11/23/2022]
Abstract
Introduction HIV-positive women who are still in the reproductive years need adequate sexual and reproductive health information to make informed reproductive health choices. However, many HIV-positive women who interface with the health system continue to miss out on this information. We sought to: a) determine the proportion of HIV-positive women enrolled in HIV care who missed family planning (FP) counselling; and b) assess if any association existed between receipt of FP counselling and current use of modern contraception to inform programming. Methods Data were drawn from a quantitative national cross-sectional survey of 5198 HIV-positive women receiving HIV care at 245 HIV clinics in Uganda; conducted between August and November 2016. Family planning counselling was defined as provision of FP information (i.e. available FP methods and choices) to an HIV-positive woman by a health provider during ANC, at the time of delivery or at the PNC visit. Analyses on receipt of FP counselling were done on 2760 HIV-positive women aged 15–49 years who were not currently pregnant and did not intend to have children in the future. We used a modified Poisson regression model to determine the Prevalence Ratio (PR) as a measure of association between receipt of any FP counselling and current use of modern contraception, controlling for potential confounders. Analyses were performed using STATA statistical software, version 14.1. Results Overall, 2104 (76.2%) HIV-positive women reported that they received FP counselling at any of the three critical time-points. Of the 24% (n = 656) who did not, 37.9% missed FP counselling at ANC; 41% missed FP counselling during delivery; while 54% missed FP counselling at the post-natal care visit. HIV-positive women who received any FP counselling were significantly more likely to report current use of modern contraception than those who did not (adjusted PR [adj. PR] = 1.21; 95% Confidence Interval [CI]: 1.10, 1.33). Conclusion Nearly one-quarter of HIV-positive women did not receive any form of FP counselling when they interfaced with the healthcare system. This presents a missed opportunity for prevention of unintended pregnancies, and suggests a need for the integration of FP counselling into HIV care at all critical time-points.
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Affiliation(s)
- Juliet Nabirye
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Joseph K B Matovu
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda. .,Busitema University Faculty of Health Sciences, Mbale, Uganda.
| | - John Baptist Bwanika
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Fredrick Makumbi
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda
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Da Costa V, Ingabire R, Sinabamenye R, Karita E, Umutoni V, Hoagland A, Allen S, Mork E, Parker R, Mukamuyango J, Haddad L, Nyombayire J, Wall KM. An Exploratory Analysis of Factors Associated With Interest in Postpartum Intrauterine Device Uptake Among Pregnant Women and Couples in Kigali, Rwanda. Clin Med Insights Reprod Health 2019; 13:1179558119886843. [PMID: 31839717 PMCID: PMC6893932 DOI: 10.1177/1179558119886843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/10/2019] [Indexed: 11/15/2022]
Abstract
Background: The desire to space or prevent future pregnancies is high among postpartum women in Rwanda. However, the use of long-acting reversible contraception (LARC), especially the highly effective and cost-effective copper intrauterine device (IUD), is very low, whereas the rates of unintended pregnancy are high. This study aims to identify factors associated with pregnant women’s and couple’s interest in receiving a postpartum intrauterine device (PPIUD) within 6 weeks after delivery. Methods: A total of 150 pregnant women or couples attending antenatal care (ANC) in Kigali, Rwanda participated in this cross-sectional study. After participating in a postpartum LARC counseling session, surveys assessed participants’ demographics, pregnancy experiences and desires, and PPIUD knowledge, attitudes, practices, and interest. Multivariable logistic regression was used to model factors associated PPIUD interest within 6 weeks postpartum. Results: Although only 3% of women had ever used an IUD previously, 124 (83%) women were interested in receiving a PPIUD after counseling. Self-reporting physical side effects (adjusted odds ratio [aOR], 0.21; 95% confidence interval [CI], 0.06-0.75) and infection (aOR, 0.19; 95% CI, 0.04-0.85) as disadvantages to the IUD were significantly associated with no interest in receiving a PPIUD. Interest did not differ by male involvement. Conclusion: Recommendations to increase PPIUD uptake include educating pregnant women and couples about the method during ANC and addressing client myths and misconceptions about the IUD. This strategy allows pregnant women and couples to make informed decisions about their future contraception use, reduce unmet need for family planning, and reduce unintended pregnancy.
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Affiliation(s)
| | | | | | | | | | | | | | - Ellen Mork
- University of Michigan, Ann Arbor, MI, USA
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Guen ML, Marsicano É, Bajos N, Desgrées du Loû A. Union break-up after HIV diagnosis among sub-Saharan African migrants in France: disclosing HIV status is linked with staying in union. AIDS Care 2018; 31:699-706. [PMID: 30512965 DOI: 10.1080/09540121.2018.1554240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Sub-Saharan African migrants living in France are particularly affected by HIV. Due to the fear of sexual transmission of the virus, those in a relationship could experience a union break-up after an HIV diagnosis. Based on data from the time-event ANRS-Parcours survey that was conducted among a representative sample of sub-Saharan migrants living with HIV (France, 2012-2013), we studied union break-ups after HIV diagnosis among people who were in a relationship at the time of their diagnosis. Women experienced a more rapid union break-up after HIV diagnosis than did men. The living conditions of men were not correlated to their risk of union break-up while among women, having a personal dwelling reduced the risk of union break-up. For both sexes, less established relationships were more likely to break up after HIV diagnosis. Having disclosed the HIV status to a partner was associated with a reduced risk of separation between partners, after adjustment on socio-economic conditions and migration characteristics.
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Affiliation(s)
- Mireille Le Guen
- a Institut de Recherche pour le Développement (IRD) - Center Population et Développement (Ceped) , UMR Université Paris Descartes-IRD, ERL INSERM U1244 , Paris , France.,b Institut National de Recherche Médicale (Inserm) - Center d'Étude en Santé des Populations (Cesp) U1018.,c EDSP , Université Paris Sud, Université Paris Saclay
| | - Élise Marsicano
- b Institut National de Recherche Médicale (Inserm) - Center d'Étude en Santé des Populations (Cesp) U1018.,d Université de Strasbourg , Strasbourg , France
| | - Nathalie Bajos
- b Institut National de Recherche Médicale (Inserm) - Center d'Étude en Santé des Populations (Cesp) U1018
| | - Annabel Desgrées du Loû
- a Institut de Recherche pour le Développement (IRD) - Center Population et Développement (Ceped) , UMR Université Paris Descartes-IRD, ERL INSERM U1244 , Paris , France
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Mashaphu S, Burns JK, Wyatt GE, Vawda NB. Psychosocial and behavioural interventions towards HIV risk reduction for serodiscordant couples in Africa: A systematic review. S Afr J Psychiatr 2018; 24:1136. [PMID: 30263215 PMCID: PMC6138108 DOI: 10.4102/sajpsychiatry.v24i0.1136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 04/19/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Sexual transmission of HIV frequently occurs in the context of a primary relationship between two partners; however, HIV prevention interventions generally focus on individuals at risk, rather than specifying couples as a unit of change and analysis, neglecting the crucial role that partners may play in sexual behaviour. This article reviews published scientific literature addressing couple-oriented HIV counselling and testing and other behavioural interventions using an online search for peer-reviewed papers. METHODS A systematic review was conducted to evaluate what has been published on psychosocial interventions in HIV serodiscordant couples in Africa. Electronic databases were searched from January 1990 to December 2015. Quality assessment of included studies was conducted using the Systematic Appraisal of Quality in Observational Research tool. RESULTS The electronic database searches initially retrieved 493 records; after cross-referencing, removing duplicates and applying strict inclusion and exclusion criteria, only eight papers were included in this review. All the studies under review showed that couples-focused counselling and educational programmes were associated with positive outcomes including reduced HIV transmission, reduced unprotected sex, increased rates of status disclosure and high levels of treatment adherence. CONCLUSIONS The literature on interventions for HIV serodiscordant couples is sparse. However, most interventions indicate that couples-focused interventions are effective in HIV risk reduction. In spite of the limited available data and repeated recommendations by different health authorities, couple-centred approaches to HIV prevention have not been implemented on a large scale.
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Affiliation(s)
| | | | - Gail E. Wyatt
- Department of Psychiatry and Bio-behavioural Sciences, University of California Los Angeles, United States
| | - Naseema B. Vawda
- Department of Behavioural Medicine, University of KwaZulu-Natal, South Africa
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Abstract
Context: Disclosure of HIV-positive status to sex partners is viewed as a preventive measure and as a social and legal responsibility for HIV-infected individuals. Aims: The aim of this study is to determine the proportions and factors responsible for disclosure of HIV seropositivity among residents of Cross River State, Nigeria. Settings and Design: This was a cross-sectional comparative study. Subjects and Methods: It involved 320 HIV-positive individuals equally selected from the urban and rural settings of Cross River State and use questionnaires. Statistical Analysis Used: Data analysis used SPSS version 20.0. Chi-square test and logistic regression were used to identify determinants of HIV status disclosure. Results: Among urban respondents, 93.8% had disclosed compared with 79.4% among rural respondents, the difference was statistically significant (P < 0.001). There was a statistically significant association between HIV status disclosure and age (P = 0.008), marital status (P = 0.027), number of nonspousal sexual partner (P = 0.006), and area of residence (P < 0.001). There was no statistically significant association between HIV status disclosure and gender (P = 0.622), between occupation (P = 0.495) or income (P = 0.351 and head of household (P = 0.241). There was statistically significant association between HIV status disclosure and level of education (P = 0.015), house ownership (P = 0.008), time from diagnosis (P = 0.003), and duration of treatment (P = 0.002). Conclusions: This study has shown that HIV seropositive status disclosure was higher when compared with other local studies, and age, marital status, and area of residence were factors associated with HIV seropositive status disclosure.
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Affiliation(s)
- Iwasam Elemi Agbor
- Department of Community Medicicne, University of Calabar, Cross River State, Abuja, Nigeria
| | - Aniekan Etokidem
- Department of Community Medicicne, University of Calabar, Cross River State, Abuja, Nigeria
| | - Emmanuel Ugwa
- Operations Research Advisor, Jhpiego-An Afilliate of Johns Hopkins University-Abuja, Nigeria
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Karita E, Nsanzimana S, Ndagije F, Wall KM, Mukamuyango J, Mugwaneza P, Remera E, Raghunathan PL, Bayingana R, Kayitenkore K, Bekan-Homawoo B, Tichacek A, Allen S. Implementation and Operational Research: Evolution of Couples' Voluntary Counseling and Testing for HIV in Rwanda: From Research to Public Health Practice. J Acquir Immune Defic Syndr 2016; 73:e51-e58. [PMID: 27741033 PMCID: PMC5367509 DOI: 10.1097/qai.0000000000001138] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/14/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Couples' voluntary HIV counseling and testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. METHODS From 1988 to 1994 in Rwanda, pregnant and postpartum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and sexually transmitted infection rates, particularly among HIV-discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were reintroduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the prevention of mother-to-child transmission program expanded to >400 clinics. In 2009, the GoR adopted joint posttest counseling procedures, and in 2010 a quarterly follow-up program for discordant couples was established in government clinics with training and technical assistance. An estimated 80%-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. CONCLUSIONS Rwanda is the first African country to have established CVCT as standard of care in antenatal care. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators, and budgets. Governments, bilateral, and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections.
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Affiliation(s)
- Etienne Karita
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Felix Ndagije
- US Centers for Disease Control and Prevention (CDC), Kigali, Rwanda
| | - Kristin M. Wall
- Department of Epidemiology, School of Public Health, Emory University, Atlanta, GA
| | - Jeannine Mukamuyango
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | | | - Eric Remera
- Rwanda Biomedical Center (RBC), Kigali, Rwanda
| | - Pratima L. Raghunathan
- US Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA; and
| | - Roger Bayingana
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kayitesi Kayitenkore
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Brigitte Bekan-Homawoo
- Project San Francisco (PSF), Kigali, Rwanda
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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Abstract
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.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Thomas W Grey
- FHI 360Social and Behavioral Health Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Mario Chen
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Julie Denison
- Johns Hopkins University Bloomberg School of Public HealthInternational HealthBaltimoreMarylandUSA
| | - Gretchen Stuart
- University of North Carolina School of MedicineDepartment of Obstetrics and Gynecology3031 Old Clinic Building CB#7570Chapel HillNorth CarolinaUSA27599‐7570
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Abstract
A significant proportion of HIV-positive adults in sub-Saharan Africa are in serodiscordant relationships. Identification of such serodiscordant couples through couple HIV testing and counseling (HTC) is thought to promote safe sexual behavior and reduce the probability of within couple seroconversion. However, it is possible HTC benefits are not sustained over time and therefore repeated HTC may be more effective at preventing seroconversion than one time HTC. We tested this theory in Zomba, Malawi by randomly assigning 170 serodiscordant couples to receive repeated HTC and 167 serodiscordant couples to receive one time HTC upon study enrollment (control group). We used linear probability models and probit model with couple fixed effects to assess the impact of the intervention on risky sexual behavior. At one-year follow-up, we found that couples that received repeated HTC reported significantly more condom use. However, we found no difference in rate of seroconversion between groups, nor did we find differences in subjective expectations about seroconversion or false beliefs about HIV, two expected pathways of behavior change. We conclude that repeated HTC may promote safe sexual behavior, but this result should be interpreted with caution, as it is inconsistent with the result from biological and subjective outcomes.
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Affiliation(s)
- Adeline Delavande
- Institute for Social and Economic Research, University of Essex, Colchester, UK
| | - Zachary Wagner
- School of Public Health, University of California, Berkeley, 50 University Hall, Berkeley, CA, United States
| | - Neeraj Sood
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, United States
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12
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Abstract
This study uses eight waves of data from the population-based Tsogolo la Thanzi study (2009-2011) in rural Malawi to examine changes in young women's contraceptive practices, including the use of condoms, non-barrier contraceptive methods and abstinence, following positive and negative HIV tests. The analysis factors in women's prior perceptions of their HIV status that may already be shaping their behaviour and separates surprise HIV test results from those that merely confirm what was already believed. Fixed-effects logistic regression models show that HIV testing frequently affects the contraceptive practices of young Malawian women, particularly when the test yields an unexpected result. Specifically, women who are surprised to test HIV positive increase their condom use and are more likely to use condoms consistently. Following an HIV-negative test (whether a surprise or expected), women increase their use of condoms and decrease their use of non-barrier contraceptives; the latter may be due to an increase in abstinence following a surprise negative result. Changes in condom use following HIV testing are robust to the inclusion of potential explanatory mechanisms, including fertility preferences, relationship status and the perception that a partner is HIV positive. The results demonstrate that both positive and negative tests can influence women's sexual and reproductive behaviours, and emphasize the importance of conceptualizing of HIV testing as offering new information only insofar as results deviate from prior perceptions of HIV status.
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13
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Audet CM, Gutin SA, Blevins M, Chiau E, Alvim F, Jose E, Vaz LME, Shepherd BE, Dawson Rose C. The Impact of Visual Aids and Enhanced Training on the Delivery of Positive Health, Dignity, and Prevention Messages to Adult Patients Living with HIV in Rural North Central Mozambique. PLoS One 2015; 10:e0130676. [PMID: 26147115 PMCID: PMC4493138 DOI: 10.1371/journal.pone.0130676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 05/24/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction Positive health, dignity, and prevention (PHDP) interventions target people living with HIV and AIDS (PLHIV) to promote well-being and prevent onward transmission. Concern that increased life expectancy and improved well-being would lead to increased risky sexual behaviour and subsequent HIV transmission motivated researchers to test novel strategies to support treatment adherence, encourage safer sex, STI treatment and partner testing, prevention of mother to child transmission, and support uptake of family planning. Methods We assessed the number and type of PHDP messages delivered to PLHIV before and after the implementation of an educational intervention for health providers combined with the distribution of visual job aids and monthly technical assistance. Results From April 21, 2013 to March 20, 2014, we documented 54,731 clinical encounters at three rural health centres in Zambézia province, Mozambique from 9,248 unique patients. The percentage of patients who received all seven PHDP messages during their last three visits was 1.9% pre-intervention vs. 13.6% post- intervention (p=<0.001). Younger patients (25 years vs. 35) and those with a recent HIV diagnosis (two weeks vs. two years) had higher odds of receiving any PHDP message (Odds Ratio [OR]: 1.22 and 2.79, respectively). Patients >59 days late collecting medications were not more likely to receive adherence messages than adherent patients (p=0.17). Discussion Targeting HIV prevention efforts to PLHIV is an effective HIV prevention approach to eliminate HIV transmission. Despite intensive training and support, PHDP message delivery remained unacceptably low in rural Mozambique. Patients at high risk for treatment abandonment were not more likely to be counselled about adherence and support measures, something that needs to be addressed. Conclusions We need to develop novel strategies to motivate health care providers to deliver these messages more consistently to all patients and develop a system that assists counsellors and clinicians to quickly and effectively determine which messages should be delivered.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Departments of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
- * E-mail:
| | - Sarah A. Gutin
- Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, United States of America
| | - Meridith Blevins
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Elvino Chiau
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Fernanda Alvim
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Eurico Jose
- Friends in Global Health, Maputo and Quelimane, Mozambique
| | - Lara M. E. Vaz
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Bryan E Shepherd
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
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14
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Kisakye P, Akena WO, Kikampikaho G, Kaye DK. Factors associated with conception among a sample of HIV-positive women at a hospital in Uganda. Afr J AIDS Res 2015; 8:255-60. [PMID: 25864541 DOI: 10.2989/ajar.2009.8.3.2.923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Conception among HIV-positive individuals is an important health and social issue. However, the proportion of HIV-positive women who conceive while being aware of their serostatus and the factors that influence this decision is not well documented. In a cross-sectional study, 385 HIV-positive women in the labour ward at Mulago Hospital, Uganda, were interviewed using a structured questionnaire. Data were collected on socio-demographic characteristics, contraception ever used, knowledge of antiretrovirals (ARVs), and ARVs ever used. To assess factors associated with conception among women who know their HIV-positive status, the variables were compared for women in two groups: those who conceived while knowing their HIV-positive status and those who discovered their HIV status during pregnancy. Bivariate and logistic regression analyses were used to assess confounding variables and interactions. The data show that one in every three HIV-positive women in the study population (37.1%) conceived despite being HIV-positive. Women who conceived while knowing they were HIV-positive differed from those who conceived without knowing their HIV status in regard to employment status, marital status, the employment status of their spouse/partner, and their intention to conceive. Logistic regression showed that factors independently associated with conception in this sample of HIV-positive women were: age below 25 years (odds ratio [OR] 2.06; 95% confidence interval [CI]: 1.18-3.62); unemployment (OR 2.7; 95% CI: 1.42-5.04); carrying a first pregnancy (OR 4.53; 95% CI: 2.02-9.94), being unaware of her partner's HIV status (OR 0.26; 95% CI: 0.15-0.44); having an awareness of ARVs (OR 3.66; 95% CI: 2.15-6.25); and having regrets about conceiving while being HIV-positive (OR 0.21; 95% CI: 0.09-0.46).
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Affiliation(s)
- Peter Kisakye
- a Department of Obstetrics and Gynecology , Makerere University Medical School , PO Box 7072 , Kampala , Uganda
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15
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Marlow HM, Maman S, Moodley D, Curtis S, McNaughton Reyes L. HIV status and postpartum contraceptive use in an antenatal population in Durban, South Africa. Contraception 2014; 91:39-43. [PMID: 25288035 DOI: 10.1016/j.contraception.2014.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 09/08/2014] [Accepted: 09/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We examined contraceptive use and dual protection in the postpartum period in a Prevention of Mother to Child Transmission population and whether it varied by HIV status. STUDY DESIGN Data are from a prospective study, the South Africa HIV Antenatal Post-test Support Study. Pregnant participants were recruited from a government clinic in an urban township, and the analytic sample was 821. Following enrollment, participants were tested for HIV and administered a questionnaire at baseline and 14 weeks postpartum. We used generalized linear regression models to examine HIV status and use of modern contraceptives at 14 weeks. RESULTS The risk ratio of condom use at 14 weeks postpartum was 1.66 [95% confidence interval (CI): 1.36-2.02] for HIV-positive compared to HIV-negative women. The risk ratio for dual protection (use of a condom and a hormonal method) was 1.96 (95% CI: 1.39-2.79) at 14 weeks for HIV-positive compared to HIV-negative women. CONCLUSIONS HIV positive status may be a motivating factor for women to use condoms and dual protection. In this setting where HIV is highly prevalent, it is ever more important that women control the timing and limiting of births so as to preserve the health of the mother and child. IMPLICATION HIV status may be an important motivating behavioral factor for women to use contraceptives and dual protection in the postpartum period.
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Affiliation(s)
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina at Chapel Hill
| | - Dhayendre Moodley
- Women's Health and HIV Research Unit, Department of Obstetrics and Gynecology, Nelson R. Mandela School of Medicine, University of KwaZulu Natal
| | - Siân Curtis
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill
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16
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O’Reilly KR, Kennedy CE, Fonner VA, Sweat MD. 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. BMC Public Health 2013; 13:935. [PMID: 24099177 PMCID: PMC3852503 DOI: 10.1186/1471-2458-13-935] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 09/30/2013] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Kevin R O’Reilly
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Virginia A Fonner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael D Sweat
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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17
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Haddad L, Wall KM, Vwalika B, Htee Khu N, Brill I, Kilembe W, Stephenson R, Chomba E, Vwalika C, Tichacek A, Allen S. Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia. AIDS 2013; 27 Suppl 1:S93-103. [PMID: 24088689 PMCID: PMC4070372 DOI: 10.1097/qad.0000000000000039] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lisa Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, Georgia, USA
| | - Kristin M Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
- Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ilene Brill
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Rob Stephenson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
- Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Cheswa Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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18
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Wall KM, Haddad L, Vwalika B, Htee Khu N, Brill I, Kilembe W, Stephenson R, Chomba E, Vwalika C, Tichacek A, Allen S. Unintended pregnancy among HIV positive couples receiving integrated HIV counseling, testing, and family planning services in Zambia. PLoS One 2013; 8:e75353. [PMID: 24098692 PMCID: PMC3787093 DOI: 10.1371/journal.pone.0075353] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/12/2013] [Indexed: 12/02/2022] Open
Abstract
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
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Affiliation(s)
- Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Lisa Haddad
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Department of Gynecology and Obstetrics, Emory University, School of Medicine, Atlanta, Georgia, United States of America
| | - Bellington Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Department of Gynecology and Obstetrics, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Naw Htee Khu
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Ilene Brill
- Department of Epidemiology, Ryals School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Rob Stephenson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Elwyn Chomba
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
- Ministry of Community Development, Mother and Child Health, Lusaka, Zambia
| | - Cheswa Vwalika
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, Georgia, United States of America
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19
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Marlow HM, Maman S, Moodley D, Curtis S. Postpartum family planning service provision in Durban, South Africa: client and provider perspectives. Health Care Women Int 2013; 35:175-99. [PMID: 23998760 DOI: 10.1080/07399332.2013.815753] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Researchers in Sub-Saharan Africa have found that health facility factors influence client contraceptive use. We sought to understand how client-provider interactions, discussions of side effects, and HIV status influence women's contraceptive use postpartum. We conducted in-depth interviews with eight HIV negative clients and six HIV positive clients in Zulu, and with five nurses in English. Interviews were translated and transcribed into English. We created a codebook and coded all transcripts. Nurses and clients reported limited time to discuss contraception, side effects, and HIV. Nurses did not comply with national contraceptive policies and created unnecessary barriers to contraceptive use.
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Affiliation(s)
- Heather M Marlow
- a Department of Maternal and Child Health , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
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20
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Abstract
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.
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Affiliation(s)
- Sten H Vermund
- Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt School of Medicine, Nashville, TN 37203, USA.
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21
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Kennedy CE, Fonner VA, Sweat MD, Okero FA, Baggaley R, O'Reilly KR. Provider-initiated HIV testing and counseling in low- and middle-income countries: a systematic review. AIDS Behav 2013; 17:1571-90. [PMID: 22752501 DOI: 10.1007/s10461-012-0241-y] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Provider-initiated HIV testing and counseling (PITC) has expanded since 2007 WHO guidelines were established. We conducted a systematic review of PITC in low- and middle-income countries. Peer-reviewed studies were included if they measured pre-post or multi-arm outcomes. Two coders abstracted data using standardized forms. Nineteen studies were included, all from sub-Saharan Africa (N = 15) or Asia (N = 4). Studies were conducted in clinics for antenatal/family planning/child health (N = 12), tuberculosis (N = 4), outpatient (N = 1), sexually transmitted diseases (N = 1), and methadone maintenance (N = 1). HIV testing uptake increased after PITC. Condom use also increased following PITC in most studies; nevirapine uptake and other outcomes were mixed. Few negative outcomes were identified. Findings support PITC as an important intervention to increase HIV testing. PITC's impact on other outcomes is mixed, but does not appear to be worse than voluntary counseling and testing. PITC should continue to be expanded and rigorously evaluated across settings and outcomes.
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22
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Stephenson R, Rentsch C, Sullivan P, McAdams-Mahmoud A, Jobson G, Struthers H, McIntyre J. Attitudes toward couples-based HIV counseling and testing among MSM in Cape Town, South Africa. AIDS Behav 2013; 17 Suppl 1:S43-50. [PMID: 22961498 PMCID: PMC3529975 DOI: 10.1007/s10461-012-0293-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Couples-based voluntary HIV counseling and testing (CVCT) allows couples to receive their HIV test results together and has been demonstrated to be effective in reducing HIV transmission, increasing and sustaining condom use, and reducing sexual risk-taking among at-risk heterosexual couples. However, the acceptability of CVCT among MSM has yet to be evaluated in an African setting. The results from seven focus group discussions and 29 in-depth interviews conducted in Cape Town, South Africa exhibit overwhelmingly high acceptance of CVCT. Participants were attracted to the counseling components of the service, stating that these would allow for the couple to increase their commitment and to explore methods of how to effectively reduce their risk of acquiring or transmitting HIV in the presence of a trained counselor. These results suggest CVCT would be highly welcomed and could work to fill the significant lack of services available and accessible to MSM couples in Cape Town.
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Affiliation(s)
- Rob Stephenson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, #7025, Atlanta, GA 30322, USA.
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Abstract
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 the increased availability of antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. This review examines behavioral interventions to improve contraceptive use, for family planning, among women who are HIV-positive. OBJECTIVES We systematically reviewed studies that examined behavioral interventions for HIV-positive women that were intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen. SEARCH METHODS Through October 2012, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, CINAHL, PsycINFO, ClinicalTrials.gov and ICTRP. For other relevant papers, we examined reference lists and unpublished project reports, and contacted investigators in the field. SELECTION CRITERIA Studies evaluated a behavioral intervention for improving contraceptive use for contraception. The comparison could be another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive women versus HIV-negative women. We included nonrandomized (observational) studies as well as randomized trials.Primary outcomes were pregnancy and contraception use, e.g., uptake of a new method, improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception in general or about a specific contraceptive method. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. One author entered the data into RevMan and a second verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale.Given the need to control for confounding factors in observational 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, we did not conduct meta-analysis. MAIN RESULTS The seven studies meeting our inclusion criteria had a total of 8882 women. All were conducted in Africa. Three studies compared a special intervention versus standard services. In one, the special intervention site showed greater use of non-condom contraceptives per visit (OR 6.40; 95% CI 5.37 to 7.62) and reported a lower pregnancy incidence. In another study, use of modern contraceptives was more likely for women at sites with enhanced versus basic integrated services (OR 2.48; 95% CI 1.31 to 4.72), but the groups did not differ significantly in change from baseline. In the third study, new use of modern contraceptives, excluding condoms, was less likely for women with integrated services versus those with routine care (OR 0.56; 95% CI 0.42 to 0.75), but new use of condoms was more likely (OR 1.73; 95% CI 1.52 to 1.98).Four older studies compared HIV-positive women versus HIV-negative women. None showed any significant difference between the HIV-status groups in use of modern contraceptives. Two did not provide an intervention for the HIV-negative women. In the larger of the two studies, HIV-positive women were less likely to become pregnant (OR 0.55; 95% CI 0.43 to 0.69). HIV-positive women were more likely to discontinue their hormonal contraceptive (OR 2.52; 95% CI 1.53 to 4.14) but more likely to use condoms (OR 2.82; 95% CI 2.18 to 3.65) and spermicide (OR 2.36; 95% CI 1.69 to 3.30). Two studies provided the intervention to both HIV-status groups. One included many of the women from the study just mentioned, and also showed fewer pregnancies for HIV-positive women (OR 0.39; 95% CI 0.23 to 0.68). In the other study, the HIV-status groups were not significantly different for pregnancy or consistent condom use. AUTHORS' CONCLUSIONS Comparative research on contraceptive counseling for HIV-positive women has been limited. We found little innovation in the behavioral interventions. Our ability to make statements about overall results is hampered by varied study designs, interventions, and outcome assessments. The quality of evidence was moderate. Since some of these studies were conducted, improvements in HIV treatment have influenced the fertility intentions of HIV-positive people.The family planning field needs better ways to help women choose an appropriate contraceptive and continue using that chosen method. Women with HIV may have special concerns regarding family planning. Research could focus on assessing the woman's needs and training providers to address those issues rather than delivering standardized information.
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Affiliation(s)
- Laureen M Lopez
- Clinical Sciences, FHI 360, Research Triangle Park, North Carolina, USA.
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Adedimeji AA, Hoover DR, Shi Q, Cohen MH, Gard T, Anastos K. Differences in the Nonuse of any Contraception and Use of Specific Contraceptive Methods in HIV Positive and HIV Negative Rwandan Women. AIDS Res Treat 2012; 2012:367604. [PMID: 23304468 DOI: 10.1155/2012/367604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 10/25/2012] [Indexed: 11/21/2022] Open
Abstract
Contraception can reduce the dual burden of high fertility and high HIV prevalence in sub-Sahara Africa, but significant barriers remain regarding access and use. We describe factors associated with nonuse of contraception and with use of specific contraceptive methods in HIV positive and HIV negative Rwandan women. Data from 395 HIV-positive and 76 HIV-negative women who desired no pregnancy in the previous 6 months were analyzed using univariate and multivariate logistic regression models to identify clinical and demographic characteristics that predict contraceptive use. Differences in contraceptive methods used were dependent on marital/partner status, partner's knowledge of a woman's HIV status, and age. Overall, condoms, abstinence, and hormonal methods were the most used, though differences existed by HIV status. Less than 10% of women both HIV+ and HIV− used no contraception. Important differences exist between HIV-positive and HIV-negative women with regard to contraceptive method use that should be addressed by interventions seeking to improve contraceptive prevalence.
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Abstract
OBJECTIVES We investigated the impact of HIV status on fertility desires in Uganda. METHODS We surveyed 1594 women aged 18 to 49 years visiting outpatient services at Mbarara Regional Hospital, from May through August 2010. Of these, 59.7% were HIV-positive; 96.4% of HIV-positive women were using antiretroviral therapy (ART). We used logistic regression models to examine relationships between HIV status and fertility desires, marital status, household structure, educational attainment, and household income. RESULTS Among married women, HIV-positive status was significantly associated with a lower likelihood of desiring more children (27.7% vs 56.4% of HIV-negative women; χ(2) = 39.97; P < .001). The difference remained highly significant net of age, parity, son parity, foster children, education, or household income. HIV-positive women were more likely to be poor, unmarried, single heads of household, in second marriages (if married), living with an HIV-positive spouse, and supporting foster children. CONCLUSIONS We found a strong association between positive HIV status and lower fertility aspirations among married women in Uganda, irrespective of ART status. Although the increasing availability of ART is a tremendous public health achievement, women affected by HIV have numerous continuing social needs.
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Affiliation(s)
- Rachel C Snow
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI 41809, USA.
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Abstract
Although HIV-prevalence and fertility rates in sub-Saharan Africa are among the highest in the world, little is known about how HIV infection affects the fertility preferences of men and women in the region. A quasi-experimental design and in-depth interviews conducted in rural Malawi are employed to examine how and through what pathways learning that one is HIV positive alters a person's childbearing desires. Among rural Malawians, particularly men, the desire to have more children decreases after receiving a positive HIV-test result. The motivations underlying this effect are greatly influenced by gender: women fear the physical health consequences of HIV-positive pregnancies and childbearing, whereas men see childbearing as futile because they anticipate their own early death and the deaths of their future children. Considerable ambivalence remains, nevertheless, particularly among women who strategize to live normal lives in spite of their infection, but whose definitions of "normal" vary.
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Affiliation(s)
- Sara Yeatman
- Department of Health and Behavioral Sciences, University of Colorado Denver, 1201 5th Street, Suite 280, Campus Box 188, Post Office Box 173364, Denver, CO 80217, USA.
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Marlow HM, Maman S, Groves AK, Moodley D. Fertility intent and contraceptive decision-making among HIV positive and negative antenatal clinic attendees in Durban, South Africa. Health Care Women Int 2012; 33:342-58. [PMID: 22420676 DOI: 10.1080/07399332.2012.655390] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We explored contraceptive decision-making among South African antenatal clinic attendees, fertility intent post-HIV diagnosis, and women's experiences at government health facilities. Data are from in-depth interviews with HIV negative and HIV positive women. We interviewed women in Zulu; interviews were recorded, transcribed, and translated. We conducted qualitative analyses of interviews. Women were the dominant decisionmakers about contraceptive use, whether they involved their partners or not. A majority of women obtained a contraceptive method at a government facility; however, several women were unable to attain sterilizations. Women were presented with limited contraceptive options and were not always able to access services.
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Affiliation(s)
- Heather M Marlow
- Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7445, USA.
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Abstract
In Ethiopia, most HIV-affected couples are in serodiscordant relationships and must weigh any childbearing desires against the risk of transmitting the virus to a partner or child. This analysis investigates the relationship between HIV diagnosis and fertility intentions among couple voluntary counseling and testing (VCT) clients in Ethiopia and whether this relationship differs between men and women. Data come from the Ethiopia Voluntary Counseling and Testing Integrated with Contraceptive Services (VICS) study, which collected information from men and women attending VCT at eight public sector health facilities in the Oromia region of Ethiopia. VCT clients were asked about their fertility intentions before (pre-test) and after (post-test) receiving their HIV test results. Sex-stratified logistic regression was used to find characteristics, such as the couple's HIV status, associated with ceasing to desire children between pre-test and post-test versus desiring children at both time points. Women belonging to serodiscordant couples were much more likely to cease desiring children than women in HIV-concordant couples, regardless of whether the woman (aOR=11.08, p<0.001) or her partner (aOR=9.97, p=0.001) was HIV+. Only HIV+ men in serodiscordant relationships were more likely to stop desiring children than men in HIV-concordant couples (aOR=12.10, p<0.001). Serodiscordant couples would benefit from family planning services or referrals during VCT to help meet their reproductive needs.
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Affiliation(s)
- Yung-Ting Bonnenfant
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Wall K, Karita E, Nizam A, Bekan B, Sardar G, Casanova D, Joseph Davey D, De Clercq F, Kestelyn E, Bayingana R, Tichacek A, Allen S. Influence network effectiveness in promoting couples' HIV voluntary counseling and testing in Kigali, Rwanda. AIDS 2012; 26:217-27. [PMID: 22008653 PMCID: PMC3679893 DOI: 10.1097/qad.0b013e32834dc593] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify predictors of promotion of couples' HIV voluntary counseling and testing (CVCT) in Kigali, Rwanda. DESIGN Analysis of CVCT promotional agent [influential network leaders (INLs), influential network agents (INAs)], and couple/invitation-level predictors of CVCT uptake. METHODS Number of invitations and couples tested were evaluated by INL, INA, and couple/contextual factors. Multivariable logistic regression accounting for two-level clustering analyzed factors predictive of couples' testing. RESULTS Twenty-six INLs recruited and mentored 118 INAs who delivered 24 991 invitations. 4513 couples sought CVCT services after invitation. INAs distributed an average of 212 invitations resulting in an average of 38 couples tested/agent. Characteristics predictive of CVCT in multivariate analyses included the invitee and INA being socially acquainted [adjusted odds ratio (aOR) = 1.4; 95% confidence interval (CI) 1.2-1.6]; invitations delivered after public endorsement (aOR = 1.3; 95% CI 1.1-1.5); and presence of a mobile testing unit (aOR = 1.4; 95% CI 1.0-2.0). In stratified analyses, predictors significant among cohabiting couples included invitation delivery to the couple (aOR = 1.2; 95% CI 1.0-1.4) and in the home (aOR = 1.3; 95% CI 1.1-1.4), whereas among noncohabiting couples, predictors included invitations given by unemployed INAs (aOR = 1.7; 95% CI 1.1-2.7). Cohabiting couples with older men were more likely to test, whereas younger age was associated with testing among men in noncohabiting unions. CONCLUSIONS Invitations distributed by influential people were successful in prompting couples to seek joint HIV testing, particularly if the invitation was given in the home to someone known to the INA and accompanied by a public endorsement of CVCT. Mobile units also increased the number of couples tested. Country-specific strategies to promote CVCT programs are needed to reduce HIV transmission among those at highest risk for HIV in sub-Saharan Africa.
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Affiliation(s)
- Kristin Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322, USA.
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Wall KM, Kilembe W, Nizam A, Vwalika C, Kautzman M, Chomba E, Tichacek A, Sardar G, Casanova D, Henderson F, Mulenga J, Kleinbaum D, Allen S. Promotion of couples' voluntary HIV counselling and testing in Lusaka, Zambia by influence network leaders and agents. BMJ Open 2012; 2:bmjopen-2012-001171. [PMID: 22956641 PMCID: PMC3467632 DOI: 10.1136/bmjopen-2012-001171] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Hypothesising that couples' voluntary counselling and testing (CVCT) promotions can increase CVCT uptake, this study identified predictors of successful CVCT promotion in Lusaka, Zambia. DESIGN Cohort study. SETTING Lusaka, Zambia. PARTICIPANTS 68 influential network leaders (INLs) identified 320 agents (INAs) who delivered 29 119 CVCT invitations to heterosexual couples. INTERVENTION The CVCT promotional model used INLs who identified INAs, who in turn conducted community-based promotion and distribution of CVCT invitations in two neighbourhoods over 18 months, with a mobile unit in one neighbourhood crossing over to the other mid-way through. PRIMARY OUTCOME The primary outcome of interest was couple testing (yes/no) after receipt of a CVCT invitation. INA, couple and invitation characteristics predictive of couples' testing were evaluated accounting for two-level clustering. RESULTS INAs delivered invitations resulting in 1727 couples testing (6% success rate). In multivariate analyses, INA characteristics significantly predictive of CVCT uptake included promoting in community-based (adjusted OR (aOR)=1.3; 95% CI 1.0 to 1.8) or health (aOR=1.5; 95% CI 1.2 to 2.0) networks versus private networks; being employed in the sales/service industry (aOR=1.5; 95% CI 1.0 to 2.1) versus unskilled manual labour; owning a home (aOR=0.7; 95% CI 0.6 to 0.9) versus not; and having tested for HIV with a partner (aOR=1.4; 95% CI 1.1 to 1.7) or alone (aOR=1.3; 95% CI 1.0 to 1.6) versus never having tested. Cohabiting couples were more likely to test (aOR=1.4; 95% CI 1.2 to 1.6) than non-cohabiting couples. Context characteristics predictive of CVCT uptake included inviting couples (aOR=1.2; 95% CI 1.0 to 1.4) versus individuals; the woman (aOR=1.6; 95% CI 1.2 to 2.2) or couple (aOR=1.4; 95% CI 1.0 to 1.8) initiating contact versus the INA; the couple being socially acquainted with the INA (aOR=1.6; 95% CI 1.4 to 1.9) versus having just met; home invitation delivery (aOR=1.3; 95% CI 1.1 to 1.5) versus elsewhere; and easy invitation delivery (aOR=1.8; 95% CI 1.4 to 2.2) versus difficult as reported by the INA. CONCLUSIONS This study demonstrated the ability of influential people to promote CVCT and identified agent, couple and context-level factors associated with CVCT uptake in Lusaka, Zambia. We encourage the development of CVCT promotions in other sub-Saharan African countries to support sustained CVCT dissemination.
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Affiliation(s)
- Kristin M Wall
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - William Kilembe
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Azhar Nizam
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Cheswa Vwalika
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Michelle Kautzman
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Elwyn Chomba
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Amanda Tichacek
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Gurkiran Sardar
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Deborah Casanova
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Faith Henderson
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
| | - Joseph Mulenga
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Zambia Emory HIV Research Project, Lusaka, Zambia
- Zambia National Blood Transfusion Services, Lusaka, Zambia
| | - David Kleinbaum
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Susan Allen
- Department of Pathology & Laboratory Medicine, Rwanda Zambia HIV Research Group, School of Medicine, Atlanta, Georgia, USA
- Hubert Dept of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Kipp W, Heys J, Jhangri GS, Alibhai A, Rubaale T. Impact of antiretroviral therapy on fertility desires among HIV-infected persons in rural Uganda. Reprod Health 2011; 8:27. [PMID: 21975089 PMCID: PMC3214790 DOI: 10.1186/1742-4755-8-27] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/06/2011] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the fertility desires of HIV infected individuals on highly active antiretroviral therapy (HAART). In order to contribute more knowledge to this topic we conducted a study to determine if HIV-infected persons on HAART have different fertility desires compared to persons not on HAART, and if the knowledge about HIV transmission from mother-to-child is different in the two groups. Methods The study was a cross-sectional survey comparing two groups of HIV-positive participants: those who were on HAART and those who were not. Semi-structured interviews were conducted with 199 HIV patients living in a rural area of western Uganda. The desire for future children was measured by the question in the questionnaire "Do you want more children in future." The respondents' HAART status was derived from the interviews and verified using health records. Descriptive, bivariate and multivariate methods were used to analyze the relationship between HAART treatment status and the desire for future children. Results Results from the multivariate logistic regression model indicated an adjusted odds ratio (OR) of 1.08 (95% CI 0.40-2.90) for those on HAART wanting more children (crude OR 1.86, 95% CI 0.82-4.21). Statistically significant predictors for desiring more children were younger age, having a higher number of living children and male sex. Knowledge of the risks for mother-to-child-transmission of HIV was similar in both groups. Conclusions The conclusions from this study are that the HAART treatment status of HIV patients did not influence the desire for children. The non-significant association between the desire for more children and the HAART treatment status could be caused by a lack of knowledge in HIV-infected persons/couples about the positive impact of HAART in reducing HIV transmission from mother-to-child. We recommend that the health care system ensures proper training of staff and appropriate communication to those living with HIV as well as to the general community.
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Affiliation(s)
- Walter Kipp
- Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
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Bankole A, Biddlecom AE, Dzekedzeke K. Women's and men's fertility preferences and contraceptive behaviors by HIV status in 10 sub-Saharan African countries. AIDS Educ Prev 2011; 23:313-328. [PMID: 21861606 DOI: 10.1521/aeap.2011.23.4.313] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This article draws on biomarker data from Demographic and Health Surveys (2003-2007) in 10 sub-Saharan African countries to examine differences in fertility preferences and contraceptive behaviors by HIV status for women and men, taking into account whether or not they probably know their HIV status. The objective is to determine if there are common patterns in the associations between these variables across several countries. Women's and men's fertility preferences and contraceptive behaviors are relatively similar across HIV status and probable knowledge of that status. However, two consistent differences emerge in some of the countries: HIV-positive women who probably know their status are less likely to want more children and are more likely to be using male condoms than women who are HIV-negative and probably know it. A similar association is observed for men for condom use but not for limiting childbearing. Other factors unrelated to HIV status seem to be shaping women's and men's unmet demand for contraception and use of methods other than the condom.
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Muhamadi L, Tumwesigye NM, Kadobera D, Marrone G, Wabwire-Mangen F, Pariyo G, Peterson S, Ekström AM. A single-blind randomized controlled trial to evaluate the effect of extended counseling on uptake of pre-antiretroviral care in Eastern Uganda. Trials 2011; 12:184. [PMID: 21794162 PMCID: PMC3170867 DOI: 10.1186/1745-6215-12-184] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 07/27/2011] [Indexed: 11/29/2022] Open
Abstract
Background Many newly screened people living with HIV (PLHIV) in Sub-Saharan Africa do not understand the importance of regular pre-antiretroviral (ARV) care because most of them have been counseled by staff who lack basic counseling skills. This results in low uptake of pre-ARV care and late treatment initiation in resource-poor settings. The effect of providing post-test counseling by staff equipped with basic counseling skills, combined with home visits by community support agents on uptake of pre-ARV care for newly diagnosed PLHIV was evaluated through a randomized intervention trial in Uganda. Methods An intervention trial was performed consisting of post-test counseling by trained counselors, combined with monthly home visits by community support agents for continued counseling to newly screened PLHIV in Iganga district, Uganda between July 2009 and June 2010, Participants (N = 400) from three public recruitment centres were randomized to receive either the intervention, or the standard care (the existing post-test counseling by ARV clinic staff who lack basic training in counseling skills), the control arm. The outcome measure was the proportion of newly screened and counseled PLHIV in either arm who had been to their nearest health center for clinical check-up in the subsequent three months +2 months. Treatment was randomly assigned using computer-generated random numbers. The statistical significance of differences between the two study arms was assessed using chi-square and t-tests for categorical and quantitative data respectively. Risk ratios and 95% confidence intervals were used to assess the effect of the intervention. Results Participants in the intervention arm were 80% more likely to accept (take up) pre-ARV care compared to those in the control arm (RR 1.8, 95% CI 1.4-2.1). No adverse events were reported. Conclusions Provision of post-test counseling by staff trained in basic counseling skills, combined with home visits by community support agents had a significant effect on uptake of pre-ARV care and appears to be a cost-effective way to increase the prerequisites for timely ARV initiation. Trial registration The trial was registered by Current Controlled Trials Ltd C/OBioMed Central Ltd as ISRCTN94133652 and received financial support from Sida and logistical support from the European Commission.
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Affiliation(s)
- Lubega Muhamadi
- District Health Office, Iganga District Administration, PO Box 358, Iganga, Uganda.
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Stephenson R, Vwalika B, Greenberg L, Ahmed Y, Vwalika C, Chomba E, Kilembe W, Tichacek A, Allen S. A randomized controlled trial to promote long-term contraceptive use among HIV-serodiscordant and concordant positive couples in Zambia. J Womens Health (Larchmt) 2011; 20:567-74. [PMID: 21410332 DOI: 10.1089/jwh.2010.2113] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Countries facing high HIV prevalence often also experience high levels of fertility and low contraceptive use, suggesting high levels of unmet need for contraceptive services. In particular, the unique needs of couples with one or both partners HIV positive are largely missing from many current family planning efforts, which focus on the prevention of pregnancies in the absence of reduction of the risk of HIV and other sexually transmitted infections (STIs). METHODS This article presents an examination of contraceptive method uptake among a cohort of HIV serodiscordant and concordant positive study participants in Zambia. RESULTS Baseline contraceptive use was low; however, exposure to a video-based intervention that provided information on contraceptive methods and modeled desirable future planning behaviors dramatically increased the uptake of modern contraceptive methods. CONCLUSIONS Including information on family planning in voluntary counseling and testing (VCT) services in addition to tailoring the delivery of family planning information to meet the needs and concerns of HIV-positive women or those with HIV-positive partners is an essential step in the delivery of services and prevention efforts to reduce the transmission of HIV. Family planning and HIV prevention programs should integrate counseling on dual method use, combining condoms for HIV/STI prevention with a long-acting contraceptive for added protection against unplanned pregnancy.
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Affiliation(s)
- Rob Stephenson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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Kaida A, Laher F, Strathdee SA, Money D, Janssen PA, Hogg RS, Gray G. Contraceptive use and method preference among women in Soweto, South Africa: the influence of expanding access to HIV care and treatment services. PLoS One 2010; 5:e13868. [PMID: 21079770 PMCID: PMC2974641 DOI: 10.1371/journal.pone.0013868] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 10/13/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. METHODS We used survey data from 563 sexually active, non-pregnant women (18-44 years) recruited from the Perinatal HIV Research Unit in Soweto (May-December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use. RESULTS Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIV-negative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIV-positive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods. CONCLUSION Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health.
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Affiliation(s)
- Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
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Kakaire O, Osinde MO, Kaye DK. Factors that predict fertility desires for people living with HIV infection at a support and treatment centre in Kabale, Uganda. Reprod Health 2010; 7:27. [PMID: 20937095 PMCID: PMC2964526 DOI: 10.1186/1742-4755-7-27] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 10/11/2010] [Indexed: 11/10/2022] Open
Abstract
Background Studies from different contexts worldwide indicate that HIV positive patients manifest high-risk sexual behavior characterized by fertility intentions, multiple sexual partners, non-use of contraceptives and non-disclosure of HIV status to their sex partners. The objective was to analyze fertility desires among persons living with HIV at a treatment centre in Kabale Hospital, Southwestern Uganda. Methods From January to August 2009, we interviewed 400 HIV positive patients seeking care using an interviewer-administered questionnaire. We assessed socio-demographic variables, reproductive history, sexuality and fertility desires. At bivariate and multivariate analysis, characteristics of participants who reported or did not report desire to have a child in the near future were compared. Results Of the 400 respondents, (25.3%) were male, 47.3% were aged 25-34 years, over 85% were currently married or had ever been married, and the 62% had primary level of education or less. Over 17% had produced a child since the HIV diagnosis was made, and 28.6% reported that they would like to have a child in the near future. Age of the respondent, being single (versus being ever-married) and whether any of the respondents' children had died were inversely associated with fertility intentions. Conclusion Factors inversely associated with fertility intentions were age of the respondent, marital status and whether any of the respondents' children had died. Use of antiretroviral therapy was not associated with fertility intentions.
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Affiliation(s)
- Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University Medical School, P,O, Box 7072, Kampala, Uganda.
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Stephenson R, Grabbe K, Vwalika B, Ahmed Y, Vwalika C, Haworth A, Fuller L, Liu F, Chomba E, Allen S. The influence of informed consent content on study participants' contraceptive knowledge and concerns. Stud Fam Plann 2010; 41:217-24. [PMID: 21331352 PMCID: PMC3039305 DOI: 10.1111/j.1728-4465.2010.00245.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Little is known about how the information presented in the informed consent process influences study outcomes among participants. This study examines the influence of informed consent content on reported baseline contraceptive knowledge and concerns among two groups of HIV-serodiscordant and seroconcordant HIV-positive couples enrolled in research projects at an HIV research center in Lusaka, Zambia. We found significant differences in the reporting of contraceptive knowledge and concerns between couples viewing consent materials that included detailed information about contraception and those viewing consent materials that lacked the detailed information. We conclude that the design of informed consent materials should strike a balance between ensuring that participants give truly informed consent and educating participants in ways that do not compromise the assessment of the impact of behavioral interventions.
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Affiliation(s)
- Rob Stephenson
- Hubert Department of Global Health, School of Medicine, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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Bradley H, Tsui A, Kidanu A, Gillespie D. HIV infection and contraceptive need among female Ethiopian voluntary HIV counseling and testing clients. AIDS Care 2010; 22:1295-304. [DOI: 10.1080/09540121003692227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- H. Bradley
- a Department of Population, Family and Reproductive Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - A. Tsui
- a Department of Population, Family and Reproductive Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - A. Kidanu
- b Miz-Hasab Research Center , Addis Ababa , Ethiopia
| | - D. Gillespie
- a Department of Population, Family and Reproductive Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Kennedy CE, Spaulding AB, Brickley DB, Almers L, Mirjahangir J, Packel L, Kennedy GE, Mbizvo M, Collins L, Osborne K. Linking sexual and reproductive health and HIV interventions: a systematic review. J Int AIDS Soc 2010; 13:26. [PMID: 20642843 PMCID: PMC2918569 DOI: 10.1186/1758-2652-13-26] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 07/19/2010] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The international community agrees that the Millennium Development Goals will not be achieved without ensuring universal access to both sexual and reproductive health (SRH) services and HIV/AIDS prevention, treatment, care and support. Recently, there has been increasing awareness and discussion of the possible benefits of linkages between SRH and HIV programmes at the policy, systems and service delivery levels. However, the evidence for the efficacy of these linkages has not been systematically assessed. METHODS We conducted a systematic review of the evidence for interventions linking SRH and HIV. Structured methods were employed for searching, screening and data extraction. Studies from 1990 to 2007 reporting pre-post or multi-arm evaluation data from SRH-HIV linkage interventions were included. Study design rigour was scored on a nine-point scale. Unpublished programme reports were gathered as "promising practices". RESULTS Of more than 50,000 citations identified, 185 studies were included in the review and 35 were analyzed. These studies had heterogeneous interventions, populations, objectives, study designs, rigour and measured outcomes. SRH-HIV linkage interventions were generally considered beneficial and feasible. The majority of studies showed improvements in all outcomes measured. While there were some mixed results, there were very few negative findings. Generally, positive effects were shown for key outcomes, including HIV incidence, sexually transmitted infection incidence, condom use, contraceptive use, uptake of HIV testing and quality of services. Promising practices (n = 23) tended to evaluate more recent and more comprehensive programmes. Factors promoting effective linkages included stakeholder involvement, capacity building, positive staff attitudes, non-stigmatizing services, and engagement of key populations. CONCLUSIONS Existing evidence provides support for linkages, although significant gaps in the literature remain. Policy makers, programme managers and researchers should continue to advocate for, support, implement and rigorously evaluate SRH and HIV linkages at the policy, systems and service levels.
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Affiliation(s)
- Caitlin E Kennedy
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, USA
| | - Alicen B Spaulding
- University of Minnesota School of Public Health, Division of Epidemiology and Community Health, Minneapolis, USA
| | | | - Lucy Almers
- University of California, San Francisco, Global Health Sciences, San Francisco, USA
| | - Joy Mirjahangir
- University of California, San Francisco, Global Health Sciences, San Francisco, USA
| | - Laura Packel
- University of California, San Francisco, Global Health Sciences, San Francisco, USA
| | - Gail E Kennedy
- University of California, San Francisco, Global Health Sciences, San Francisco, USA
| | - Michael Mbizvo
- World Health Organization, Reproductive Health and Research, Geneva, Switzerland
| | | | - Kevin Osborne
- International Planned Parenthood Federation, London, UK
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Magadi MA, Agwanda AO. Investigating the association between HIV/AIDS and recent fertility patterns in Kenya. Soc Sci Med 2010; 71:335-344. [DOI: 10.1016/j.socscimed.2010.03.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Revised: 03/09/2010] [Accepted: 03/19/2010] [Indexed: 11/29/2022]
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Kennedy CE, Medley AM, Sweat MD, O'Reilly KR. Behavioural interventions for HIV positive prevention in developing countries: a systematic review and meta-analysis. Bull World Health Organ 2010; 88:615-23. [PMID: 20680127 DOI: 10.2471/blt.09.068213] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 12/27/2009] [Accepted: 01/06/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess the evidence for a differential effect of positive prevention interventions among individuals infected and not infected with human immunodeficiency virus (HIV) in developing countries, and to assess the effectiveness of interventions targeted specifically at people living with HIV. METHODS We conducted a systematic review and meta-analysis of papers on positive prevention behavioural interventions in developing countries published between January 1990 and December 2006. Standardized methods of searching and data abstraction were used. Pooled effect sizes were calculated using random effects models. FINDINGS Nineteen studies met the inclusion criteria. In meta-analysis, behavioural interventions had a stronger impact on condom use among HIV-positive (HIV+) individuals (odds ratio, OR: 3.61; 95% confidence interval, CI: 2.61-4.99) than among HIV-negative individuals (OR: 1.32; 95% CI: 0.77-2.26). Interventions specifically targeting HIV+ individuals also showed a positive effect on condom use (OR: 7.84; 95% CI: 2.82-21.79), which was particularly strong among HIV-serodiscordant couples (OR: 67.38; 95% CI: 36.17-125.52). Interventions included in this review were limited both in scope (most were HIV counselling and testing interventions) and in target populations (most were conducted among heterosexual adults or HIV-serodiscordant couples). CONCLUSION Current evidence suggests that interventions targeting people living with HIV in developing countries increase condom use, especially among HIV-serodiscordant couples. Comprehensive positive prevention interventions targeting diverse populations and covering a range of intervention modalities are needed to keep HIV+ individuals physically and mentally healthy, prevent transmission of HIV infection and increase the agency and involvement of people living with HIV.
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Affiliation(s)
- Caitlin E Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-1996, USA
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Torpey K, Mwenda L, Kabaso M, Malebe T, Makelele P, Mwema F, Phiri H, Mukundu J, Weaver MA, Stanback J. Excluding pregnancy among women initiating antiretroviral therapy: efficacy of a family planning job aid. BMC Public Health 2010; 10:249. [PMID: 20470367 PMCID: PMC2876108 DOI: 10.1186/1471-2458-10-249] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 05/14/2010] [Indexed: 11/22/2022] Open
Abstract
Background Guidelines for initiating ART recommend pregnancy testing, typically a urine test, as part of the basic laboratory package. The principal reason for this recommendation is that Efavirenz, a first-line antiretroviral medication, has the potential of causing birth defects when used in the first trimester of pregnancy and is therefore contraindicated for use by pregnant women. Unfortunately, in many African countries pregnancy tests are not routinely provided or available in ART clinics, and, when available outside clinics, are often not affordable for clients. Recently, the World Health Organization added a family planning job aid called the 'pregnancy checklist,' developed by researchers at Family Health International, as a recommended tool for screening new ART clients to exclude pregnancy. Although the checklist has been validated for excluding pregnancy among family planning clients, there are no data on its efficacy among ART clients. This study was conducted to assess the clinical performance of a job aid to exclude pregnancy among HIV positive women initiating ART. Methods Non-menstruating women eligible for ART were enrolled from 20 sites in four provinces in Zambia. The pregnancy checklist was administered followed by a urine pregnancy test as a reference standard. Sensitivity, specificity, and positive and negative predictive values were estimated. Results Of the 200 women for whom the checklist ruled out pregnancy, 198 were not pregnant, for an estimated negative predictive value of 99%. The sensitivity of the checklist was 90.0%, and specificity was 38.7%. Among the women, 416 out of 534 (77.9%) did not abstain from sex since their last menses. Only 72 out of the 534 women (13.4%) reported using reliable contraception. Among the 416 women who did not abstain, 376 (90.4%) did not use reliable contraception. Conclusion The pregnancy checklist is effective for excluding pregnancy in many women initiating ART, but its moderate sensitivity and specificity precludes its use to completely replace pregnancy testing. Its use should be encouraged in low resource settings where pregnancy tests are unavailable or must be rationed. Family planning methods should be available and integrated into ART clinics.
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Affiliation(s)
- Kwasi Torpey
- Family Health International/Zambia Plot 2055 Nasser Road, Lusaka, Zambia.
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Myer L, Carter RJ, Katyal M, Toro P, El-Sadr WM, Abrams EJ. Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study. PLoS Med 2010; 7:e1000229. [PMID: 20161723 PMCID: PMC2817715 DOI: 10.1371/journal.pmed.1000229] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/30/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates. METHODS AND FINDINGS We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19-2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. CONCLUSIONS ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Landon Myer
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
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Allen S. The Bert and Peggy DuPont lecture. "Love, death, and commitment: twenty three years of HIV and genocide prevention in Africa" or "Passionate not equal unhinged". Trans Am Clin Climatol Assoc 2010; 121:221-237. [PMID: 20697563 PMCID: PMC2917146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Over the last 20 years, HIV emerged as the #1 cause of death in African adults, and the Rwanda genocide became the most concentrated mass murder in recorded history. Though one catastrophe surfaced slowly and inexorably while the other smoldered for years before exploding in 1994, the lessons learned are similar. In both situations, the international community has combined moral bankruptcy with a spectacular display of incompetence. Genocide masterminds continue living in Michigan, Minneapolis and Boston, brazenly planning the final extermination of the Tutsi. Students of law, diplomacy and international development are astoundingly sanguine about this, as though our current abdication of responsibility today is mitigated by the centuries of unprincipled idiots who preceded us. If medicine operated this way we'd still be treating syphilis with arsenic. Unfortunately, medicine has lost the moral high ground in Africa through missed opportunities and misappropriation of resources. In the last five years we have spent 20% of the US bilateral foreign assistance budget putting 2.5 million Africans on anti-retroviral treatment (ART), while twice that number of new HIV infections occurred. We tested 50 million Africans for HIV without acting on the evidence and common sense: rather than-transmission happens between two people. Had we tested Africans as couples, a prevention strategy proven to be effective in multiple publications since the early '90s, we could have averted more HIV infections than we are now treating, and at a fraction of the cost.
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Affiliation(s)
- Susan Allen
- Emory University, Rwanda Zambia HIV Research Group, 1520 Clifton Rd NE#234, Atlanta, GA 30322, USA
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Dhont N, Ndayisaba GF, Peltier CA, Nzabonimpa A, Temmerman M, van de Wijgert J. Improved access increases postpartum uptake of contraceptive implants among HIV-positive women in Rwanda. EUR J CONTRACEP REPR 2009; 14:420-5. [DOI: 10.3109/13625180903340584] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE To determine how a positive HIV diagnosis influences fertility desires and reproductive decisions for women and men living in western Uganda. DESIGN : Cross-sectional survey comparing two groups of participants: those who tested HIV-positive and those who tested HIV-negative. METHODS Semistructured interviews were conducted with 421 individuals living in rural areas. Descriptive, bivariate and multivariate methods were used to analyze the relationship of the HIV status to the desire to stop childbearing, reproductive decision-making and to the use of family planning methods. RESULTS The multivariate logistic regression model indicated that the odds ratio (OR) of wanting to stop childbearing was found to be 6.25 times greater (P < 0.01) for HIV-positive than for HIV-negative individuals. Additional predictors included older age (OR 1.13, P < 0.01), female sex (OR 2.42, P = 0.03), Mutooro ethnic group (OR 3.20, P < 0.01) and greater number of living children (OR 1.62, P < 0.01). Use of dual protection against HIV/sexually transmitted infection and unwanted pregnancy was rare in both groups with seven HIV-positive participants (3.5%) using two contraceptives compared with only one (0.4%) in the HIV-negative group. The unmet need for a highly effective family planning method was higher in HIV-positive participants compared with HIV-negative ones (90 vs. 78%). CONCLUSION HIV-positive individuals in the Kabarole region have a much greater desire to stop childbearing than their HIV-negative counterparts. The barriers to utilizing family planning services, as evidenced through the very low use of highly effective contraceptive methods, have to be jointly addressed by HIV/AIDS care/prevention and family planning programs.
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Spaulding AB, Brickley DB, Kennedy C, Almers L, Packel L, Mirjahangir J, Kennedy G, Collins L, Osborne K, Mbizvo M. Linking family planning with HIV/AIDS interventions: a systematic review of the evidence. AIDS 2009; 23 Suppl 1:S79-88. [PMID: 20081392 DOI: 10.1097/01.aids.0000363780.42956.ff] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. DESIGN Systematic review of peer-reviewed articles and unpublished program reports ('promising practices') evaluating interventions linking family planning and HIV services. METHODS Articles were included if they reported post-intervention evaluation results from an intervention linking family planning and HIV services between 1990 and 2007. Systematic methods were used for searching, screening, and data extraction. Quality assessment was conducted using a 9-point rigor scale. RESULTS Sixteen studies were included in the analysis (10 peer-reviewed studies and six promising practices). Interventions were categorized into six types: family planning services provided to HIV voluntary counseling and testing (VCT) clients, family planning and VCT services provided to maternal and child health clients, family planning services provided to people living with HIV, community health workers provided family planning and HIV services, VCT provided to family planning clinic clients, and VCT and family planning services provided to women receiving postabortion care. Average study design rigor was low (3.25 out of 9). Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. CONCLUSION Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.
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Bradley H, Gillespie D, Kidanu A, Bonnenfant YT, Karklins S. Providing family planning in Ethiopian voluntary HIV counseling and testing facilities: client, counselor and facility-level considerations. AIDS 2009; 23 Suppl 1:S105-14. [PMID: 20081382 DOI: 10.1097/01.aids.0000363783.88698.a2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Governments and donors encourage the integration of family planning into voluntary HIV counseling and testing (VCT) services. We aimed to determine whether VCT counselors could feasibly offer family planning and whether clients would accept such services. DESIGN AND METHODS We employed a quasi-experimental, pre and postintervention survey design, interviewing 4019 VCT clients attending eight Ethiopian public sector facilities and 4027 additional clients 18 months after introducing family planning services in the same facilities. We constructed sex-stratified multilevel models assessing three outcomes: whether clients received contraceptive counseling, whether clients obtained contraceptive methods during VCT and whether clients intended to use condoms consistently after VCT. RESULTS Clients demonstrated lower than expected immediate need for contraception. After intervention, only 29% of women had sex in the past 30 days, and 74% of these women were already using contraceptives. Despite the relatively low risk this population had for unwanted pregnancy, family planning counseling in VCT increased from 2 to 41% for women and from 3 to 29% for men (P < 0.01). Approximately, 6% of clients received contraceptive methods. However, sexually active men and women and those with more perceived HIV risk were more likely to obtain contraceptives and intend to use condoms consistently. Men attending facilities with higher client loads were 88% less likely to receive family planning information and 93% less likely to receive contraceptives than those attending facilities with lower client loads. Male and female clients whose counselors perceived contraceptive availability to be adequate were four and two times more likely, respectively, to receive contraceptive methods than those counseled by providers who felt supplies were inadequate (P < 0.01). CONCLUSION Integrating VCT and family planning services is likely to be an effective programmatic option, but populations at risk for HIV or unintended pregnancy should be targeted.
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Abstract
Surprisingly little is known about how or if knowledge of one's HIV status influences the desire to have children in sub-Saharan Africa. This paper takes advantage of a unique situation in rural Malawi where no one knew their HIV status prior to testing being introduced as part of an ongoing panel study. Using a sample of men and women (n = 1,380) who were interviewed in 2001 and 2006, we examine how HIV positive and negative test results impact respondents' desires to continue childbearing. We then consider how prior perceptions of one's status influence this effect. Respondents who received a positive test result reduced their childbearing desires. When self-assessed likelihood of infection was considered, however, only those who were surprised by their test result altered their fertility preferences, a finding which held true for both positive and negative results. The implications of the results and potential applications to other HIV/AIDS research are discussed.
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Affiliation(s)
- Sara E Yeatman
- Department of Health and Behavioral Sciences, University of Colorado Denver, Campus Box 188, P.O. Box 173364, Denver, CO 80217, USA.
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Matthews LT, Mukherjee JS. Strategies for harm reduction among HIV-affected couples who want to conceive. AIDS Behav 2009; 13 Suppl 1:5-11. [PMID: 19347575 DOI: 10.1007/s10461-009-9551-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 03/16/2009] [Indexed: 10/20/2022]
Abstract
As effective HIV treatments become more widespread, HIV-infected individuals are living longer, healthier lives. Many HIV-affected couples (sero-discordant and sero-concordant) are considering options for safer reproduction. A large body of evidence suggests that reproductive technologies can help HIV-affected couples to safely conceive with minimal risk of HIV transmission to their partner. However, for most couples such technologies are neither geographically nor economically accessible. This paper addresses the options for safer procreation among HIV-affected couples who cannot access reproductive technologies.
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