What the better half is thinking: A comparison of men's and women's responses and agreement between spouses regarding reported sexual and reproductive behaviors in Rwanda

A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data

BACKGROUND

Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia.

METHODS/DESIGN

Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics.

RESULTS

The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline.

DISCUSSION

In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.

Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda

BACKGROUND

When integrated with couples' voluntary HIV counselling and testing (CVCT), family planning including long acting reversible contraceptives (LARC) addresses prongs one and two of prevention of mother-to-child transmission (PMTCT).

METHODS

In this observational study, we enrolled equal numbers of HIV concordant and discordant couples in four rural and four urban clinics, with two Catholic and two non-Catholic clinics in each area. Eligible couples were fertile, not already using a LARC method, and wished to limit or delay fertility for at least 2 years. We provided CVCT and fertility goal-based family planning counselling with the offer of LARC and conducted multivariate analysis of clinic, couple, and individual predictors of LARC uptake.

RESULTS

Of 1290 couples enrolled, 960 (74%) selected LARC: Jadelle 5-year implant (37%), Implanon 3-year implant (26%), or copper intrauterine device (IUD) (11%). Uptake was higher in non-Catholic clinics (85% vs. 63% in Catholic clinics, p < 0.0001), in urban clinics (82% vs. 67% in rural clinics, p < 0.0001), and in HIV concordant couples (79% vs. 70% of discordant couples, p = .0005). Religion of the couple was unrelated to clinic religious affiliation, and uptake was highest among Catholics (80%) and lowest among Protestants (70%) who were predominantly Pentecostal. In multivariable analysis, urban location and non-Catholic clinic affiliation, Catholic religion of woman or couple, younger age of men, lower educational level of both partners, non-use of condoms or injectable contraception at enrollment, prior discussion of LARC by the couple, and women not having concerns about negative side effects of implant were associated with LARC uptake.

CONCLUSIONS

Fertility goal-based LARC recommendations combined with couples' HIV counselling and testing resulted in a high uptake of LARC methods, even among discordant couples using condoms for HIV prevention, in Catholic clinics, and in rural populations. This model successfully integrates prevention of HIV and unplanned pregnancy.

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

BACKGROUND

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

An Exploratory Analysis of Factors Associated With Interest in Postpartum Intrauterine Device Uptake Among Pregnant Women and Couples in Kigali, Rwanda

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.

Community health worker promotions increase uptake of long-acting reversible contraception in Rwanda

BACKGROUND

We coordinated community health worker (CHW) promotions with training and support of government clinic nurses to increase uptake of long-acting reversible contraception (LARC), specifically the copper intrauterine device (IUD) and the hormonal implant, in Kigali, Rwanda.

METHODS

From August 2015 to September 2016, CHW provided fertility goal-based family planning counseling focused on LARC methods, engaged couples in family planning counseling, and provided written referrals to clients expressing interest in LARC methods. Simultaneously, we provided didactic and practical training to clinic nurses on LARC insertion and removal. We evaluated: 1) aggregate pre- versus post-implementation LARC uptake as a function of CHW promotions, and 2) demographic factors associated with LARC uptake among women responding to CHW referrals.

RESULTS

7712 referrals were delivered by 184 CHW affiliated with eight government clinics resulting in 6072 family planning clinic visits (79% referral uptake). 95% of clinic visits resulted in LARC uptake (16% copper IUD, 79% hormonal implant). The monthly average for IUD insertions doubled from 29 prior to service implementation to 61 after (p < 0.0001), and the monthly average for implant insertions increased from 109 to 309 (p < 0.0001). In adjusted analyses, LARC uptake was associated (p < 0.05) with the CHW referral being issued to the couple (versus the woman alone, adjusted odds ratio, aOR = 2.6), having more children (aOR = 1.3), desiring more children (aOR = 0.8), and having a religious affiliation (aOR = 2.9 Protestant, aOR = 3.1 Catholic, aOR = 2.5 Muslim each versus none/other). Implant versus non-LARC uptake was associated with having little or no education; meanwhile, having higher education was associated with IUD versus implant uptake.

CONCLUSIONS

Fertility goal-based and couple-focused family planning counseling delivered by CHW, coupled with LARC training and support of nursing staff, substantially increased uptake of LARC methods.

Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

'He said, she said': assessing dyadic agreement of reported sexual behaviour and decision-making among an HIV sero-discordant couples cohort in Uganda

BACKGROUND

The intimate nature of sexuality makes it challenging to accurately measure sexual behaviour. To assess response reliability, we examined agreement between couples in heterosexual HIV sero-discordant partnership on survey questions regarding condom use and sexual decision-making.

METHODS

Data for this analysis come from baseline data from a cohort study of HIV sero-discordant couples in Jinja, Uganda. We examined the degree of agreement between male and female partners on standard measures of sexual behaviour using the kappa (κ) statistic and 95% confidence intervals (95% CIs).

RESULTS

Among 409 couples, the median age for the male partner was 41 [interquartile range (IQR) 35-48] years and the female partner was 35 (IQR 30-40) years. Among 58.2% of the couples, the male was the HIV-positive partner. Questions with high or substantial couple agreement included condom use at last sex (κ=0.635, 95% CI 0.551-0.718) and frequency of condom use (κ=0.625, 95% CI 0.551-0.698). Questions with low or fair couple agreement included decision-making regarding condom use (κ=0.385, 95% CI 0.319-0.451), wanting more biological children (κ=0.375, 95% CI 0.301-0.449) and deciding when to have sex (κ=0.236, 95% CI 0.167-0.306).

CONCLUSIONS

Survey questions assessing condom use had the highest level of couple agreement and questions regarding sexual decision-making and fertility desire had low couple agreement. Questions with high agreement have increased reliability and reduced measurement bias; however, questions with low agreement between couples identify important areas for further investigation, particularly perceived relationship control and gender differences.

Concordance of risk behavior reporting within HCV serodiscordant injecting partnerships of young injection drug users in San Francisco, CA

INTRODUCTION

Young injection drug users (IDU, under age 30) often inject with other IDU, creating an environment for risk of blood-borne disease transmission through sharing of needles and drug preparation equipment. Epidemiologic studies rely on self reported injection behavior data for measures of transmission risk, therefore we sought to quantify the degree of concordance of reported injecting risk behaviors between injecting dyads.

METHODS

From May, 2006 through 2013 we enrolled 72 injecting dyads in San Francisco, California, who were hepatitis C virus (HCV) RNA discordant. Each partnership was followed prospectively for up to six months. Monthly interviews from each partner were date-matched and responses to relationship characteristics and risk behavior questions were compared. Concordance of reporting was estimated with the concordance correlation coefficient for longitudinal data (CCC) and the prevalence adjusted bias adjusted kappa (PABAK).

RESULTS

Participants had a median age of 26 (IQR: 23, 28) years and median years injecting of 7.0 (IQR: 3.0, 10.6). Thirty-eight percent of the injecting dyads were also sexual partners. Concordance levels were highest for partnership characteristics, such as length of acquaintance, number of days cohabitating, and sexual intercourse in the past month (CCC=0.95; 0.82, and 0.90, respectively). Shared injection risk behaviors such as injecting with the HCV+ partner's previously used syringe and using contaminated injection preparation equipment had slight to fair agreement (CCC=0.22; 0.23; PABAK=0.43, 0.36, respectively).

CONCLUSIONS

Concordance levels ranged from low to high. Potential sources of measurement error for low agreement items include recall and social-desirability biases and question interpretation.

Decisions, decisions: the importance of condom use decision making among HIV sero-discordant couples in a prospective cohort study in Uganda

OBJECTIVES

We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use.

METHODS

Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples' individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time.

RESULTS

Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders.

CONCLUSIONS

Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population.

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objective

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

Design

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

Methods

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

Results

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

Conclusions

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

Trial registration

ClinicalTrials.gov NCT00067522