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Logie CH, Okumu M, Berry I, Hakiza R, Baral SD, Musoke DK, Nakitende A, Mwima S, Kyambadde P, Loutet M, Batte S, Lester R, Neema S, Newby K, Mbuagbaw L. Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda. J Int AIDS Soc 2023; 26:e26185. [PMID: 37850816 PMCID: PMC10583643 DOI: 10.1002/jia2.26185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda. METHODS We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions. RESULTS We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up). CONCLUSIONS Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.
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Affiliation(s)
- Carmen H. Logie
- Factor‐Inwentash Faculty of Social WorkUniversity of TorontoTorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
- United Nations University Institute for Water, Environment & HealthHamiltonOntarioCanada
- Centre for Gender & Sexual Health EquityVancouverBritish ColumbiaCanada
| | - Moses Okumu
- School of Social WorkUniversity of Illinois Urbana‐ChampaignUrbanaIllinoisUSA
- School of Social SciencesUganda Christian UniversityMukonoUganda
| | - Isha Berry
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Robert Hakiza
- Young African Refugees for Integral Development (YARID)KampalaUganda
| | - Stefan D. Baral
- Johns Hopkins Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | | | - Simon Mwima
- School of Social WorkUniversity of Illinois Urbana‐ChampaignUrbanaIllinoisUSA
- National AIDS and STI Control Programme, Ministry of HealthKampalaUganda
| | - Peter Kyambadde
- National AIDS and STI Control Programme, Ministry of HealthKampalaUganda
- Most at Risk Population InitiativeMulago HospitalKampalaUganda
| | - Miranda Loutet
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Shamilah Batte
- Organization for Gender Empowerment and Rights Advocacy (OGERA Uganda)KampalaUganda
| | - Richard Lester
- Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Stella Neema
- Department of Sociology and AnthropologyMakerere UniversityKampalaUganda
| | - Katie Newby
- Centre for Research in Psychology and Sport SciencesSchool of Life and Medical SciencesUniversity of HertfordshireHatfieldUK
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Department of AnesthesiaMcMaster UniversityHamiltonOntarioCanada
- Department of PediatricsMcMaster UniversityHamiltonOntarioCanada
- Biostatistics Unit, Father Sean O'Sullivan Research CentreSt Joseph's HealthcareHamiltonOntarioCanada
- Centre for Development of Best Practices in Health (CDBPH)Yaoundé Central HospitalYaoundéCameroon
- Division of Epidemiology and BiostatisticsDepartment of Global HealthStellenbosch UniversityCape TownSouth Africa
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Kosugi H, Shibanuma A, Kiriya J, Ong KIC, Mucunguzi S, Muzoora C, Jimba M. Positive deviance for promoting dual-method contraceptive use among women in Uganda: a cluster randomised controlled trial. BMJ Open 2021; 11:e046536. [PMID: 34408034 PMCID: PMC8375745 DOI: 10.1136/bmjopen-2020-046536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To examine the effects of a positive deviance intervention on dual-method contraceptive use among married or in-union women. DESIGN Open-label cluster randomised controlled trial. SETTING 20 health facilities in Mbarara District, Uganda. PARTICIPANTS 960 married or in-union women aged 18-49 years using a non-barrier modern contraceptive method. INTERVENTIONS A combination of clinic-based and telephone-based counselling and a 1-day participatory workshop, which were developed based on a preliminary qualitative study of women practising dual-method contraception. PRIMARY OUTCOME MEASURE Dual-method contraceptive use at the last sexual intercourse and its consistent use in the 2 months prior to each follow-up. These outcomes were measured based on participants' self-reports, and the effect of intervention was assessed using a mixed-effects logistic regression model. RESULTS More women in the intervention group used dual-method contraception at the last sexual intercourse at 2 months (adjusted OR (AOR)=4.12; 95% CI 2.02 to 8.39) and 8 months (AOR=2.16; 95% CI 1.06 to 4.41) than in the control group. At 4 and 6 months, however, the proportion of dual-method contraceptive users was not significantly different between the two groups. Its consistent use was more prevalent in the intervention group than in the control group at 2 months (AOR=14.53; 95% CI 3.63 to 58.13), and this intervention effect lasted throughout the follow-up period. CONCLUSIONS The positive deviance intervention increased dual-method contraceptive use among women, and could be effective at reducing the dual risk of unintended pregnancies and HIV infections. This study demonstrated that the intervention targeting only women can change behaviours of couples to practise dual-method contraception. Because women using non-barrier modern contraceptives may be more reachable than men, interventions targeting such women should be recommended. TRIAL REGISTRATION NUMBER UMIN000037065.
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Affiliation(s)
- Hodaka Kosugi
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Kiriya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ken Ing Cherng Ong
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Logie C, Okumu M, Hakiza R, Kibuuka Musoke D, Berry I, Mwima S, Kyambadde P, Kiera UM, Loutet M, Neema S, Newby K, McNamee C, Baral SD, Lester R, Musinguzi J, Mbuagbaw L. Mobile Health-Supported HIV Self-Testing Strategy Among Urban Refugee and Displaced Youth in Kampala, Uganda: Protocol for a Cluster Randomized Trial (Tushirikiane, Supporting Each Other). JMIR Res Protoc 2021; 10:e26192. [PMID: 33528378 PMCID: PMC7886618 DOI: 10.2196/26192] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/14/2020] [Accepted: 12/18/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND HIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth. OBJECTIVE This study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 24 years in Kampala, Uganda. METHODS A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated. RESULTS The study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021. CONCLUSIONS This study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations. TRIAL REGISTRATION ClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/26192.
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Affiliation(s)
- Carmen Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Moses Okumu
- School of Social Work, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
| | - Robert Hakiza
- Young African Refugees for Integral Development, Kampala, Uganda
| | | | - Isha Berry
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Peter Kyambadde
- Most At Risk Population Initiative, Mulago Hospital, Kampala, Uganda
| | | | - Miranda Loutet
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Stella Neema
- Department of Sociology and Anthropology, Makerere University, Kampala, Uganda
| | - Katie Newby
- Centre for Research in Psychology and Sport Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Clara McNamee
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Stefan D Baral
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Richard Lester
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Kosugi H, Shibanuma A, Kiriya J, Ong KIC, Mucunguzi S, Muzoora C, Jimba M. Positive deviance for dual-method promotion among women in Uganda: study protocol for a cluster randomized controlled trial. Trials 2020; 21:270. [PMID: 32183908 PMCID: PMC7077095 DOI: 10.1186/s13063-020-4192-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/20/2020] [Indexed: 12/04/2022] Open
Abstract
Background Dual-method use is known as the most reliable protection against unintended pregnancies and sexually transmitted infections, including HIV. However, it is not commonly used in sub-Sharan Africa, especially among women using highly effective contraceptives. This article describes a protocol to evaluate the effect of an intervention formulated under the positive deviance approach for promoting dual-method use in Uganda. Methods A total of 150 women will be interviewed using a structured questionnaire to find those practicing dual-method use. In-depth interviews will then be conducted with all women using the dual method and 10 women using only highly effective contraceptives to identify their unique practice. Then, a cluster randomized controlled trial will be conducted to examine the effect of an intervention formulated under the positive deviance approach on dual-method uptake and adherence. Twenty health facilities will be randomized to an intervention or control arm and 480 women will be enrolled in each group. The participants will be followed up for 8 months. Discussion This trial focuses on women who already adapted dual-method use and identifies their unique solutions to promote dual-method use. This trial could tackle barriers for dual-method use, which expert outsiders may fail to recognize, by analyzing and promulgating their unique behaviors. This study could provide evidence that the positive deviance approach can address unintended pregnancies and sexually transmitted infections as well as other health problems which usual approaches have failed to address. Trial registration UMIN-CTR Clinical Trial, UMIN000037065. Registered on 14 June 2019.
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Affiliation(s)
- Hodaka Kosugi
- Department of Community and Global Health, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Akira Shibanuma
- Department of Community and Global Health, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Junko Kiriya
- Department of Community and Global Health, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ken Ing Cherng Ong
- Department of Community and Global Health, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Stephen Mucunguzi
- Department of Community Health, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda
| | - Masamine Jimba
- Department of Community and Global Health, School of International Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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Sample size estimation and re-estimation of cluster randomized controlled trials for real-time feedback, debriefing, and retraining system of cardiopulmonary resuscitation for out-of-hospital cardiac arrests. Contemp Clin Trials Commun 2019; 14:100316. [PMID: 31049459 PMCID: PMC6486519 DOI: 10.1016/j.conctc.2019.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/28/2018] [Accepted: 01/03/2019] [Indexed: 11/20/2022] Open
Abstract
Background In cluster randomized controlled trials (RCTs) for emergency medical services (EMS) system, we encounter the situation that the actual cluster size and ratio of allocated patients between two groups eventually differ from those used for sample size estimation because of the nature of patient enrollment. In such trials, estimations of effect size of test intervention and intra-cluster correlation coefficient (ICC) used for sample size estimation are also difficult. To improve efficient management on clinical cluster RCTs, we need to understand the effect of such inconsistencies of the design parameters on the type I error rate and statistical power of testing. Methods We planned the trial which evaluated the 1-month favorable neurological survival of out-of-hospital cardiac arrest patients with or without real-time feedback, debriefing, and retraining system by EMS personnel. Under the conditions that we possibly encountered in this trial, we examined the effect of inconsistencies in the actual ICC, cluster size, and ratio of patient allocation with those expected for sample size estimation on the type I error rate and power, using simulation studies. We further investigated the contribution of incorporating sample size re-estimation, based on the results of interim analysis of the trial, on the power increase. Results This simulation study showed that the inconsistencies of cluster size and patient allocation ratio decreased the power by 5-10% in some cases. In addition, the power decreased by 3-4% when the actual ICC was larger than that expected for sample size estimation. Furthermore, the use of a generalized estimating equation method to evaluate the difference in the 1-month favorable neurological survival between two groups caused inflation of type I error rate. Finally, the increase in power by incorporating sample size re-estimation was limited. Conclusions We identified remarkable effects of sample size estimation and re-estimations in a cluster RCT for real-time feedback, debriefing, and retraining system of cardiopulmonary resuscitation for out-of-hospital cardiac arrests. The estimation of design parameters for sample size estimation is generally challenging in cluster RCTs for EMS system; therefore, it is important to conduct a trial simulation that assesses the statistical performances under sample sizes based on the various expected values of the design parameters before beginning the trial.
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Barnhart D, Hertzmark E, Liu E, Mungure E, Muya AN, Sando D, Chalamilla G, Ulenga N, Bärnighausen T, Fawzi W, Spiegelman D. Intra-Cluster Correlation Estimates for HIV-related Outcomes from Care and Treatment Clinics in Dar es Salaam, Tanzania. Contemp Clin Trials Commun 2016; 4:161-169. [PMID: 27766318 PMCID: PMC5066589 DOI: 10.1016/j.conctc.2016.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction Researchers planning cluster-randomized controlled trials (cRCTs) require estimates of the intra-cluster correlation coefficient (ICC) from previous studies for sample size calculations. This paper fills a persistent gap in the literature by providing estimates of ICCs for many key HIV-related clinical outcomes. Methods Data from HIV-positive patients from 47 HIV care and treatment clinics in Dar es Salaam, Tanzania were used to calculate ICCs by site of enrollment or site of ART initiation for various clinical outcomes using cross-sectional and longitudinal data. ICCs were estimated using linear mixed models where either clinic of enrollment or clinic of ART initiation served as the random effect. Results ICCs ranged from 0 to 0.0706 (95% CI: 0.0447, 0.1098). For most outcomes, the ICCs were large enough to meaningfully affect sample size calculations. For binary outcomes, the ICCs for event prevalence at baseline tended to be larger than the ICCs for later cumulative incidences. For continuous outcomes, the ICCs for baseline values tended to be larger than the ICCs for the change in values from baseline. Conclusion The ICCs for HIV-related outcomes cannot be ignored when calculating sample sizes for future cluster-randomized trials. The differences between ICCs calculated from baseline data alone and ICCs calculated using longitudinal data demonstrate the importance of selecting an ICC that reflects a study's intended design and duration for sample size calculations. While not generalizable to all contexts, these estimates provide guidance for future researchers seeking to design adequately powered cRCTs in Sub-Saharan African HIV treatment and care clinics.
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Affiliation(s)
- Dale Barnhart
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Enju Liu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Ester Mungure
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Aisa N Muya
- Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Guerino Chalamilla
- Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Nzovu Ulenga
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Management and Development of Health, Mwai Kibaki Road, Dar es Salaam, Tanzania
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Wellcome Trust Africa Centre for Population Health, A2074 Road, Mtubatuba, KwaZulu-Natal 3935, South Africa
| | - Wafaie Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Nutrition, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
| | - Donna Spiegelman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, Massachusetts 02115, USA
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Lopez LM, Grey TW, Chen M, Denison J, Stuart G. Behavioral interventions for improving contraceptive use among women living with HIV. Cochrane Database Syst Rev 2016; 2016:CD010243. [PMID: 27505053 PMCID: PMC7092487 DOI: 10.1002/14651858.cd010243.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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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Glassman JR, Potter SC, Baumler ER, Coyle KK. Estimates of Intraclass Correlation Coefficients From Longitudinal Group-Randomized Trials of Adolescent HIV/STI/Pregnancy Prevention Programs. HEALTH EDUCATION & BEHAVIOR 2015; 42:545-53. [PMID: 25626433 DOI: 10.1177/1090198114568308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Group-randomized trials (GRTs) are one of the most rigorous methods for evaluating the effectiveness of group-based health risk prevention programs. Efficiently designing GRTs with a sample size that is sufficient for meeting the trial's power and precision goals while not wasting resources exceeding them requires estimates of the intraclass correlation coefficient (ICC)-the degree to which outcomes of individuals clustered within groups (e.g., schools) are correlated. ICC estimates vary widely depending on outcome, population, and setting, and small changes in ICCs can have large effects on the sample size needed to estimate intervention effects. This study addresses a gap in the literature by providing estimates of ICCs for adolescent sexual risk-taking outcomes under a range of study conditions. METHOD Multilevel regression analyses were applied to existing data from four federally funded GRTs of school-based HIV/STI/pregnancy prevention programs to obtain a variety of ICC estimates. RESULTS ICCs ranged from 0 to 0.15, with adjustment for covariates and repeated measurements reducing the ICC in the majority of cases. Minimum detectable effect sizes with 80% power and 0.05 significance levels ranged from small to medium Cohen's d (0.13 to 0.53) assuming 20 schools of 100 students each. CONCLUSIONS This study provides the first known set of ICC estimates for investigators to use when planning studies of school-based programs to prevent sexual risk behaviors in youth. The results provide further evidence of the importance of using the appropriate adjusted ICC estimate at the design stage to maximize resources in costly GRTs.
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