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Montt-Maray E, Adamjee L, Horanieh N, Witt A, González-Capella T, Zinke-Allmang A, Cislaghi B. Understanding ethical challenges of family planning interventions in sub-Saharan Africa: a scoping review. Front Glob Womens Health 2023; 4:1149632. [PMID: 37674903 PMCID: PMC10478786 DOI: 10.3389/fgwh.2023.1149632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023] Open
Abstract
Background Improving the design of family planning (FP) interventions is essential to advancing gender equality, maternal health outcomes, and reproductive autonomy for both men and women. While progress has been made towards applying a rights-based approach to FP interventions in sub-Saharan Africa, the ethical implications of FP interventions has been underreported and underexplored. Several ethical challenges persist related to measuring success, choice, and target population. Methods We conducted a scoping review to understand if and how FP interventions published between 2000 and 2020 within sub-Saharan Africa address the ethical challenges raised within the literature. We identified a total of 1,652 papers, of which 40 were included in the review. Results Our review demonstrated that the majority of family planning interventions in sub-Saharan Africa place a strong emphasis, on measuring success through quantitative indicators such as uptake of modern contraception methods among women, specifically those that are married and visiting healthcare centres. They also tend to bias the provision of family planning by promoting long-acting reversible contraception over other forms of contraception methods potentially undermining individuals' autonomy and choice. The interventions in our review also found most interventions exclusively target women, not recognising the importance of gender norms and social networks on women's choice in using contraception and the need for more equitable FP services. Conclusion The results of this review highlight how FP interventions measured success through quantitative indicators that focus on uptake of modern contraception methods among women. Utilising these measures makes it difficult to break away from the legacy of FP as a tool for population control as they limit the ability to incorporate autonomy, choice, and rights. Our results are meant to encourage members of the global family planning community to think critically about the ethical implications of their existing interventions and how they may be improved. More public health and policy research is required to assess the effect of applying the new indicators with the FP community as well as explicitly outlining monitoring and evaluation strategies for new interventions to allow for programme improvement and the dissemination of lessons learned.
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Affiliation(s)
- Eloisa Montt-Maray
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lamiah Adamjee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Nour Horanieh
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alice Witt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thaïs González-Capella
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anja Zinke-Allmang
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Beniamino Cislaghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Owan VJ, Akah LU, Ekpo AJ, Ubi IO, Abeng FA, Akah GT. Socioeconomic factors and the evaluation of HIV/AIDS prevention programs: A psychometric analysis of an instrument. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2022. [DOI: 10.29333/ejgm/12320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Evolution of Condom Use Among a 5-Year Cohort of Female Sex Workers in Zambia. AIDS Behav 2022; 26:470-477. [PMID: 34333718 PMCID: PMC8801539 DOI: 10.1007/s10461-021-03403-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 02/03/2023]
Abstract
Observing sexual behaviour change over time could help develop behavioural HIV prevention interventions for female sex workers in Zambia, where these interventions are lacking. We investigated the evolution of consistent condom use among female sex workers and their clients and steady partners. Participants were recruited into an HIV incidence cohort from 2012 to 2017. At each visit, women received HIV counselling and testing, screening for sexually transmitted infections (STIs) and free condoms. Our outcome was reported consistent (100%) condom use in the previous month with steady partners, repeat clients, and non-repeat clients. Consistent condom use at baseline was highest with non-repeat clients (36%) followed by repeat clients (27%) and steady partners (17%). Consistent condom use between baseline and Month 42 increased by 35% with steady partners, 39% with repeat clients and 41% with non-repeat clients. Access to condoms, HIV/STI counselling and testing promoted positive sexual behaviour change.
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Sharkey T, Wall KM, Parker R, Tichacek A, Pappas-DeLuca KA, Kilembe W, Inambao M, Malama K, Hoagland A, Peeling R, Allen S. 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. Contemp Clin Trials Commun 2021; 24:100850. [PMID: 34622087 PMCID: PMC8481973 DOI: 10.1016/j.conctc.2021.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Tyronza Sharkey
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- London School of Hygiene and Tropical Medicine, UK
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Katina A. Pappas-DeLuca
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Mubiana Inambao
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Kalonde Malama
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Alexandra Hoagland
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | | | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
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Sarnak DO, Wood SN, Zimmerman LA, Karp C, Makumbi F, Kibira SPS, Moreau C. The role of partner influence in contraceptive adoption, discontinuation, and switching in a nationally representative cohort of Ugandan women. PLoS One 2021; 16:e0238662. [PMID: 33434205 PMCID: PMC7802956 DOI: 10.1371/journal.pone.0238662] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/09/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Understanding contraceptive use dynamics is critical to addressing unmet need for contraception. Despite evidence that male partners may influence contraceptive decision-making, few studies have prospectively examined the supportive ways that men influence women's contraceptive use and continuation. OBJECTIVE This study sought to understand the predictive effect of partner influence, defined as partner's fertility intentions and support for contraception, and discussions about avoiding pregnancy prior to contraceptive use, on contraceptive use dynamics (continuation, discontinuation, switching, adoption) over a one-year period. METHODS This study uses nationally representative longitudinal data of Ugandan women aged 15-49 collected in 2018-2019 (n = 4,288 women baseline; n = 2,755 women one-year follow-up). Two analytic sub-samples of women in union and in need of contraception at baseline were used (n = 618 contraceptive users at baseline for discontinuation/switching analysis; n = 687 contraceptive non-users at baseline for adoption analysis). Primary dependent variables encompassed contraceptive use dynamics (continuation, discontinuation, switching, and adoption); three independent variables assessed partner influence. For each sub-sample, bivariate associations explored differences in sociodemographic and partner influences by contraceptive dynamics. Multinomial regression models were used to examine discontinuation and switching for contraceptive users at baseline; logistic regression identified predictors of contraceptive adoption among non-users at baseline. RESULTS Among users at baseline, 26.3% of women switched methods and 31.5% discontinued contraceptive use by follow-up. Multinomial logistic regression, adjusting for women's characteristics, indicated the relative risk of contraceptive discontinuation doubled when women did not discuss pregnancy avoidance with their partner prior to contraceptive use. Partner influence was not related to method switching. Among non-users at baseline, partner support for future contraceptive use was associated with nearly three-fold increased odds of contraceptive adoption. SIGNIFICANCE These results highlight the potentially supportive role of male partners in contraceptive adoption. Future research is encouraged to elucidate the complex pathways between couple-based decision-making and contraceptive dynamics through further prospective studies.
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Affiliation(s)
- Dana O Sarnak
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shannon N Wood
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Linnea A Zimmerman
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Celia Karp
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Simon P S Kibira
- Department of Community Health and Behavioural Sciences, School of Public Health, Makerere University, Kampala, Uganda
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.,Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
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Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples. AIDS 2020; 34:1633-1642. [PMID: 32701577 DOI: 10.1097/qad.0000000000002584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services. DESIGN Implementation and modelling. SETTING Fifty-five government health facilities in Zambia. SUBJECTS Patients in government health facilities. INTERVENTION Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015. MAIN OUTCOME MEASURES We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year. RESULTS Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use. CONCLUSION Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.
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Mukamuyango J, Ingabire R, Parker R, Nyombayire J, Abaasa A, Asiki G, Easter SR, Wall KM, Nyirazinyoye L, Tichacek A, Kaslow N, Price MA, Allen S, Karita E. 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. Reprod Health 2020; 17:126. [PMID: 32807177 PMCID: PMC7433361 DOI: 10.1186/s12978-020-00981-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/11/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
| | - Rosine Ingabire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Julien Nyombayire
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
| | - Andrew Abaasa
- London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, London, WC1E 7HT, UK
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Gershim Asiki
- Medical Research Council, Uganda Vaccine Research Institute & LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Sarah Rae Easter
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristin M Wall
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Nadine Kaslow
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Atlanta, GA, USA
| | - Matt A Price
- International AIDS Vaccine Initiative, New York, NY, USA
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA, USA
| | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA, USA.
| | - Etienne Karita
- Projet San Francisco, Rwanda Zambia HIV Research Group, Kigali, Rwanda
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