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Brown JM, Musara P, Gitome S, Chitukuta M, Mataveke B, Chirenda T, Mgodi N, Mutero P, Matubu A, Chareka G, Chasakara C, Murombedzi C, Makurumure T, Hughes CS, Bukusi E, Cohen CR, Shiboski S, Darbes L, Rutherford GW, Chirenje ZM, Mhlanga F. "We chose PrEP because I wanted to be sure that this child my wife was going to conceive was indeed mine." Factors influencing the choice of safer conception methods and experiences with its use: a qualitative study among HIV sero-discordant couples in Zimbabwe. BMC Public Health 2024; 24:1936. [PMID: 39030487 PMCID: PMC11264618 DOI: 10.1186/s12889-024-19155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/14/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples' actual experiences using safer conception methods, and why some couples switch safer conception methods. METHODS Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods. RESULTS We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely. CONCLUSIONS The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.
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Affiliation(s)
- Joelle M Brown
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA.
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Petina Musara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Serah Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Miria Chitukuta
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Thandiwe Chirenda
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Nyaradzo Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- University of Zimbabwe, Harare, Zimbabwe
| | - Prisca Mutero
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Allen Matubu
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Gift Chareka
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- University of Zimbabwe, Harare, Zimbabwe
| | - Charles Chasakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | - Carolyn Smith Hughes
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stephen Shiboski
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Lynae Darbes
- Department of Health Behavior and Biological Sciences, University of Michigan, Ann Arbor, MI, USA
| | - George W Rutherford
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Z Michael Chirenje
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- University of Zimbabwe, Harare, Zimbabwe
| | - Felix Mhlanga
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
- University of Zimbabwe, Harare, Zimbabwe
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Wagner GJ, Gwokyalya V, Akena D, Nakigudde J, McBain R, Faherty L, Ngo V, Nakku J, Kyohangirwe L, Banegura A, Beyeza-Kashesya J, Wanyenze RK. Stressors and Maladaptive Coping Mechanisms Associated with Elevated Perinatal Depressive Symptoms and Suicidality Among Women Living with HIV in Uganda. Int J Behav Med 2023; 30:743-752. [PMID: 36127627 PMCID: PMC10084842 DOI: 10.1007/s12529-022-10124-3] [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] [Accepted: 09/05/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population. METHOD Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education. RESULTS The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving. CONCLUSIONS Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes. TRIAL REGISTRATION Clinicaltrials.gov NCT03892915 (registered March 21, 2019).
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Affiliation(s)
| | | | | | | | | | - Laura Faherty
- RAND Corporation, Santa Monica, CA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Victoria Ngo
- RAND Corporation, Santa Monica, CA, USA
- City University of New York Graduate School of Public Health and Health Policy, New York City, NY, USA
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Brown JM, Gitome S, Mataveke B, Chirenda T, Matubu A, Chareka G, Chasakara C, Mgodi N, Murombedzi C, Musara P, Makurumure T, Hughes CS, Bukusi E, Cohen CR, Shiboski S, Darbes L, Kahn JG, Rutherford GW, Chirenje ZM, Mhlanga F. Preventing HIV and achieving pregnancy among HIV sero-different couples: Pilot study of a safer conception intervention in Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000796. [PMID: 36963004 PMCID: PMC10022125 DOI: 10.1371/journal.pgph.0000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/31/2023] [Indexed: 06/18/2023]
Abstract
Safer conception services are needed to minimize HIV transmission among HIV sero-different couples desiring pregnancy. Few studies have evaluated the choices couples make when offered multiple safer conception methods or real-world method acceptability and effectiveness. We piloted a comprehensive safer conception program (Clintrials.gov identifier: NCT03049176) for HIV sero-different couples planning pregnancy in Zimbabwe to measure feasibility, method uptake, acceptability, pregnancy outcome, and HIV transmission. This study was not designed to compare rates of HIV transmission by safer conception method choice but rather to understand choices couples make when seeking to minimize risk of HIV transmission and maximize likelihood of pregnancy. Couples in this prospective, non-randomized study were given a choice of one or more currently available safer conception methods: antiretroviral therapy (ART) with monthly viral load (VL) monitoring for the HIV-positive partner (ART/VL), pre-exposure prophylaxis (PrEP) for the HIV-negative partner, vaginal insemination (VI) for couples with an HIV-positive woman, and semen washing (SW) for couples with an HIV-positive man. Couples were followed monthly for up to 12 months of pregnancy attempts, quarterly during pregnancy, and 12 weeks post-partum. At each visit, data on method use, urine for pregnancy testing, and blood for HIV antibody testing, or viral load if HIV-positive, were obtained. Infants born to HIV-positive women were tested for HIV at 6 and 12 weeks. Between March 2017 and June 2019, 46 individuals from 23 HIV sero-different partnerships were enrolled and followed. At enrollment, all couples chose ART/VL, and all couples chose at least one additional method; 74% chose PrEP, 36% chose SW, and 25% chose VI. During pre-pregnancy follow-up visits, three couples discontinued SW, and one couple discontinued VI; all four of these couples opted for ART/VL plus PrEP. Satisfaction with safer conception methods was high among those who chose ART/VL and PrEP. Twelve couples achieved pregnancy. There were no cases of HIV transmission to partners, and no infants tested positive for HIV. This safer conception program is feasible and acceptable, allowing sero-different couples to safely achieve pregnancy. Sero-different couples in Zimbabwe seek a combination of HIV prevention methods, particularly ART/VL plus PrEP. Trial Registration: Clintrials.gov, NCT03049176.
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Affiliation(s)
- Joelle M. Brown
- Department of Obstetrics, Gynecology, Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Serah Gitome
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Thandiwe Chirenda
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Allen Matubu
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Gift Chareka
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Charles Chasakara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Nyaradzo Mgodi
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Petina Musara
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | | | - Carolyn Smith Hughes
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Craig R. Cohen
- Department of Obstetrics, Gynecology, Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Stephen Shiboski
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Lynae Darbes
- Department of Health Behavior and Biological Sciences, University of Michigan, Ann Arbor, Michigan, United States of America
| | - James G. Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - George W. Rutherford
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
| | - Z. Michael Chirenje
- Department of Obstetrics, Gynecology, Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
- University of Zimbabwe, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Felix Mhlanga
- University of Zimbabwe, Harare, Zimbabwe
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
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Sexual and Relationship Benefits of a Safer Conception Intervention Among Men with HIV Who Seek to Have Children with Serodifferent Partners in Uganda. AIDS Behav 2022; 26:1841-1852. [PMID: 34796420 DOI: 10.1007/s10461-021-03533-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
Many men with HIV (MWH) in Uganda desire children, yet seldom receive reproductive counseling related to HIV care. Because men are under engaged in safer conception programming, they miss opportunities to reap the benefits of these programs. The objective of this sub-analysis was to explore the relationship and intimacy benefits of integrating safer conception counseling and strategies into HIV care, an emergent theme from exit interviews with men who participated in a pilot safer conception program and their partners. Twenty interviews were conducted with MWH who desired a child in the next year with an HIV-uninfected/status unknown female partner, and separate interviews were conducted with female partners (n = 20); of the 40 interviews, 28 were completed by both members of a couple. Interviews explored experiences participating in The Healthy Families program, which offered MWH safer conception counseling and access to specific strategies. Data were analyzed using thematic analysis. Three major subthemes or "pathways" to the relationship and intimacy benefits associated with participation in the program emerged: (1) improved dyadic communication; (2) joint decision-making and power equity in the context of reproduction; and (3) increased sexual and relational intimacy, driven by reduced fear of HIV transmission and relationship dissolution. These data suggest that the intervention not only helped couples realize their reproductive goals; it also improved relationship dynamics and facilitated intimacy, strengthening partnerships and reducing fears of separation. Directly addressing these benefits with MWH and their partners may increase engagement with HIV prevention strategies for conception.
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Mathenjwa M, Khidir H, Milford C, Mosery N, Rambally Greener L, Pratt MC, O'Neil K, Harrison A, Bangsberg DR, Safren SA, Smit JA, Psaros C, Matthews LT. Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings. AIDS Behav 2022; 26:1-12. [PMID: 34097209 PMCID: PMC8786780 DOI: 10.1007/s10461-021-03278-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/15/2023]
Abstract
Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.
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Affiliation(s)
- Mxolisi Mathenjwa
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Letitia Rambally Greener
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- Population Services International, South Africa, Johannesburg, South Africa
| | - Madeline C Pratt
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA
| | | | | | | | | | - Jennifer A Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Lynn T Matthews
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA.
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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Gutin SA, Harper GW, Moshashane N, Bitsang C, Harries J, Ramogola-Masire D, Morroni C. "What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana. Front Glob Womens Health 2021; 1. [PMID: 33693437 PMCID: PMC7943178 DOI: 10.3389/fgwh.2020.582463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.
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Affiliation(s)
- Sarah A Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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De Vincentis S, Tartaro G, Rochira V, Santi D. HIV and Sexual Dysfunction in Men. J Clin Med 2021; 10:jcm10051088. [PMID: 33807833 PMCID: PMC7961513 DOI: 10.3390/jcm10051088] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Sexual issues tend to go unaddressed in human immunodeficiency virus (HIV) management, although overt sexual dysfunctions are more prevalent in people living with HIV than uninfected people. Erectile dysfunction is the most frequent sexual problem, with a prevalence of 30–50% even in men <40 years of age, but other issues such as loss of libido and ejaculatory disorders should not be overlooked. Peculiar factors related to HIV infection (e.g., fear of virus transmission, changes in body image, HIV-related comorbidities, HIV distress and stigma), alongside classical factors non-related to HIV, should be considered when approaching sexual problems in HIV patients. For this reason, the diagnostic and therapeutic workout of sexual dysfunction in the context of HIV requires a multidisciplinary approach, involving specialists in both infectious diseases and sexual medicine. This narrative review presents an overview of current knowledge on sexual dysfunction in HIV men, deepening the factors driving and taking part in these issues, providing advice for the clinical approach, and underlining the importance of caring for sexual health to improve the quality of life of HIV patients.
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Affiliation(s)
- Sara De Vincentis
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini 1355, 41126 Modena, Italy; (S.D.V.); (G.T.); (D.S.)
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Giulia Tartaro
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini 1355, 41126 Modena, Italy; (S.D.V.); (G.T.); (D.S.)
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
| | - Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini 1355, 41126 Modena, Italy; (S.D.V.); (G.T.); (D.S.)
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
- Correspondence: ; Tel.: +39-059-396-2453; Fax: +39-059-396-1335
| | - Daniele Santi
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Via Giardini 1355, 41126 Modena, Italy; (S.D.V.); (G.T.); (D.S.)
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy
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Wagner GJ, Mindry D, Hurley EA, Beyeza-Kashesya J, Gwokyalya V, Finocchario-Kessler S, Wanyenze RK, Nanfuka M, Tebeka MG, Goggin K. Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships. BMC Public Health 2021; 21:156. [PMID: 33468072 PMCID: PMC7814634 DOI: 10.1186/s12889-021-10163-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 01/04/2021] [Indexed: 11/16/2022] Open
Abstract
Context Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low. Methods Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception. Results Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression. Conclusion Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention. Trial registration Clinicaltrials.gov, NCT03167879; date registered May 23, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10163-7.
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Affiliation(s)
- Glenn J Wagner
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90407, USA.
| | - Deborah Mindry
- UC Global Health Institute, Center for Women's Health Gender and Empowerment, Los Angeles, CA, USA
| | - Emily A Hurley
- Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, USA
| | - Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Violet Gwokyalya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | - Mahlet G Tebeka
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90407, USA
| | - Kathy Goggin
- Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, USA.,Schools of Medicine and Pharmacy, University of Missouri - Kansas City, Kansas City, USA
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10
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Gutin SA, Harper GW, Bitsang C, Moshashane N, Ramogola-Masire D, Harries J, Morroni C. Perspectives about childbearing and pregnancy planning amongst people living with HIV in Gaborone, Botswana. CULTURE, HEALTH & SEXUALITY 2020; 22:1063-1079. [PMID: 31478784 PMCID: PMC7182082 DOI: 10.1080/13691058.2019.1650202] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
Despite advances in clinical care, safer conception services are not utilised in many high HIV prevalence countries, including Botswana. We conducted in-depth interviews with 10 HIV healthcare providers and 10 women living with HIV to develop a deeper understanding of attitudes surrounding childbearing and pregnancy planning. Interviews were analysed using a phenomenological approach. Providers felt it was a human right and normative for women living with HIV to have children but also expressed concern about women living with HIV having children. Women themselves anticipated stigma from providers regarding childbearing, although most described supportive care and had not experienced stigmatising treatment. Although providers believed pregnancies amongst women living with HIV were unplanned, women described discussing pregnancy desires with sexual partners. Despite providers voicing a rights-based approach to childbearing amongst women living with HIV, hesitancy towards pregnancy remains. This is felt by women living with HIV and perceived as stigma, which may make them less likely to seek fertility and safer conception advice. Safer conception interventions are unlikely to be successful if women do not feel comfortable discussing childbearing with health-care providers.
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Affiliation(s)
- Sarah A. Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Gary W. Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counselling Services, University of Botswana, Gaborone, Botswana
| | - Neo Moshashane
- Botswana - University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynaecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Chelsea Morroni
- Women’s Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Botswana - University of Pennsylvania Partnership, University of Botswana Main Campus, Gaborone, Botswana
- Liverpool School of Tropical Medicine, Liverpool, UK
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11
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Iliyasu Z, Galadanci HS, Zubairu AA, Amole TG, Sam-Agudu NA, Aliyu MH. Health workers' knowledge of safer conception and attitudes toward reproductive rights of HIV-infected couples in Kano, Nigeria. Int Health 2020; 11:536-544. [PMID: 31028377 DOI: 10.1093/inthealth/ihz016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 01/28/2019] [Accepted: 03/01/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The restriction of reproductive rights of HIV-positive couples in low-resource settings could be related to the attitudes and skills of health workers. We assessed health workers' knowledge of safer conception and their attitudes toward the reproductive rights of HIV-positive couples in a tertiary hospital in Nigeria. METHODS A cross-section of health workers (n=294) was interviewed using structured questionnaires. Knowledge and attitude scores were analyzed. Logistic regression was employed to generate adjusted odds ratios (AORs) for predictors of attitude. RESULTS Safer conception methods mentioned by respondents included timed unprotected intercourse with (27.9%) and without antiretroviral pre-exposure prophylaxis (37.4%), in vitro fertilization plus intracytoplasmic sperm injection (26.5%), and sperm washing and intrauterine insemination (24.8%). The majority (94.2%) of health workers acknowledged the reproductive rights of HIV-infected persons, although (64.6%) strongly felt that HIV-infected couples should have fewer children. Health workers reported always/nearly always counseling their patients on HIV transmission risks (64.1%) and safer conception (59.2% and 48.3% for females and males, respectively) (p<0.05). Among health workers, being older (30-39 vs <30 y) (AOR=1.33, 95% CI=1.13-2.47), married (AOR=2.15, 95% CI=1.17-5.58) and having a larger HIV-positive daily caseload (20-49 vs <20) (AOR=1.98, 95% CI=1.07-3.64) predicted positive attitude towards reproductive rights of HIV-affected couples. CONCLUSIONS Health workers had limited knowledge of safer conception methods, but were supportive of the reproductive rights of HIV-positive couples. Health workers in Nigeria require training to effectively counsel couples on their reproductive rights, risks and options.
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Affiliation(s)
- Zubairu Iliyasu
- Departments of Community Medicine, Bayero University, PMB 3011 Kano, Kano State, Nigeria.,Centre for Infectious Diseases Research, Bayero University, PMB 3011 Kano, Kano State, Nigeria
| | - Hadiza S Galadanci
- Departments of Obstetrics and Gynecology, Bayero University, PMB 3011 Kano, Kano State, Nigeria
| | - Ahmad A Zubairu
- Departments of Community Medicine, Bayero University, PMB 3011 Kano, Kano State, Nigeria
| | - Taiwo G Amole
- Departments of Community Medicine, Bayero University, PMB 3011 Kano, Kano State, Nigeria
| | - Nadia A Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology, Maina Court, Plot 252, Abuja, Nigeria.,Institute of Human Virology, University of Maryland, 725 W Lombard St, Baltimore, MD 21201, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 725, Nashville, TN 37203, USA
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12
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Khidir H, Psaros C, Greener L, O’Neil K, Mathenjwa M, Mosery FN, Moore L, Harrison A, Bangsberg DR, Smit JA, Safren SA, Matthews LT. Developing a Safer Conception Intervention for Men Living with HIV in South Africa. AIDS Behav 2019; 22:1725-1735. [PMID: 28194587 PMCID: PMC5554741 DOI: 10.1007/s10461-017-1719-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Within sexual partnerships, men make many decisions about sexual behavior, reproductive goals, and HIV prevention. There are increasing calls to involve men in reproductive health and HIV prevention. This paper describes the process of creating and evaluating the acceptability of a safer conception intervention for men living with HIV who want to have children with partners at risk for acquiring HIV in KwaZulu-Natal, South Africa. Based on formative work conducted with men and women living with HIV, their partners, and providers, we developed an intervention based on principles of cognitive-behavioral therapy to support men in the adoption of HIV risk-reduction behaviors such as HIV-serostatus disclosure and uptake of and adherence to antiretroviral therapy. Structured group discussions were used to explore intervention acceptability and feasibility. Our work demonstrates that men are eager for reproductive health services, but face unique barriers to accessing them.
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13
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Gwokyalya V, Beyeza-Kashesya J, Bwanika JB, Matovu JKB, Mugerwa S, Arinaitwe J, Kasozi D, Bukenya J, Kindyomunda R, Wagner GJ, Makumbi FE, Wanyenze RK. Knowledge and correlates of use of safer conception methods among HIV-infected women attending HIV care in Uganda. Reprod Health 2019; 16:64. [PMID: 31138254 PMCID: PMC6538556 DOI: 10.1186/s12978-019-0717-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many people living with HIV would like to have children but family planning (FP) services often focus on only contraception. Availability of safer conception services is still very low in most low income countries. In this study we assessed the knowledge and use of safer conception methods (SCM) among HIV infected women in HIV care in Uganda to inform integration of safer conception in existing FP services. METHODS Data were accrued from a nationally representative cross-sectional survey of 5198 HIV+ women aged 15-49 years from 245 HIV clinics in Uganda. Knowledge and use of safer conception methods and associated factors were determined. The measure of association was prevalence ratio (PR) with corresponding 95% confidence intervals, obtained using a modified Poisson regression via generalized linear models. All the analyses were conducted using STATA version 12.0. RESULTS Overall knowledge of any safer conception method was 74.1% (3852/5198). However only 13.2% knew 3 to 4 methods, 18.9% knew only 2 methods and 42% knew only one method. Knowledge of specific SCM was highest for timed unprotected intercourse (TUI) at 39% (n = 2027) followed by manual self-insemination (MSI) at 34.8% (n = 1809), and pre-exposure prophylaxis (PrEP) at 24.8% (n = 1289). Knowledge of SCM was higher in the Eastern region (84.8%, P < 0.001), among women in HIV-discordant relationships (76.7%, p < 0.017), and those on ART (74.5%, p < 0.034). Overall, 1796 (34.6%) women were pregnant or reported a birth in the past 2 years-overall use of SCM in this group was 11.6% (209/1796). The odds of use of SCM were significantly lower in Kampala [adj. PR = 0.489(0.314, 0.764)] or Eastern region [adj.PR = 0.244; (0.147, 0.405)] compared to Northern region. Higher odds of SCM use were associated with HIV status disclosure to partner [adj.PR = 2.613(1.308, 5.221)] and sero-discordant compared to HIV+ concordant relationship [adj.PR = 1.637(1.236, 2.168)]. Pre-existing knowledge of any one SCM did not influence SCM use. CONCLUSIONS Knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods.
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Affiliation(s)
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | | | | | | | | | - Dickson Kasozi
- Makerere University School of Public Health, Kampala, Uganda
| | - Justine Bukenya
- Makerere University School of Public Health, Kampala, Uganda
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14
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Patwa MC, Bassett J, Holmes L, Mutunga L, Mudavanhu M, Makhomboti T, Van Rie A, Schwartz SR. Integrating safer conception services into primary care: providers' perspectives. BMC Public Health 2019; 19:532. [PMID: 31072352 PMCID: PMC6507034 DOI: 10.1186/s12889-019-6904-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting. Methods Twenty in-depth interviews were conducted between October–November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh’umndeni safer conception demonstration project had enrolled patients from July 2013–July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh’umndeni project and possible integration plans to inform the translation of the stand-alone Sakh’umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) ‘Integration of Targeted Interventions into Health Systems’ conceptual framework was applied as an analysis tool. Results Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a “couples-based” intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers. Conclusion A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.
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Affiliation(s)
- Mariya C Patwa
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Leah Holmes
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Lillian Mutunga
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Mutsa Mudavanhu
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | | | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerpen, Belgium
| | - Sheree R Schwartz
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA.
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15
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Davies NE, Chersich M, Mullick S, Naidoo N, Makhoba N, Rees H, Schwartz SR. Integrating Cervical Cancer Screening Into Safer Conception Services to Improve Women's Health Outcomes: A Pilot Study at a Primary Care Clinic in South Africa. Sex Transm Dis 2019; 46:91-97. [PMID: 30308532 PMCID: PMC6336485 DOI: 10.1097/olq.0000000000000914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/09/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Sub-optimal cervical cancer screening in low- and middle-income countries contributes to preventable cervical cancer deaths, particularly among human immunodeficiency virus (HIV)-positive women. We assessed feasibility and outcomes of integrating cervical cancer screening into safer conception services for HIV-affected women. METHODS At a safer conception service in Johannesburg, South Africa, HIV-affected women desiring pregnancy received a standard package of care designed to minimize HIV transmission risks while optimizing prepregnancy health. All eligible women were offered Papanicolaou smear, and those with significant pathology were referred for colposcopy before attempting pregnancy. Multivariable analyses identified associations between patient characteristics and abnormal pathology. RESULTS In total, 454 women were enrolled between June 2015 and April 2017. At enrolment, 91% were HIV-positive, 92% were on antiretroviral therapy (ART) and 82% virally suppressed. Eighty-three percent (376 of 454) of clients were eligible for cervical cancer screening and 85% (321 of 376) of these completed screening. More than half had abnormal cervical pathology (185 of 321) and 20% required colposcopy for possible high-grade or persistently atypical lesions (64 of 321). Compared with HIV-negative women, abnormal pathology was more likely among HIV-positive women, both those on ART <2 years (adjusted prevalence ratio, 2.5; 95% confidence interval, 1.2-5.0) and those on ART 2 years or longer (adjusted prevalence ratio, 2.1; 95% confidence interval, 1.0-4.2). CONCLUSIONS Integrating cervical cancer screening into safer conception care was feasible with high coverage, including for HIV-positive women. Significant pathology, requiring colposcopy, was common, even among healthy women on ART. Safer conception services present an opportunity for integration of cervical cancer screening to avert preventable cancer-related deaths among HIV-affected women planning pregnancy.
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Affiliation(s)
- Natasha E.C.G. Davies
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Matthew Chersich
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Saiqa Mullick
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Nicolette Naidoo
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Nokuthula Makhoba
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Helen Rees
- From the Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
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16
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Okoli ML, Alao S, Ojukwu S, Emechebe NC, Ikhuoria A, Kip KE. Predictive and spatial analysis for estimating the impact of sociodemographic factors on contraceptive use among women living with HIV/AIDS (WLWHA) in Kenya: Implications for policies and practice. BMJ Open 2019; 9:e022221. [PMID: 30617098 PMCID: PMC6326424 DOI: 10.1136/bmjopen-2018-022221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the availability and knowledge of various contraceptive methods, consistent utilisation in women living with HIV/AIDS (WLWHA) within the reproductive age group remains below the Sustainable Development Goals (SDGs) and Family Planning 2020 goals. This study examines the association between sociodemographic factors and contraceptive use including the effect of clustering tendencies of these factors on contraceptive usage among WLWHA in Kenya. METHODS Weighted multivariate logistic regression models were conducted to determine the association of sociodemographic factors on contraception use among WLWHA using the 2008-2009 Kenya Demographic Health Survey. Spatial autocorrelation techniques were used to explore clustering tendencies of these factors on contraception utilisation. Our study population included 304 HIV positive women, aged 15-49 years. RESULTS Among 304 HIV-positive women in our study population, 92 (30.3%) reported using one method of contraception. Contraceptive use was significantly associated with wealth and education after adjustment for other sociodemographic variables. Women classified as having low and middle wealth index were less likely to use contraceptives (OR=0.17, 95% CI 0.07 to 0.43; OR=0.33, 95% CI 0.11 to 0.98, respectively) compared with women classified as having high wealth index. Similarly, women with primary education only were less likely to use contraceptives compared with women with secondary or higher education (OR=0.42, 95% CI 0.18 to 0.98). Spatial autocorrelation revealed significant positive clusters with weak clustering tendencies of non-contraceptive use among different levels of wealth index and education within different regions of Kenya. CONCLUSION These findings underscores the need for intervention programmes to further target socially disadvantaged WLWHA, which is necessary for achieving the SDGs.
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Affiliation(s)
- Menkeoma Laura Okoli
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Samuel Alao
- Department of Global Health, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Somtochukwu Ojukwu
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Nnadozie C Emechebe
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Kevin E Kip
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, Florida, USA
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17
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Goggin K, Hurley EA, Wagner GJ, Staggs V, Finocchario-Kessler S, Beyeza-Kashesya J, Mindry D, Birungi J, Wanyenze RK. Changes in Providers' Self-Efficacy and Intentions to Provide Safer Conception Counseling Over 24 Months. AIDS Behav 2018; 22:2895-2905. [PMID: 29464428 DOI: 10.1007/s10461-018-2049-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers' self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers' knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers' intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers' confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA.
- Schools of Medicine and Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA.
- Children's Mercy Hospital Kansas City and University of Missouri - Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Vincent Staggs
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
- Schools of Medicine and Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | | | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Deborah Mindry
- Los Angeles Center for Culture and Health, University of California, Los Angeles, CA, USA
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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18
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Goggin K, Hurley EA, Beyeza-Kashesya J, Gwokyalya V, Finocchario-Kessler S, Birungi J, Mindry D, Wanyenze RK, Wagner GJ. Study protocol of "Our Choice": a randomized controlled trial of the integration of safer conception counseling to transform HIV family planning services in Uganda. Implement Sci 2018; 13:110. [PMID: 30107843 PMCID: PMC6092849 DOI: 10.1186/s13012-018-0793-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/10/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services. METHODS Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined. DISCUSSION Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda. TRIAL REGISTRATION NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO USA
- Schools of Medicine and Pharmacy, University of Missouri–Kansas City, Kansas City, MO USA
| | - Emily A. Hurley
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City, MO USA
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Violet Gwokyalya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | | | - Josephine Birungi
- The AIDS Support Organization, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Deborah Mindry
- Los Angeles Center for Social Medicine and Humanities, University of California, Los Angeles, CA USA
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Beyeza-Kashesya J, Wanyenze RK, Goggin K, Finocchario-Kessler S, Woldetsadik MA, Mindry D, Birungi J, Wagner GJ. Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda. PLoS One 2018; 13:e0192902. [PMID: 29462171 PMCID: PMC5819785 DOI: 10.1371/journal.pone.0192902] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 02/01/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda. METHODS 400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis. RESULTS 75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics. CONCLUSIONS Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.
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Affiliation(s)
- Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, College of Health Sciences, Kampala, Uganda
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Schools of Medicine and Pharmacy, University of Missouri–Kansas City, Missouri, United States of America
| | - Sarah Finocchario-Kessler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, Missouri, United States of America
| | | | - Deborah Mindry
- University of California, Los Angeles Center for Culture and Health, Los Angeles, California, United States of America
| | | | - Glenn J. Wagner
- RAND Corporation, Santa Monica, California, United States of America
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Abstract
The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and addressing HIV-related infertility are key components of such interventions. In this commentary, we present challenges and opportunities for achieving safe pregnancies for serodiscordant couples through a social ecological lens. At the individual level, knowledge (e.g. of HIV status, assisted reproductive technologies) and skills (e.g. adhering to antiretroviral therapy or pre-exposure prophylaxis) are important. At the couple level, communication between partners around HIV status disclosure, fertility desires and safer pregnancy is required. Within the structural domain, social norms, stigma and discrimination from families, community and social networks influence individual and couple experiences. The availability and quality of safer conception and fertility support services within the healthcare system remains essential, including training for healthcare providers and strengthening integration of SRHR and HIV services. Policies, legislation and funding can improve access to SRHR services. A social ecological framework allows us to examine interactions between levels and how interventions at multiple levels can better support HIV-serodiscordant couples to achieve safe pregnancies. Strategies to achieve safer pregnancies should consider interrelated challenges at different levels of a social ecological framework. Interventions across multiple levels, implemented concurrently, have the potential to maximize impact and ensure the full SRHR of HIV-serodiscordant couples.
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21
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Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa. J Int AIDS Soc 2017; 20:21271. [PMID: 28361506 PMCID: PMC5577693 DOI: 10.7448/ias.20.2.21271] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV-affected persons to safely meet reproductive goals. However, aside from select research-supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield. Discussion: Four key implementation barriers were identified by combining authors’ safer conception service delivery experiences with available literature. First, strategic implementation frameworks stipulating where, and by whom, safer conception services should be provided are needed. Integrating safer conception services into universal test-and-treat (UTT) and elimination-of-mother-to-child-transmission (eMTCT) priority programmes would support HIV testing, ART initiation and management, viral suppression and early antenatal/eMTCT care engagement goals, reducing horizontal and vertical transmissions. Embedding measurable safer conception targets into these priority programmes would ensure accountability for implementation progress. Second, facing an organizational clinic culture that often undermines clients’ reproductive rights, healthcare providers’ (HCP) positive experiences with eMTCT and enthusiasm for UTT provide opportunities to shift facility-level and individual attitudes in favour of safer conception provision. Third, safer conception guidelines have not been incorporated into HCP training. Combining safer conception with “test-and-treat” training would efficiently ensure that providers are better equipped to discuss clients’ reproductive goals and support safer conception practices. Lastly, HIV-affected couples remain largely unaware of safer conception strategies. HIV-affected populations need to be mobilized to engage with safer conception options alongside other HIV-related healthcare services. Conclusion: Key barriers to widespread safer conception service provision in South Africa include poor translation of policy into practical and measurable implementation plans, inadequate training and limited community engagement. South Africa should leverage the momentum and accountability associated with high priority UTT and eMTCT programmes to reinvigorate implementation efforts by incorporating safer conception into implementation and monitoring frameworks and associated HCP training and community engagement activities. South Africa’s experiences should be used to inform policy development and implementation processes in other HIV high-burden countries.
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22
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Mindry D, Wanyenze RK, Beyeza-Kashesya J, Woldetsadik MA, Finocchario-Kessler S, Goggin K, Wagner G. Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda. AIDS Behav 2017; 21:2488-2496. [PMID: 28597343 DOI: 10.1007/s10461-017-1816-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.
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23
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Wagner GJ, Linnemayr S, Goggin K, Mindry D, Beyeza-Kashesya J, Finocchario-Kessler S, Robinson E, Birungi J, Wanyenze RK. Prevalence and Correlates of Use of Safer Conception Methods in a Prospective Cohort of Ugandan HIV-Affected Couples with Fertility Intentions. AIDS Behav 2017; 21:2479-2487. [PMID: 28229244 PMCID: PMC5536997 DOI: 10.1007/s10461-017-1732-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We examined the prevalence and correlates of safer conception methods (SCM) use in HIV-affected couples with fertility intentions. A prospective cohort of 400 HIV clients in Uganda who had fertility intentions with their partner was surveyed every 6 months for 24 months. Logistic regression analysis was used to determine individual, relationship and provider level predictors of SCM use. Over one-third (35%) reported any use of timed unprotected intercourse (TUI) during the study; use of other SCM was rare. Baseline predictors of any TUI use included lower social support, greater perceived provider stigma of childbearing, greater SCM awareness, greater control over sexual decision making in the relationship, inconsistent condom use, and the belief that a desire for childbearing impedes condom use. These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV.
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Affiliation(s)
- Glenn J Wagner
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA.
| | | | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, USA
- Schools of Medicine and Pharmacy, University of Missouri, Kansas City, USA
| | - Deborah Mindry
- University of California, Los Angeles Center for Culture and Health, Los Angeles, USA
| | - Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Eric Robinson
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA
| | | | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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24
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Mantell JE, Cooper D, Exner TM, Moodley J, Hoffman S, Myer L, Leu CS, Bai D, Kelvin EA, Jennings K, Stein ZA, Constant D, Zweigenthal V, Cishe N, Nywagi N. Emtonjeni-A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study. AIDS Behav 2017; 21:905-922. [PMID: 27807792 PMCID: PMC5552040 DOI: 10.1007/s10461-016-1562-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.
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Affiliation(s)
- J E Mantell
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA.
| | - D Cooper
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - T M Exner
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - J Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - S Hoffman
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - L Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - C-S Leu
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Biostatistics and Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, NY, USA
| | - D Bai
- Department of Biostatistics and Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, NY, USA
| | - E A Kelvin
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Epidemiology and Biostatistics Department, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - K Jennings
- City of Cape Town Department of Health, Cape Town, South Africa
| | - Z A Stein
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - D Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - V Zweigenthal
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - N Cishe
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - N Nywagi
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Brown J, Njoroge B, Akama E, Breitnauer B, Leddy A, Darbes L, Omondi R, Mmeje O. A Novel Safer Conception Counseling Toolkit for the Prevention of HIV: A Mixed-Methods Evaluation in Kisumu, Kenya. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2016; 28:524-538. [PMID: 27925487 PMCID: PMC5292923 DOI: 10.1521/aeap.2016.28.6.524] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).
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Affiliation(s)
- Joelle Brown
- Department of Epidemiology and Biostatistics and the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Betty Njoroge
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Brooke Breitnauer
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Anna Leddy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lynae Darbes
- School of Nursing and the Center for Sexuality and Health Disparities, Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Okeoma Mmeje
- Department of Obstetrics and Gynecology, University of Michigan Medical School, and the Department of Health Education and Health Behavior, School of Public Health, University of Michigan
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26
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Goggin K, Wexler C, Nazir N, Staggs VS, Gautney B, Okoth V, Khamadi SA, Ruff A, Sweat M, Cheng AL, Finocchario-Kessler S. Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya. AIDS Behav 2016; 20:2141-50. [PMID: 27108002 PMCID: PMC4995224 DOI: 10.1007/s10461-016-1404-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.
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Affiliation(s)
- Kathy Goggin
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA.
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA.
- University of Missouri-Kansas City, School of Pharmacy, Kansas City, MO, USA.
| | - Catherine Wexler
- University of Kansas Medical Center, Department of Family Medicine, Kansas City, KS, USA
| | - Niaman Nazir
- University of Kansas Medical Center, Department of Preventive Medicine, Kansas City, KS, USA
| | - Vincent S Staggs
- Children's Mercy Hospitals and Clinics, Health Services and Outcomes Research, 2401 Gillham Road, Kansas City, MO, 64108, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | | | | | | | - Andrea Ruff
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, MD, USA
| | - Michael Sweat
- Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA
| | - An-Lin Cheng
- University of Missouri-Kansas City, School of Nursing and Health Studies, Kansas City, MO, USA
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Woldetsadik MA, Goggin K, Staggs VS, Wanyenze RK, Beyeza-Kashesya J, Mindry D, Finocchario-Kessler S, Khanakwa S, Wagner GJ. Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers. AIDS Behav 2016; 20:1370-81. [PMID: 26487299 DOI: 10.1007/s10461-015-1199-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach's alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60-0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.
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Affiliation(s)
- Mahlet Atakilt Woldetsadik
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.
- Pardee RAND Graduate School, 1776 Main Street, Santa Monica, CA, USA.
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas, USA
- Schools of Medicine and Pharmacy, University of Missouri - Kansas City, Kansas, USA
| | - Vincent S Staggs
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas, USA
- School of Medicine, University of Missouri - Kansas City, Kansas, USA
| | - Rhoda K Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynecology, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deborah Mindry
- Los Angeles Center for Culture and Health, University of California, Los Angeles, USA
| | | | | | - Glenn J Wagner
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
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Mmeje O, Njoroge B, Akama E, Leddy A, Breitnauer B, Darbes L, Brown J. Perspectives of healthcare providers and HIV-affected individuals and couples during the development of a Safer Conception Counseling Toolkit in Kenya: stigma, fears, and recommendations for the delivery of services. AIDS Care 2016; 28:750-7. [PMID: 26960581 DOI: 10.1080/09540121.2016.1153592] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Reproduction is important to many HIV-affected individuals and couples and healthcare providers (HCPs) are responsible for providing resources to help them safely conceive while minimizing the risk of sexual and perinatal HIV transmission. In order to fulfill their reproductive goals, HIV-affected individuals and their partners need access to information regarding safer methods of conception. The objective of this qualitative study was to develop a Safer Conception Counseling Toolkit that can be used to train HCPs and counsel HIV-affected individuals and couples in HIV care and treatment clinics in Kenya. We conducted a two-phased qualitative study among HCPs and HIV-affected individuals and couples from eight HIV care and treatment sites in Kisumu, Kenya. We conducted in-depth interviews (IDIs) and focus group discussions (FGDs) to assess the perspectives of HCPs and HIV-affected individuals and couples in order to develop and refine the content of the Toolkit. Subsequently, IDIs were conducted among HCPs who were trained using the Toolkit and FGDs among HIV-affected individuals and couples who were counseled with the Toolkit. HIV-related stigma, fears, and recommendations for delivery of safer conception counseling were assessed during the discussions. One hundred and six individuals participated in FGDs and IDIs; 29 HCPs, 49 HIV-affected women and men, and 14 HIV-serodiscordant couples. Participants indicated that a safer conception counseling and training program for HCPs is needed and that routine provision of safer conception counseling may promote maternal and child health by enhancing reproductive autonomy among HIV-affected couples. They also reported that the Toolkit may help dispel the stigma and fears associated with reproduction in HIV-affected couples, while supporting them in achieving their reproductive goals. Additional research is needed to evaluate the Safer Conception Toolkit in order to support its implementation and use in HIV care and treatment programs in Kenya and other HIV endemic regions of sub-Saharan Africa.
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Affiliation(s)
- Okeoma Mmeje
- a Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA.,b Department of Health Behavior and Health Education , University of Michigan , Ann Arbor , MI , USA
| | - Betty Njoroge
- c Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research , Nairobi City , Kenya
| | - Eliud Akama
- c Kenya Medical Research Institute (KEMRI), Centre for Microbiology Research , Nairobi City , Kenya.,d Family AIDS Care and Education Services (FACES) , Kisumu , Kenya
| | - Anna Leddy
- e Department of Health, Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Brooke Breitnauer
- f Department of Obstetrics and Gynecology , University of Colorado, School of Medicine , Aurora , CO , USA
| | - Lynae Darbes
- g Center for AIDS Prevention Studies and Global Health Sciences, University of California , San Francisco , CA , USA
| | - Joelle Brown
- h Department of Obstetrics, Gynecology, and Reproductive Science , University of California , San Francisco , CA , USA.,i Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
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Wagner GJ, Woldetsadik MA, Beyeza-Kashesya J, Goggin K, Mindry D, Finocchario-Kessler S, Khanakwa S, Wanyenze RK. Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions. Afr J Reprod Health 2016; 20:40-51. [PMID: 28190955 DOI: 10.29063/ajrh2016/v20i1.4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.
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30
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Goggin K, Finocchario-Kessler S, Staggs V, Woldetsadik MA, Wanyenze RK, Beyeza-Kashesya J, Mindry D, Khanakwa S, Wagner GJ. Attitudes, Knowledge, and Correlates of Self-Efficacy for the Provision of Safer Conception Counseling Among Ugandan HIV Providers. AIDS Patient Care STDS 2015; 29:651-60. [PMID: 26588429 PMCID: PMC4684655 DOI: 10.1089/apc.2015.0089] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
- Schools of Medicine and Pharmacy, University of Missouri – Kansas City, Missouri
| | | | - Vincent Staggs
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
- School of Medicine, University of Missouri – Kansas City, Missouri
| | | | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Kampala, Uganda
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Deborah Mindry
- University of California, Los Angeles Center for Culture and Health, Los Angeles, California
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A discussion of key values to inform the design and delivery of services for HIV-affected women and couples attempting pregnancy in resource-constrained settings. J Int AIDS Soc 2015; 18:20272. [PMID: 26643454 PMCID: PMC4672397 DOI: 10.7448/ias.18.6.20272] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/28/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
Abstract
Introduction HIV-affected women and couples often desire children and many accept HIV risk in order to attempt pregnancy and satisfy goals for a family. Risk reduction strategies to mitigate sexual and perinatal HIV transmission include biomedical and behavioural approaches. Current efforts to integrate HIV and reproductive health services offer prime opportunities to incorporate strategies for HIV risk reduction during pregnancy attempts. Key client and provider values about services to optimize pregnancy in the context of HIV risk provide insights for the design and implementation of large-scale “safer conception” programmes. Discussion Through our collective experience and discussions at a multi-disciplinary international World Health Organization–convened workshop to initiate the development of guidelines and an algorithm of care to support the delivery of services for HIV-affected women and couples attempting pregnancy, we identified four values that are key to the implementation of these programmes: (1) understanding fertility care and an ability to identify potential fertility problems; (2) providing equity of access to resources enabling informed decision-making about reproductive choices; (3) creating enabling environments that reduce stigma associated with HIV and infertility; and (4) creating enabling environments that encourage disclosure of HIV status and fertility status to partners. Based on these values, recommendations for programmes serving HIV-affected women and couples attempting pregnancy include the following: incorporation of comprehensive reproductive health counselling; training to support the transfer and exchange of knowledge between providers and clients; care environments that reduce the stigma of childbearing among HIV-affected women and couples; support for safe and voluntary disclosure of HIV and fertility status; and increased efforts to engage men in reproductive decision-making at times that align with women's desires. Conclusions Programmes, policies and guidelines that integrate HIV treatment and prevention, sexual and reproductive health and fertility care services in a manner responsive to user values and preferences offer opportunities to maximize demand for and use of these services. For HIV-affected women and couples attempting pregnancy, the provision of comprehensive services using available tools – and the development of new tools that are adaptable to many settings and follow consensus recommendations – is a public health imperative. The impetus now is to design and deliver value-driven inclusive programming to achieve the greatest coverage and impact to reduce HIV transmission during pregnancy attempts.
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West N, Schwartz S, Phofa R, Yende N, Bassett J, Sanne I, Van Rie A. "I don't know if this is right … but this is what I'm offering": healthcare provider knowledge, practice, and attitudes towards safer conception for HIV-affected couples in the context of Southern African guidelines. AIDS Care 2015; 28:390-6. [PMID: 26445035 DOI: 10.1080/09540121.2015.1093596] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 2011 guidelines for safer conception for HIV-affected individuals and couples were adopted by the South African Department of Health in December 2012. We assessed implementation gaps and facilitators and barriers to delivering safer conception services through examining patient and healthcare provider (HCP) experiences. At Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, we conducted in-depth interviews (IDIs) with nine HCPs (doctors, nurses, and counselors) and IDIs and focus group discussions with 42 HIV-affected men and women interested in having a child. Data were analyzed using a grounded theory approach. HCPs were supportive of fertility intentions of HIV-affected couples and demonstrated some knowledge of safer conception methods, especially ART initiation to suppress viral load in infected partners. Unfortunately, HCPs did not follow the key recommendation that HCPs initiate conversations on fertility intentions with HIV-affected men and women. Providers and clients reported that conversations about conception only occur when client-initiated, placing the onus on HIV-affected individuals. Important barriers underlying this were the misconception held by some HCPs that uninfected partners in serodiscordant partnerships are "latently" infected and the desire by most HCPs to protect or control knowledge around fertility and safer conception methods out of concern over what clients will do with this knowledge before they are virally suppressed or ready to conceive. Almost all participants who had conceived or attempted conception did so without safer conception methods knowledge. HCP concern over conception readiness, perception of what clients will do with safer conception knowledge, and gaps in safer conception knowledge prevent HCPs from initiating conversations with HIV-affected patients on the issue of childbearing. Examining these findings in the context of existing South African guidelines illuminates areas that need to be addressed to facilitate implementation of the guidelines.
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Affiliation(s)
- Nora West
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Sheree Schwartz
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,c Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , MD , USA
| | - Rebecca Phofa
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | | | - Jean Bassett
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Ian Sanne
- d Department of Medicine , Clinical HIV Research Unit, University of the Witwatersrand , Johannesburg , South Africa.,e Right to Care, ThembaLethu Wing, Helen Joseph Hospital , Johannesburg , South Africa
| | - Annelies Van Rie
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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"If I don't use a condom … I would be stressed in my heart that I've done something wrong": Routine Prevention Messages Preclude Safer Conception Counseling for HIV-Infected Men and Women in South Africa. AIDS Behav 2015; 19:1666-75. [PMID: 25711300 DOI: 10.1007/s10461-015-1026-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.
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Saleem HT, Surkan PJ, Kerrigan D, Kennedy CE. Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples. AIDS Care 2015; 28:197-204. [PMID: 26288153 DOI: 10.1080/09540121.2015.1074652] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.
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Affiliation(s)
- Haneefa T Saleem
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Pamela J Surkan
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
| | - Deanna Kerrigan
- b Department of Health , Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University , 624 North Broadway, Hampton House, 257, Baltimore , MD 21205 , USA
| | - Caitlin E Kennedy
- a Department of International Health , Bloomberg School of Public Health, Johns Hopkins University , 615 N. Wolfe Street, Baltimore , MD 21205 , USA
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Community perceptions of childbearing and use of safer conception strategies among HIV-discordant couples in Kisumu, Kenya. J Int AIDS Soc 2015; 18:19972. [PMID: 26077644 PMCID: PMC4468054 DOI: 10.7448/ias.18.1.19972] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/19/2015] [Accepted: 05/06/2015] [Indexed: 11/08/2022] Open
Abstract
Introduction Safer conception strategies (SCS) have the potential to decrease HIV transmission among HIV-discordant couples who desire children. Community perceptions of SCS may influence the scale-up and uptake of these services, but little is known about how communities will react to these strategies. Without community support for SCS, their success as an HIV prevention tool may be limited. The objective of this study is to characterize community perceptions of SCS for HIV-discordant couples in Kisumu, Kenya, to inform ongoing and future safer conception intervention studies in low-resource settings. Methods We conducted six focus group discussions and 11 in-depth-interviews in Kisumu, Kenya, among a diverse group (N=59) of community members, including men, women, youth (age 19–25), community health workers and local leaders. An iterative qualitative analysis using a grounded theory approach was employed. Results and discussion All participants emphasized the importance of childbearing in their society and the right to have children, regardless of an individual's HIV status. While most participants believed that HIV-discordant couples should be allowed to have children, they discussed several barriers to the uptake of SCS such as HIV-related stigma, fear of HIV transmission to the uninfected partner and child, fear of unfamiliar medical procedures and lack of information among community members and health care providers about HIV prevention interventions that allow safer conception. Access to information, community experiences with successful safer conception interventions, healthcare provider training, male engagement and community mobilization may help overcome these barriers. Though assisted reproduction strategies generated the most negative reactions from participants, our results suggest that with education and explanation of these services, participants express interest in these strategies and want them to be offered in their community. Conclusions Many community members noted a need and desire for safer conception education and services in Kisumu. However, community barriers such as fear, stigma and lack of information should be addressed before safer conception interventions can be successfully implemented and delivered. Further research focused on community education, male engagement and healthcare provider training is a crucial next step in delivering safer conception in this region.
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Wagner GJ, Goggin K, Mindry D, Beyeza-Kashesya J, Finocchario-Kessler S, Woldetsadik MA, Khanakwa S, Wanyenze RK. Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions. AIDS Behav 2015; 19:1078-88. [PMID: 25280448 DOI: 10.1007/s10461-014-0906-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care.
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