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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: 4] [Impact Index Per Article: 2.0] [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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Zia Y, Velloza J, Oluoch L, Momanyi R, Mbugua S, Njoroge J, Gakuo S, Mugo E, Thuo N, Kiptinness C, Njuguna N, Ngure K, R Mugo N, Heffron R. Use of fertility awareness methods as a component of safer conception for women in HIV-serodifferent relationships in Kenya. Reprod Health 2021; 18:73. [PMID: 33794936 PMCID: PMC8017620 DOI: 10.1186/s12978-021-01128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/21/2021] [Indexed: 11/15/2022] Open
Abstract
Background For couples affected by HIV, and serodifferent couples in particular, pregnancy desire is often juxtaposed against the risk of HIV transmission between the couple and the potential neonate leading to thinking about measures to minimize risk of HIV transmission. We assess the use of fertility awareness methods [FAM] and evaluate the drivers of alignment between indicators of fertility and sexual behavior among HIV-serodifferent couples desiring pregnancy. Methods HIV-serodifferent couples from Thika, Kenya were enrolled into an open-label pilot evaluation of safer conception strategies. Women responded to daily 7-item short message service [SMS] surveys on FAM and sexual activity. Menstrual cycles were categorized as having condomless sex aligned, not aligned, or partially aligned to the predicted peak fertility. We used binomial logit models with generalized estimating equations to assess alignment between condomless sex during peak fertility days and FAM results. We used Cox proportional hazards to compare pregnancy incidence among months with sex and peak fertility aligned and mis-aligned. Results A total of 6929 SMS surveys across 252 menstrual cycles of 65 women were included. Reporting “sticky” cervical mucus (adjusted odds ratio [aOR]: 2.25, 95% confidence interval [95% CI]: 1.30, 3.90) and positive ovulation prediction kit [OPK] result (aOR: 2.07, 95% CI: 1.11, 3.86) were associated with increased likelihood of alignment of condomless sex during peak fertility. Pregnancy incidence was statistically similar among periods with sex aligned and not aligned with peak fertility. Conclusions Among women engaged in a comprehensive safer conception program, a moderate percentage of women aligned condomless sex and predicted peak fertility days at least once. While FAM, particularly cervical mucus and OPK, are an inexpensive option for couples to consider using as a component of their safer conception strategies, antiretroviral-based strategies remain important to minimize risk.
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Affiliation(s)
- Yasaman Zia
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Jennifer Velloza
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA
| | - Lynda Oluoch
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Sarah Mbugua
- Kenya Medical Research Institute, Nairobi, Kenya
| | - John Njoroge
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Edwin Mugo
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Njambi Njuguna
- Kenya Medical Research Institute, Nairobi, Kenya.,KAVI Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.,Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Nelly R Mugo
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA.,Kenya Medical Research Institute, Nairobi, Kenya
| | - Renee Heffron
- Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA, 98104, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA.
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Mandell LN, Rodriguez VJ, Peltzer K, Weiss SM, Jones DL. Fertility intentions of women living with HIV and their male partners during the perinatal period in rural South Africa. Int J STD AIDS 2021; 32:740-750. [PMID: 33769899 DOI: 10.1177/0956462420987447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Understanding the fertility intentions of people living with HIV can guide safer conception planning and prevention of mother-to-child transmission (PMTCT). Most research has addressed fertility intentions among women, rather than couples, at a single time point. This clinical trial of a PMTCT intervention in rural Mpumalanga province, South Africa, examined longitudinal fertility intentions among perinatal women living with HIV and their male partners. Study assessments and intervention and control sessions were conducted prenatally and postpartum. Longitudinal predictors of participants' (n = 360 men, n = 917 women) fertility intentions were similar between sexes. Younger age and male involvement in perinatal care were associated with reporting fertility intentions at both baseline and 12 months postpartum. Having an HIV-positive infant and discussing pregnancy plans with a healthcare provider by 12 months postpartum were associated with incident fertility intentions after reporting no plans for further children at baseline. Results highlight the important role of healthcare providers to educate men and women on issues surrounding conception, as well as the potential for incorporating PMTCT and safer conception education into HIV clinical services.
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Affiliation(s)
- Lissa N Mandell
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Psychology, University of Georgia, Athens, GA, USA
| | - Karl Peltzer
- HIV/AIDS/STIs and TB (HAST) Research Programme, 56867Human Sciences Research Council, Pretoria, South Africa.,Department of Research & Innovation, 37714University of Limpopo, Sovenga, South Africa
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, 5452University of Miami Miller School of Medicine, Miami, FL, USA
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Mandell LN, Rodriguez VJ, Jones DL. Safer Conception and Family Planning Knowledge, Attitudes, and Practices Among Postpartum Women with HIV in Rural South Africa. Open Access J Contracept 2021; 12:17-25. [PMID: 33603508 PMCID: PMC7882456 DOI: 10.2147/oajc.s288569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/23/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction With the help of safer conception strategies (SCS), women with HIV (WHIV) can achieve their reproductive goals while minimizing the risk of transmission to their partners or infants. However, interpregnancy intervals of at least 24 months are recommended to optimize maternal and infant health outcomes, so postpartum WHIV need to use contraception to delay subsequent pregnancies. Understanding safer conception and family planning knowledge, attitudes, and practices among WHIV is key to tailoring family planning policy and intervention development in regions with high HIV prevalence. Methods This study described the safer conception and family planning knowledge, attitudes, and practices of postpartum WHIV (N = 956) in rural Mpumalanga province, South Africa, 12 months after delivery. Results Almost all women understood the importance of condom use, but most overestimated the risk of sexual transmission. A majority of women reported that their partner’s desires (53%) and the risk of perinatal transmission (58%) were very important factors when making childbearing decisions. Most women (81%) used condoms for HIV prevention and most (83%) used contraception for pregnancy prevention. Many women (33% of contraceptive users) used condoms for both HIV prevention and contraception without using another contraceptive method as well. Only 43% of contraceptive users endorsed dual method use of condoms with hormones, intrauterine devices, or sterilization. Discussion Results highlight the prominence of condom-based pregnancy and HIV transmission prevention, the influence of male partners in fertility decision-making, and the opportunity for further education and promotion of long acting methods in this setting.
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Affiliation(s)
- Lissa N Mandell
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Psychology, University of Georgia, Athens, GA, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Rucinski KB, Powers KA, Pettifor AE, Black V, Pence BW, Chi BH, Rees H, Schwartz SR. Trajectories of fertility intentions among women living with HIV in South Africa. AIDS Care 2021; 33:180-186. [PMID: 32008361 PMCID: PMC7395884 DOI: 10.1080/09540121.2020.1719969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
Fertility intentions are thought to be dynamic among women of reproductive age, yet few studies have assessed fertility intentions over time among women with HIV. We examine temporal patterns of fertility intentions in women with HIV to assess the extent to which fertility intentions - and the corresponding need for safer conception and judicious antiretroviral therapy (ART) regimen selection - vary over time. 850 non-pregnant HIV-positive women aged 18-35 on or being initiated onto ART in Johannesburg, South Africa were enrolled into a prospective cohort study (2009-2010). Fertility intentions were assessed at enrollment and at 30-day intervals via an interviewer-administered questionnaire. We used group-based trajectory modelling to identify longitudinal patterns of fertility intentions over 12 months. We identified four patterns of fertility intentions, which we labelled "consistently low" (representing ∼60% of the population), "low and increasing" (∼23%), "high and increasing" (∼12%), and "high and decreasing" (∼5%). Our findings suggest that a single family-planning assessment at one time point is insufficient to fully identify and meet the reproductive needs of women with HIV. As HIV testing and treatment evolve in South Africa, routine screening for fertility intentions can offer important opportunities to optimize HIV treatment, prevention, and maternal and child health.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Vivian Black
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, Clinical Microbiology and Infectious Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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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: 17] [Impact Index Per Article: 3.4] [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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Iliyasu Z, Galadanci HS, Oladimeji AI, Babashani M, Gajida AU, Aliyu MH. Predictors of Safer Conception Practices Among HIV-Infected Women in Northern Nigeria. Int J Health Policy Manag 2019; 8:480-487. [PMID: 31441288 PMCID: PMC6706964 DOI: 10.15171/ijhpm.2019.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 05/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Persons living with HIV often face discrimination in safe sex and reproductive choices, especially in lowresource settings. This study assessed fertility desires and intentions, risk perception and correlates of ever use of at least one safer conception method among HIV-infected women attending a tertiary health facility in Kano, Nigeria.
Methods: Structured questionnaires were administered to a cross section of 328 of 427 eligible HIV-infected women. Fertility desires and intentions, risk perception and safer conception practice were analyzed. Logistic regression was employed to assess for predictors.
Results: Of the 328 respondents, 150 respondents (45.7%) wanted more children. The proportions of respondents aware of their transmission risk during pregnancy, delivery, and breastfeeding were 69.5%, 75.3%, and 78.9%, respectively. Further, 68.9% of respondents were aware of the prospects of bearing HIV-negative children without infecting their partners. About 64.8% of women were aware of at least one safer conception method. Safer conception methods everused by the participants include: antiretroviral therapy (ART) (36.7%), timed unprotected intercourse with (10.9%), and without pre-exposure prophylaxis (PrEP) (17.2%), intravaginal insemination (7.3%) and intrauterine insemination (4.7%). Safer conception practice was predicted by marital status (married versus single, adjusted odds ratio [AOR]=1.50, 95% CI =1.10-3.55), parity (2-4 versus 0, AOR=12.1, 95% CI=3.7-39.8), occupation (civil servants versus traders, AOR=0.37, 95% CI=0.16-0.86), husband’s serostatus (seroconcordant versus serodiscordant) (AOR=1.51, 95% CI=1.13-4.64), couple contraceptive use (users versus non-users) (AOR=1.62, 95% CI=1.16-5.83) and transmission risk perception (high risk versus low/no risk) (AOR=2.14, 95% CI=1.18-3.90).
Conclusion: We found high levels of fertility desires and intentions and moderate risk perception among a cohort of HIV-infected women in urban Kano, Nigeria. The use of safer conception practices was not common. Our findings underscore the need for healthcare provider capacity building to enhance safer conception counseling and service delivery.
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Affiliation(s)
- Zubairu Iliyasu
- Department of Community Medicine, Bayero University, Kano, Nigeria.,Centre for Infectious Diseases Research, Bayero University, Kano, Nigeria
| | - Hadiza S Galadanci
- Department of Obstetrics and Gynecology, Bayero University, Kano, Nigeria
| | - Alfa I Oladimeji
- Department of Community Medicine, Bayero University, Kano, Nigeria
| | - Musa Babashani
- Department of Medicine, Bayero University, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, Bayero University, Kano, Nigeria
| | - Muktar H Aliyu
- Department of Health Policy & Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
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Schwartz SR, Bassett J, Mutunga L, Yende N, Mudavanhu M, Phofa R, Sanne I, Van Rie A. HIV incidence, pregnancy, and implementation outcomes from the Sakh'umndeni safer conception project in South Africa: a prospective cohort study. Lancet HIV 2019; 6:e438-e446. [PMID: 31160268 DOI: 10.1016/s2352-3018(19)30144-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/22/2019] [Accepted: 03/28/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Safer conception strategies empower individuals trying to conceive to minimise HIV transmission risk to partners and potential children; however, effectiveness data are scarce. We aimed to assess adoption of safer conception methods and HIV and pregnancy outcomes from Sakh'umndeni, a novel safer conception service in South Africa. METHODS In this prospective cohort study, the Sakh'umndeni clinical cohort at Witkoppen Cinic in Johannesburg (South Africa) enrolled adults aged at least 18 years who were trying to conceive and in relationships with an HIV-positive partner. Couples who were pregnant at enrolment or had been previously diagnosed as infertile were excluded. Participants received safer conception care by a nurse, including antiretroviral therapy (ART) for HIV-positive partners, pre-exposure prophylaxis (PrEP) for HIV-negative partners, counselling around timed condomless sex, or syringes for self-insemination. Primary outcomes were pregnancy incidence and HIV transmission to partners and infants. We estimated time to first pregnancy using Kaplan-Meier curves; pregnancy and HIV incidence were estimated as events per person-years of risk. FINDINGS Between July 16, 2013, and April 5, 2017, 526 individuals (334 women and 192 men) from 334 partnerships enrolled. 162 (48%) of 334 couples were serodifferent, 149 (45%) were HIV-positive seroconcordant, and 23 (7%) were an HIV-positive woman and an unknown status male partner. At enrolment, 176 (61%) of 287 HIV-positive women and 60 (46%) of 131 HIV-positive men were virally suppressed (<50 copies per mL). Among the safer conception strategies, ART was initiated by 73 (91%) of 80 HIV-positive participants not on ART and PrEP was initiated by 28 (28%) of 101 HIV-negative participants. 2719 follow-up visits were completed, and 99 pregnancies were observed in 89 women. Pregnancy incidence was 41·2 per 100 person-years (95% CI 33·4-50·7); 25 (28%) of 89 pregnancies with a known outcome were miscarried or terminated because of risk to the mother. Pregnancy incidence was 79·0 per 100 person-years (95% CI 49·8-125·4) among HIV-negative women and 36·7 per 100 person-years (29·1-46·3) among HIV-positive women. At the time of pregnancy, viral suppression among women was high (68 [87%] of 78 women had viral loads of <50 copies per mL and 77 [99%] had viral loads of <1000 copies per mL). No horizontal or vertical HIV transmission events were observed. INTERPRETATION Safer conception strategies empowered couples to safely conceive. Pregnancy incidence among service users was high. Integration of safer conception counselling could promote HIV prevention and linkage to care. FUNDING US Agency for International Development; UJMT Consortium/Fogarty International Center, US National Institutes of Health (NIH); and Johns Hopkins University Center for AIDS Research (NIH).
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Affiliation(s)
- Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Lillian Mutunga
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Nompumelelo Yende
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa; Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Mutsa Mudavanhu
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Rebecca Phofa
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa; Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ian Sanne
- Clinical HIV Research Unit, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa; Right to Care, Johannesburg, South Africa
| | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium
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Schwartz S, Davies N, Naidoo N, Pillay D, Makhoba N, Mullick S. Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models. Reprod Health 2019; 16:65. [PMID: 31138252 PMCID: PMC6538560 DOI: 10.1186/s12978-019-0718-5] [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] [Indexed: 11/13/2022] Open
Abstract
Background Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients’ experiences utilizing safer conception services in sub-Saharan Africa are limited. Methods Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016–August 2017 for a cross-sectional interview assessing clients’ perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients’ experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were < 50, 50–79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended. Results Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits. Conclusions Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a ‘lighter touch’ approach while still minimizing HIV transmission risks. Electronic supplementary material The online version of this article (10.1186/s12978-019-0718-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. .,Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa.
| | - Natasha Davies
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicolette Naidoo
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Diantha Pillay
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Nokuthula Makhoba
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
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Longitudinal patterns of unmet need for contraception among women living with HIV on antiretroviral therapy in South Africa. PLoS One 2018; 13:e0209114. [PMID: 30571702 PMCID: PMC6301780 DOI: 10.1371/journal.pone.0209114] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/29/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Fertility intentions and contraceptive use are often not assessed in the context of clinical HIV care, representing a possible programming gap if women's family planning needs change over time. We aimed to identify longitudinal patterns of unmet need for contraception over a 12-month period among women living with HIV taking antiretroviral therapy (ART). STUDY DESIGN 850 non-pregnant, HIV-positive women aged 18-35 on or initiating ART in Johannesburg, South Africa, were enrolled into a prospective cohort study in 2009-2010. Fertility intentions and contraceptive use were assessed during routine HIV care visits via an interviewer-administered questionnaire, and women were referred for on-site contraceptive counseling. We used group-based trajectory modeling to identify patterns of unmet need for contraception over 12 months, first in the entire population and then in a subset of recent ART initiators. RESULTS In the full population we identified four patterns of unmet need for contraception over one year. Half of the enrolled women were predicted to have a consistently high probability of unmet need, 22.9% a consistently low probability, 16.7% a decreasing probability, and 10.4% an increasing probability over time. Contraceptive method discontinuation and rapidly changing fertility intentions were the primary drivers of changing (increasing or decreasing) unmet need over follow-up. Results were similar in recent ART initiators. CONCLUSIONS Half of women were estimated to have a high probability of unmet need that persisted over time, and more than a quarter were estimated to experience patterns of changing unmet need over 12 months. Family planning needs should be assessed more regularly in HIV-positive women to prevent unintended pregnancies and support safer conception among women trying to conceive.
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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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A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa. AIDS Behav 2018; 22:2916-2946. [PMID: 29869184 DOI: 10.1007/s10461-018-2170-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.
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15
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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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16
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Matthews LT, Beyeza-Kashesya J, Cooke I, Davies N, Heffron R, Kaida A, Kinuthia J, Mmeje O, Semprini AE, Weber S. Consensus statement: Supporting Safer Conception and Pregnancy For Men And Women Living with and Affected by HIV. AIDS Behav 2018; 22:1713-1724. [PMID: 28501964 PMCID: PMC5683943 DOI: 10.1007/s10461-017-1777-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Safer conception interventions reduce HIV incidence while supporting the reproductive goals of people living with or affected by HIV. We developed a consensus statement to address demand, summarize science, identify information gaps, outline research and policy priorities, and advocate for safer conception services. This statement emerged from a process incorporating consultation from meetings, literature, and key stakeholders. Three co-authors developed an outline which was discussed and modified with co-authors, working group members, and additional clinical, policy, and community experts in safer conception, HIV, and fertility. Co-authors and working group members developed and approved the final manuscript. Consensus across themes of demand, safer conception strategies, and implementation were identified. There is demand for safer conception services. Access is limited by stigma towards PLWH having children and limits to provider knowledge. Efficacy, effectiveness, safety, and acceptability data support a range of safer conception strategies including ART, PrEP, limiting condomless sex to peak fertility, home insemination, male circumcision, STI treatment, couples-based HIV testing, semen processing, and fertility care. Lack of guidelines and training limit implementation. Key outstanding questions within each theme are identified. Consumer demand, scientific data, and global goals to reduce HIV incidence support safer conception service implementation. We recommend that providers offer services to HIV-affected men and women, and program administrators integrate safer conception care into HIV and reproductive health programs. Answers to outstanding questions will refine services but should not hinder steps to empower people to adopt safer conception strategies to meet reproductive goals.
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Affiliation(s)
- Lynn T. Matthews
- MGH Global Health and Division of Infectious Diseases, 125 Nashua Street, Suite 722, Boston, MA 02114 USA
| | - Jolly Beyeza-Kashesya
- Department of Obstetrics and Gynaecology, Mulago National Referral Hospital, Kampala, Uganda
| | - Ian Cooke
- University of Sheffield, Sheffield, UK
| | - Natasha Davies
- University of the Witwatersrand, WITS RHI, Johannesburg, South Africa
| | | | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia Canada
| | - John Kinuthia
- University of Washington, Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | | | | | - Shannon Weber
- University of California at San Francisco, Zukerberg San Francisco General Hospital, San Francisco, USA
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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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18
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Peltzer K, Sifunda S, Mandell LN, Rodriguez VJ, Lee TK, Cook R, Weiss SM, Jones DL. Fertility intentions of prenatal and postpartum HIV-positive women in primary care in Mpumalanga province, South Africa: a longitudinal study. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:9-17. [PMID: 29497335 PMCID: PMC5818871 DOI: 10.2147/hiv.s153212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction This study aimed to assess fertility intentions (planning to have more children in the future) and associated factors among pregnant and postpartum HIV positive women in rural South Africa. Methods In a longitudinal study, as part of a prevention of mother to child transmission (PMTCT) intervention trial, 699 HIV positive prenatal women, were systematically recruited and followed up at 6 months and 12 months postpartum (retention rate = 59.5%). Results At baseline, 32.9% of the women indicated fertility intentions and at 12 months postnatal, 120 (28.0%) reported fertility intentions. In longitudinal analyses, which included time-invariant baseline characteristics predicting fertility intention over time, not having children, having a partner with unknown/HIV-negative status, and having disclosed their HIV status to their partner, were associated with fertility intentions. In a model with time-varying covariates, decreased family planning knowledge, talking to a provider about a future pregnancy, and increased male involvement were associated with fertility intentions. Conclusion Results support ongoing perinatal family planning and PMTCT education.
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Affiliation(s)
- Karl Peltzer
- HIV/AIDS/STIs and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, South Africa.,Department of Research and Innovation, University of Limpopo, Sovenga, South Africa
| | - Sibusiso Sifunda
- HIV/AIDS/STIs and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, South Africa
| | - Lissa N Mandell
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Violeta J Rodriguez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tae Kyoung Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ryan Cook
- School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephen M Weiss
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Deborah L Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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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: 19] [Impact Index Per Article: 2.7] [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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Client uptake of safer conception strategies: implementation outcomes from the Sakh'umndeni Safer Conception Clinic in South Africa. J Int AIDS Soc 2017; 20:21291. [PMID: 28361507 PMCID: PMC5577727 DOI: 10.7448/ias.20.2.21291] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh’umndeni, which is a safer conception clinic in South Africa. Methods:Sakh’umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression. Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%. Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms.
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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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Haberlen SA, Narasimhan M, Beres LK, Kennedy CE. Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review. Stud Fam Plann 2017; 48:153-177. [PMID: 28337766 PMCID: PMC5516228 DOI: 10.1111/sifp.12018] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.
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