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Ensor S, Mechie I, Ryan R, Mussa A, Bame B, Tamuthiba L, Moshashane N, Morroni C. Measuring the impact of COVID-19 social distancing measures on sexual health behaviours and access to HIV and sexual and reproductive health services for people living with HIV in Botswana. Front Glob Womens Health 2023; 4:981478. [PMID: 36970120 PMCID: PMC10030995 DOI: 10.3389/fgwh.2023.981478] [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: 06/29/2022] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
Introduction Uninterrupted access to HIV and sexual and reproductive health (SRH) services is essential, particularly in high HIV prevalence settings, to prevent unintended pregnancy and vertical HIV transmission. Understanding the challenges that COVID-19 and associated social distancing measures (SDMs) posed on health service access is imperative for future planning. Methods This cross-sectional study was conducted in Botswana between January-February 2021. A web-based questionnaire was disseminated on social media as part of the International Sexual Health and REproductive Health (I-SHARE) Survey. Respondents answered questions on SRH, before and during COVID-19 SDMs. Subgroup analysis and comparison of descriptive data was performed for people living with HIV (PLWH). Results Of 409 participants, 65 were PLWH (80% female, 20% male). During SDMs, PLWH found it more difficult to access condoms and treatment for HIV and STIs; attend HIV appointments; and maintain adherence to antiretroviral therapy. Compared to HIV-negative women, a higher proportion of women living with HIV used condoms as their primary method of contraception (54% vs. 48%), and had lower use of long-acting reversible contraception (8% vs. 14%) and dual contraception (8% vs. 16%). Discussion Mirroring global trends, COVID-19 disrupted HIV and SRH service access in Botswana. However, in high HIV-prevalence settings, disruption may more severely impact population health with disproportionate effects on women. Integration of HIV and SRH services could build health system capacity and resilience, reduce missed opportunities for delivering SRH services to PLWH and limit the consequences of future restrictions that may cause health system disruption.
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Affiliation(s)
- Samuel Ensor
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Imogen Mechie
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Rebecca Ryan
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Aamirah Mussa
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Bame Bame
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Lefhela Tamuthiba
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Neo Moshashane
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Chelsea Morroni
- Botswana Sexual and Reproductive Health Initiative, Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- MRC Centre for Reproductive Health and Centre for Global Health, University of Edinburgh, Edinburgh, United Kingdom
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Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, El-Sadr WM, Apollo T, Rabkin M, Atun R, Bärnighausen T. Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003836. [PMID: 34752477 PMCID: PMC8577772 DOI: 10.1371/journal.pmed.1003836] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. METHODS AND FINDINGS We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. CONCLUSIONS Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.
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Affiliation(s)
- Caroline A. Bulstra
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Jan A. C. Hontelez
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Moritz Otto
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Anna Stepanova
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
| | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
- Aix-Marseille School of Economics, CNRS, EHESS, Centrale Marseille, Aix-Marseille University, Les Milles, France
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Wafaa M. El-Sadr
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States of America
| | | | - Rifat Atun
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University Medical Center, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts, United States of America
- Africa Health Research Institute, KwaZulu-Natal, South Africa
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Makins A, Cameron S. Post pregnancy contraception. Best Pract Res Clin Obstet Gynaecol 2020; 66:41-54. [DOI: 10.1016/j.bpobgyn.2020.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/10/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
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Eastment MC, Wanje G, Richardson BA, Nassir F, Mwaringa E, Barnabas RV, Sherr K, Mandaliya K, Jaoko W, McClelland RS. Performance of family planning clinics in conducting recommended HIV counseling and testing in Mombasa County, Kenya: a cross-sectional study. BMC Health Serv Res 2019; 19:665. [PMID: 31521157 PMCID: PMC6744633 DOI: 10.1186/s12913-019-4519-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022] Open
Abstract
Background A high proportion of African women utilize family planning (FP) services. Accordingly, incorporating HIV testing into FP services may strategically target the first WHO 90–90-90 goal of 90% of people living with HIV knowing their status. Methods The objective of this analysis was to determine the proportion of new FP clients counseled and tested for HIV, as well as correlates of HIV testing, in a random sample of 58 FP clinics in Mombasa County, Kenya. Structured interviews of FP clinic managers collected data on characteristics of FP clinics and staff. Study staff performed a 3-month review of FP registers, summarizing new client HIV testing and counseling (HTC). Because overall rates of HTC were quite low, a binary variable was created comparing clinics performing any HIV counseling and/or testing to clinics performing none. Generalized linear models were used to calculate prevalence ratios (PR) and identify correlates of HTC. Factors associated with any HTC with a p-value < 0.10 in univariate analysis were included in a multivariate analysis. Results Of the 58 FP clinics, 26 (45%) performed any counseling for HIV testing, and 23 (40%) performed any HIV testing. Counseling for HIV testing was conducted for 815/4389 (19%) new clients, and HIV testing was performed for 420/4389 (10%). Clinics without trained HIV testing providers uniformly did not conduct HIV counseling and/or testing (0/12 [0%]), while 27/46 (59%) of clinics with ≥1 provider performed some HTC (p < 0.001). In the subset of 46 clinics with ≥1 trained HIV testing provider, correlates of performing HTC included being a public versus non-public clinic (PR 1.70 95%CI 1.01–2.88), and having an HIV comprehensive care center (CCC) onsite (PR 2.05, 95%CI 1.04–4.06). Conclusion Trained HIV testing providers are crucial for FP clinics to perform any HTC. Approaches are needed to increase routine HTC in FP clinics including staffing changes and/or linkages with other testing services (in standalone VCT services or lab facilities) in order to improve the implementation of existing national guidelines. A future cluster randomized trial is planned to test an implementation strategy, the Systems Analysis and Improvement Approach (SAIA) to increase HTC in FP clinics.
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Affiliation(s)
| | - George Wanje
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA.,Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, WA, USA
| | - Faiza Nassir
- Department of Obstetrics and Gynecology, Coast General Hospital, Mombasa, Kenya
| | | | - Ruanne V Barnabas
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, Seattle, WA, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Walter Jaoko
- University of Nairobi, Medical Microbiology, Nairobi, Kenya
| | - R Scott McClelland
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, Seattle, WA, USA
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Narasimhan M, Yeh PT, Haberlen S, Warren CE, Kennedy CE. Integration of HIV testing services into family planning services: a systematic review. Reprod Health 2019; 16:61. [PMID: 31138307 PMCID: PMC6538541 DOI: 10.1186/s12978-019-0714-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite significant interest in integrating sexual and reproductive health (SRH) services into HIV services, less attention has been paid to linkages in the other direction. Where women and girls are at risk of HIV, offering HIV testing services (HTS) during their visits to family planning (FP) services offers important opportunities to address both HIV and unwanted pregnancy needs simultaneously. METHODS We conducted a systematic review of studies comparing FP services with integrated HTS to those without integrated HTS or with a lower level of integration (e.g., referral versus on-site services), on the following outcomes: uptake/counseling/offer of HTS, new cases of HIV identified, linkage to HIV care and treatment, dual method use, client satisfaction and service quality, and provider knowledge and attitudes about integrating HTS. We searched three online databases and included studies published in a peer-reviewed journal prior to the search date of June 20, 2017. RESULTS Of 530 citations identified, six studies ultimately met the inclusion criteria. Three studies were conducted in Kenya, and one each in Uganda, Swaziland, and the USA. Most were in FP clinics. Three were from the Integra Initiative. Overall rigor was moderate, with one cluster-randomized trial. HTS uptake was generally higher with integrated sites versus comparison or pre-integration sites, including in adjusted analyses, though outcomes varied slightly across studies. One study found that women at integrated sites were more likely to have high satisfaction with services, but experienced longer waiting times. One study found a small increase in HIV seropositivity among female patients testing after full integration, compared to a dedicated HIV tester. No studies comparatively measured linkage to HIV care and treatment, dual method use, or provider knowledge/attitudes. CONCLUSIONS Global progress and success for reaching SRH and HIV targets depends on progress in sub-Saharan Africa, where women bear a high burden of both unintended pregnancy and sexually transmitted infections, including HIV. While the evidence base is limited, it suggests that integration of HTS into FP services is feasible and has potential for positive joint outcomes. The success and scale-up of this approach will depend on population needs and health system factors.
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Affiliation(s)
- Manjulaa Narasimhan
- Department of Reproductive Health and Research and UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme, World Health Organization, Geneva, Switzerland
| | - Ping Teresa Yeh
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Sabina Haberlen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Kwarisiima D, Atukunda M, Owaraganise A, Chamie G, Clark T, Kabami J, Jain V, Byonanebye D, Mwangwa F, Balzer LB, Charlebois E, Kamya MR, Petersen M, Havlir DV, Brown LB. Hypertension control in integrated HIV and chronic disease clinics in Uganda in the SEARCH study. BMC Public Health 2019; 19:511. [PMID: 31060545 PMCID: PMC6501396 DOI: 10.1186/s12889-019-6838-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/15/2019] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND There is an increasing burden of hypertension (HTN) across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. HIV treatment infrastructure could be leveraged for the care of other chronic diseases, including HTN. However, little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time. METHODS Population screening for HIV and HTN, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study (NCT01864603). Individuals with either HIV, HTN, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. We describe demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of HTN control. RESULTS Following population screening (2013-2014) of 34,704 adults age ≥ 18 years, 4554 individuals with HTN alone or both HIV and HTN were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with HTN linked to care and contributed 15,653 follow-up visits over 3 years. HTN was controlled at 15% of baseline visits and at 46% (95% CI: 44-48%) of post-baseline follow-up visits. Scheduled visit interval more frequent than clinical indication among patients with controlled HTN was associated with lower HTN control at the subsequent visit (aOR = 0.89; 95% CI 0.79-0.99). Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients to have controlled blood pressure at follow-up visits (48% vs 46%; aOR 1.28; 95% CI 0.95-1.71). CONCLUSIONS Improved HTN control was achieved in an integrated HIV and chronic care model. Similar to HIV care, visit frequency determined by drug supply chain rather than clinical indication is associated with worse HTN control. TRIAL REGISTRATION The SEARCH Trial was prospectively registered with ClinicalTrials.gov : NCT01864603.
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Affiliation(s)
| | | | | | - Gabriel Chamie
- University of California San Francisco, San Francisco, CA USA
| | - Tamara Clark
- University of California San Francisco, San Francisco, CA USA
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Vivek Jain
- University of California San Francisco, San Francisco, CA USA
| | | | | | | | | | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Diane V. Havlir
- University of California San Francisco, San Francisco, CA USA
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Jarolimova J, Kabakyenga J, Bennett K, Muyindike W, Kembabazi A, Martin JN, Hunt PW, Boum Y, Haberer JE, Bangsberg DR, Kaida A, Matthews LT. Contraceptive use following unintended pregnancy among Ugandan women living with HIV. PLoS One 2018; 13:e0206325. [PMID: 30359430 PMCID: PMC6201927 DOI: 10.1371/journal.pone.0206325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 10/10/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Preventing unintended pregnancy is critical for women living with HIV (WLWH) to safely achieve their reproductive goals. Family planning services should support WLWH at risk of repeat unintended pregnancies. We examined the relationship between unintended pregnancy and subsequent contraception use among WLWH in Uganda. STUDY DESIGN This was a retrospective analysis of data from a longitudinal cohort of individuals initiating antiretroviral therapy (ART), restricted to women with pregnancy (confirmed via urine β-hcg testing) between 2011-2013. The exposure of interest was intended vs unintended pregnancy, and the outcome was self-report of modern contraceptive use (hormonal methods, intrauterine device, sterilization, and/or consistent condom use) at 12 (range 6-18) months post-partum. A log-binomial model was used to estimate relative risks of modern contraceptive use post-partum based on intent of the index pregnancy, adjusted for age, socioeconomic status, education, relationship and HIV status of pregnancy partner, contraceptive use prior to pregnancy, years since HIV diagnosis, ART regimen, and CD4 cell count. RESULTS Among 455 women, 110 women reported 110 incident pregnancies with report on intent. Women had a baseline median age of 29 years, baseline CD4 count 403 cells/mm3, and were living with HIV for 3.8 years. Fifty pregnancies (45%) were reported as unintended and 60 (55%) as intended. Postpartum, 64% of women with unintended and 51% with intended pregnancy reported modern contraception (p = 0.24). In adjusted models, there was no association between pregnancy intent and post-partum contraception. However, contraceptive use prior to the referent pregnancy was positively associated with post-partum contraceptive use (aRR 1.97 (95% CI 1.12-3.48, p = 0.02), while higher baseline CD4 cell count was associated with lower post-partum contraceptive use (aRR 0.95, 95% CI 0.90-0.99, p = 0.02). CONCLUSIONS Almost half of incident pregnancies among WLWH in this cohort were unintended. Experiencing an unintended pregnancy was not associated with post-partum contraceptive use. Creative strategies to support contraceptive uptake for birth spacing and prevention of unintended pregnancies in the post-partum period are needed.
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Affiliation(s)
- Jana Jarolimova
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, NY, United States
| | | | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeffrey N. Martin
- University of California at San Francisco, San Francisco, CA, United States
| | - Peter W. Hunt
- University of California at San Francisco, San Francisco, CA, United States
| | - Yap Boum
- Epicentre, Médicins sans Frontières (MSF), Yaounde, Cameroon
| | - Jessica E. Haberer
- Center for Global Health and Department of Medicine, Massachusetts General Hospital; Harvard Medical School, Boston, MA, United States
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR, United States
| | - Angela Kaida
- Simon Fraser University, Faculty of Health Sciences, Burnaby, British Columbia, Canada
| | - Lynn T. Matthews
- Center for Global Health and Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, United States
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Birdthistle IJ, Fenty J, Collumbien M, Warren C, Kimani J, Ndwiga C, Mayhew S. Integration of HIV and reproductive health services in public sector facilities: analysis of client flow data over time in Kenya. BMJ Glob Health 2018; 3:e000867. [PMID: 30245866 PMCID: PMC6144905 DOI: 10.1136/bmjgh-2018-000867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 11/07/2022] Open
Abstract
Introduction Integration of HIV/AIDS with reproductive health (RH) services can increase the uptake and efficiency of services, but gaps in knowledge remain about the practice of integration, particularly how provision can be expanded and performance enhanced. We assessed the extent and nature of service integration in public sector facilities in four districts in Kenya. Methods Between 2009 and 2012, client flow assessments were conducted at six time points in 24 government facilities, purposively selected as intervention or comparison sites. A total of 25 539 visits were tracked: 15 270 in districts where 6 of 12 facilities received an intervention to strengthen HIV service integration with family planning (FP); and 10 266 visits in districts where half the facilities received an HIV-postnatal care intervention in 2009–2010. We tracked the proportion of all visits in which: (1) an HIV service (testing, counselling or treatment) was received together with an RH service (FP counselling or provision, antenatal care, or postnatal care); (2) the client received HIV counselling. Results Levels of integrated HIV-RH services and HIV counselling were generally low across facilities and time points. An initial boost in integration was observed in most intervention sites, driven by integration of HIV services with FP counselling and provision, and declined after the first follow-up. Integration at most sites was driven by temporary rises in HIV counselling. The most consistent combination of HIV services was with antenatal care; the least common was with postnatal care. Conclusions These client flow data demonstrated a short-term boost in integration, after an initial intervention with FP services providing an opportunity to expand integration. Integration was not sustained over time highlighting the need for ongoing support. There are multiple opportunities for integrating service delivery, particularly within antenatal, FP and HIV counselling services, but a need for sustained systems and health worker support over time. Trial registration number NCT01694862
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Affiliation(s)
- Isolde J Birdthistle
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Justin Fenty
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Martine Collumbien
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Mutemwa R, Mayhew SH, Warren CE, Abuya T, Ndwiga C, Kivunaga J. Does service integration improve technical quality of care in low-resource settings? An evaluation of a model integrating HIV care into family planning services in Kenya. Health Policy Plan 2017; 32:iv91-iv101. [PMID: 29194543 PMCID: PMC5886058 DOI: 10.1093/heapol/czx090] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/29/2022] Open
Abstract
The aim of this study was to investigate association between HIV and family planning integration and technical quality of care. The study focused on technical quality of client-provider consultation sessions. The cross-sectional study observed 366 client-provider consultation sessions and interviewed 37 health care providers in 12 public health facilities in Kenya. Multilevel random intercept and linear regression models were fitted to the matched data to investigate relationships between service integration and technical quality of care as well as associations between facility-level structural and provider factors and technical quality of care. A sensitivity analysis was performed to test for hidden bias. After adjusting for facility-level structural factors, HIV/family planning integration was found to have significant positive effect on technical quality of the consultation session, with average treatment effect 0.44 (95% CI: 0.63-0.82). Three of the 12 structural factors were significantly positively associated with technical quality of consultation session including: availability of family planning commodities (9.64; 95% CI: 5.07-14.21), adequate infrastructure (5.29; 95% CI: 2.89-7.69) and reagents (1.48; 95% CI: 1.02-1.93). Three of the nine provider factors were significantly positively associated with technical quality of consultation session: appropriate provider clinical knowledge (3.14; 95% CI: 1.92-4.36), job satisfaction (2.02; 95% CI: 1.21-2.83) and supervision (1.01; 95% CI: 0.35-1.68), while workload (-0.88; 95% CI: -1.75 to - 0.01) was negatively associated. Technical quality of the client-provider consultation session was also determined by duration of the consultation and type of clinic visit and appeared to depend on whether the clinic visit occurred early or later in the week. Integration of HIV care into family planning services can improve the technical quality of client-provider consultation sessions as measured by both health facility structural and provider factors.
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Affiliation(s)
- Richard Mutemwa
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Susannah H Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Charlotte E Warren
- Population Council, 4301 Connecticut Avenue NW, Suite 280 Washington, DC 20008 United States
| | - Timothy Abuya
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
| | - Charity Ndwiga
- Population Council, Ralph Bunche Rd, Upper Hill, Nairobi, Kenya
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Siapka M, Obure CD, Mayhew SH, Sweeney S, Fenty J, Initiative I, Vassall A. Impact of integration of sexual and reproductive health services on consultation duration times: results from the Integra Initiative. Health Policy Plan 2017; 32:iv82-iv90. [PMID: 29194545 PMCID: PMC5886289 DOI: 10.1093/heapol/czx141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2017] [Indexed: 11/24/2022] Open
Abstract
The lack of human resources is a key challenge in scaling up of HIV services in Africa's health care system. Integrating HIV services could potentially increase their effectiveness and optimize the use of limited resources and clinical staff time. We examined the impact of integration of provider initiated HIV counselling and testing (PITC) and family planning (FP counselling and FP provision) services on duration of consultation to assess the impact of PITC and FP integration on staff workload. This study was conducted in 24 health facilities in Kenya under the Integra Initiative, a non-randomized, pre/post intervention trial to evaluate the impact of integrated HIV and sexual and reproductive health services on health and service outcomes. We compared the time spent providing PITC-only services, FP-only services and integrated PITC/FP services. We used log-linear regression to assess the impact of plausible determinants on the duration of clients' consultation times. Median consultation duration times were highest for PITC-only services (30 min), followed by integrated services (10 min) and FP-only services (8 min). Times for PITC-only and FP-only services were 69.7% higher (95% Confidence Intervals (CIs) 35.8-112.0) and 43.9% lower (95% CIs -55.4 to - 29.6) than times spent on these services when delivered as an integrated service, respectively. The reduction in consultation times with integration suggests a potential reduction in workload. The higher consultation time for PITC-only could be because more pre- and post-counselling is provided at these stand-alone services. In integrated PITC/FP services, the duration of the visit fell below that required by HIV testing guidelines, and service mix between counselling and testing substantially changed. Integration of HIV with FP services may compromise the quality of services delivered and care must be taken to clearly specify and monitor appropriate consultation duration times and procedures during the process of integrating HIV and FP services.
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Affiliation(s)
- Mariana Siapka
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Carol Dayo Obure
- Human Capital Youth and Skills Development Department, African Development Bank, Abidjan, Côte d'Ivoire
| | - Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Justin Fenty
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Integra Initiative
- Full list of Integra Initiative team members is provided in the Acknowledgements
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Warren CE, Mayhew SH, Hopkins J. The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services. Stud Fam Plann 2017; 48:91-105. [PMID: 28493283 PMCID: PMC5518217 DOI: 10.1111/sifp.12024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.
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12
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Wesevich A, Mtande T, Saidi F, Cromwell E, Tweya H, Hosseinipour MC, Hoffman I, Miller WC, Rosenberg NE. Role of male partner involvement in ART retention and adherence in Malawi's Option B+ program. AIDS Care 2017; 29:1417-1425. [PMID: 28355926 DOI: 10.1080/09540121.2017.1308464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Malawi's Option B+ program provides all HIV-infected pregnant women free lifelong antiretroviral therapy (ART), but challenges remain regarding retention and ART adherence, potentially due to male partner barriers. We explored relationships between male partner involvement and Option B+ retention and adherence. In 2014, a randomized controlled trial in Malawi compared male recruitment strategies for couple HIV testing and counseling (cHTC) at an antenatal clinic. This secondary analysis was conducted among the entire cohort (N = 200) of women, irrespective of randomization status. We assessed whether cHTC attendance, early disclosure of HIV-positive status, and partner ART reminders were associated with retention and adherence at one month after starting treatment. Retention was defined as attending HIV clinic follow-up within one day of running out of pills. Adherence was defined as taking ≥95% of ARTs by pill count. We used binomial regression to calculate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Median female age was 26 years. Most women (79%) were retained; of these, 68% were adherent. Receiving cHTC was associated with improved retention (aRR 1.33, 95% CI 1.12, 1.59). Receiving male partner ART reminders was weakly associated with retention (aRR 1.16, 95% CI 0.96, 1.39). Disclosure within one day was not associated with retention (aRR 1.08, 95% CI: 0.91, 1.28). Among those who were retained, these three behaviors were not associated with improved 95% adherence. CHTC could play an important role in improving Option B+ retention. Increasing cHTC participation and enhancing adherence-related messages within cHTC are important.
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Affiliation(s)
- Austin Wesevich
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Tiwonge Mtande
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Friday Saidi
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi
| | - Elizabeth Cromwell
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Hannock Tweya
- c Lighthouse Trust , Lilongwe , Malawi.,d The International Union Against Tuberculosis and Lung Disease , Paris , France
| | - Mina C Hosseinipour
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Irving Hoffman
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - William C Miller
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
| | - Nora E Rosenberg
- a UNC Project , University of North Carolina at Chapel Hill , Lilongwe , Malawi.,b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , USA.,e Department of Medicine , University of North Carolina at Chapel Hill , Chapel Hill , USA
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13
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Development of a mother and baby unit contraception assessment tool. Arch Womens Ment Health 2016; 19:1129-1140. [PMID: 27664103 DOI: 10.1007/s00737-016-0665-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/02/2016] [Indexed: 10/21/2022]
Abstract
Unplanned pregnancies are a unique, yet significant risk factor in perinatal mental health. Our aim was to create an assessment tool to assess mother's views on contraception as part of the discharge planning process. We used a quantitative-qualitative approach. A clinician-guided questionnaire was completed by patients prior to their discharge from hospital and analysed using Microsoft Excel. Semi-structured interviews were used to explore views regarding family planning in greater depth. Interviews were recorded and transcribed verbatim onto Microsoft Word. Emerging themes were identified using a grounded theory thematic analysis approach. Eighteen inpatients were assessed at the Bethlem Mother and Baby Unit over a 4-month period (May-August 2015). Half of the women stated that the pregnancy was unplanned. The most common contraception methods used were condoms, followed by no method/natural cycle technique. Forty-four percent felt unsure of contraception options available and were keen for further advice and referral to family planning services. Interestingly, almost all the women interviewed stated that their experience of perinatal mental illness had changed their views on having more children. The contraception assessment tool is a short, simple questionnaire that can be adopted across inpatient and community settings. In cooperating family, planning into the discharge care plan could be protective in preventing future unplanned pregnancies in women at high risk of perinatal mental illness relapse. Performing the assessment also provided an added opportunity for psycho-education regarding reproductive health and medication use during the perinatal period. The tool also encouraged liaison with GPs and local family planning services.
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14
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Lopez LM, Grey TW, Chen M, Denison J, Stuart G. Behavioral interventions for improving contraceptive use among women living with HIV. Cochrane Database Syst Rev 2016; 2016:CD010243. [PMID: 27505053 PMCID: PMC7092487 DOI: 10.1002/14651858.cd010243.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling or education, can help women choose and use an appropriate contraceptive method. OBJECTIVES We systematically reviewed studies of behavioral interventions for HIV-positive women intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen. SEARCH METHODS Until 2 August 2016, we searched MEDLINE, CENTRAL, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP. For the initial review, we examined reference lists and unpublished project reports, and we contacted investigators in the field. SELECTION CRITERIA Studies evaluated a behavioral intervention for improving contraceptive use for family planning (FP). The comparison could have been another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive versus HIV-negative women. We included non-randomized studies as well as randomized controlled trials (RCTs).Primary outcomes were pregnancy and contraception use, e.g. uptake of a new method or improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception or a specific contraceptive method. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. We evaluated RCTs according to recommended principles. For non-randomized studies, we examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Given the need to control for confounding factors in non-randomized studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs and interventions, we did not conduct meta-analysis. MAIN RESULTS With three new reports, 10 studies from seven African countries met our eligibility criteria. Eight non-randomized studies included 8980 participants. Two cluster RCTs had 7136 participants across 36 sites. Three studies compared a special FP intervention versus usual care, three examined FP services integrated with HIV services, and four compared outcomes for HIV-positive and HIV-negative women.In four studies with high or moderate quality evidence, the special intervention was associated with contraceptive use or pregnancy. A study from Nigeria compared enhanced versus basic FP services. All sites had integrated FP and HIV services. Women with enhanced services were more likely to use a modern contraceptive method versus women with basic services (OR 2.48, 95% CI 1.31 to 4.72). A cluster RCT conducted in Kenya compared integrated FP and HIV services versus standard referral to a separate FP clinic. Women with integrated services were more likely to use more effective contraception (adjusted OR 1.81, 95% CI 1.24 to 2.63). Another cluster RCT compared an HIV prevention and FP intervention versus usual care in Kenya, Namibia, and Tanzania. Women at the special intervention sites in Tanzania were more likely to use highly effective contraception (adjusted OR 2.25, 95% CI 1.24 to 4.10). They were less likely to report unprotected sex (no condom use) at last intercourse (adjusted OR 0.23, 95% CI 0.14 to 0.40). Across the three countries, women at the special intervention sites were less likely to report any unprotected sex in the past two weeks (adjusted OR 0.56, 95% CI 0.32 to 0.99). A study in Côte d'Ivoire integrated HIV and FP services. HIV-positive women had a lower incidence of undesired pregnancy, but not overall pregnancy, compared with HIV-negative women (1.07 versus 2.38; reported P = 0.023). AUTHORS' CONCLUSIONS The studies since 2009 focused on using modern or more effective methods of contraception. In those later reports, training on FP methods and counseling was more common, which may strengthen the intervention and improve the ability to meet clients' needs. The quality of evidence was moderate from the more recent studies and low for those from the 1990s.Comparative research involving contraceptive counseling for HIV-positive women is limited. The FP field needs better ways to help women choose an appropriate contraceptive and continue using that method. Improved counseling methods are especially needed for limited resource settings, such as clinics focusing on people living with HIV.
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Affiliation(s)
- Laureen M Lopez
- FHI 360Clinical and Epidemiological Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Thomas W Grey
- FHI 360Social and Behavioral Health Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Mario Chen
- FHI 360Biostatistics359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | - Julie Denison
- Johns Hopkins University Bloomberg School of Public HealthInternational HealthBaltimoreMarylandUSA
| | - Gretchen Stuart
- University of North Carolina School of MedicineDepartment of Obstetrics and Gynecology3031 Old Clinic Building CB#7570Chapel HillNorth CarolinaUSA27599‐7570
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Joseph Davey D, Myer L, Bukusi E, Ramogola-Masire D, Kilembe W, Klausner JD. Integrating Human Immunodeficiency Virus and Reproductive, Maternal and Child, and Tuberculosis Health Services Within National Health Systems. Curr HIV/AIDS Rep 2016; 13:170-6. [PMID: 27221628 PMCID: PMC5767277 DOI: 10.1007/s11904-016-0316-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Joint United Nations Programme on HIV/AIDS (UNAIDS) established 90-90-90 HIV treatment targets for 2020 including the following: 90 % of HIV-infected people know their HIV status, 90 % of HIV-infected people who know their status are on treatment, and 90 % of people on HIV treatment have a suppressed viral load. Integration of HIV and other programs into the national health system provides an important pathway to reach those targets. We examine the case for integrating HIV and other health services to ensure sustainability and improve health outcomes within national health systems. In this non-systematic review, we examined recent studies on integrating HIV, tuberculosis (TB), maternal-child health (MCH), and sexually transmitted infection (STI) programs. Existing evidence is limited about the effectiveness of integration of HIV and other services. Most studies found that service integration increased uptake of services, but evidence is mixed about the effect on health outcomes or quality of health services. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. Research on how best to maximize benefits, including sustainability, of integrated services is necessary to help inform international and national policy. We recommend additional interventions to test how best to integrate HIV and MCH services, HIV and TB services, HIV testing and treatment, and STI testing and treatment.
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Affiliation(s)
- Dvora Joseph Davey
- Fielding School of Public Health, Department of Epidemiology, University of California, Los Angeles, CA, USA.
- Division of Infectious Disease, Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Landon Myer
- Center for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | | | | | | | - Jeffrey D Klausner
- Fielding School of Public Health, Department of Epidemiology, University of California, Los Angeles, CA, USA
- Division of Infectious Disease, Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Kuete M, Yuan H, Tchoua Kemayou AL, Songo EA, Yang F, Ma X, Xiong C, Zhang H. Scale up use of family planning services to prevent maternal transmission of HIV among discordant couples: a cross-sectional study within a resource-limited setting. Patient Prefer Adherence 2016; 10:1967-1977. [PMID: 27757019 PMCID: PMC5055043 DOI: 10.2147/ppa.s105624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Integration of family planning services (FPS) into human immunodeficiency virus (HIV) care for HIV-infected women is an important aspect of the global prevention of mother-to-child transmission (PMTCT) strategy. We assessed the integration of FPS into routine care of HIV-infected mothers by evaluating the uptake and barriers of contraception and PMTCT services. METHODS We conducted an interventional study using the interrupted time series approach in the health care facilities located in Yaounde, Cameroon. First, structured questionnaires related to family planning use, PMTCT services use, and infection risk of the sexual partner were administered to the first trimester pregnant women who were HIV infected and living with uninfected partners. Second, 2 weeks before the delivery date, the women were interviewed according to the prior counseling interventions received, in order to assess their behavior on FPS, antiretroviral therapy (ART) use, delivery option, and infant nourishment to be adopted. P-values below 0.05 were considered statistically significant in the statistical analyses. RESULTS Of 94 HIV-infected women, 69% were stable couples. Only 13% of women had attended FPS before conception. Although the vast majority were knowledgeable about modern and traditional contraception methods, only 19% had experienced effective contraceptive methods. However, 66% preferred condom use, 45% having three children still expressed a desire to conceive, while 44% reported abortions, 65% had tried to avoid the current pregnancy, and 12% of women were ART naïve. Several predictors such as education, abortion rate, unplanned pregnancies, and partners' decision were associated with the nonuse of effective contraceptive methods. Moreover, barriers including sex inequity, lack of partner support, ART shortages, and lack of HIV viral load monitoring were prevalent among the participants (P=0.001). However FPS use, ART compliance, and safe options to PMTCT significantly increased after the educational counseling interventions (P=0.001). CONCLUSION Scaling up the FPS by incorporating routine PMTCT services into reproductive health care should contribute to preventing both horizontal and vertical transmission of HIV.
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Affiliation(s)
- Martin Kuete
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Main Maternity of Obstetrics and Gynecology, Yaounde Central Hospital, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon
| | - HongFang Yuan
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - Aude Laure Tchoua Kemayou
- Main Maternity of Obstetrics and Gynecology, Yaounde Central Hospital, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon
| | - Emmanuel Ancel Songo
- Main Maternity of Obstetrics and Gynecology, Yaounde Central Hospital, Faculty of Medicine and Biomedical Sciences, Yaounde, Cameroon
| | - Fan Yang
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - XiuLan Ma
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - ChengLiang Xiong
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
| | - HuiPing Zhang
- Obstetrics and Gynecology, Reproductive Center, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China
- Correspondence: HuiPing Zhang, Family Planning and Research Institute, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan 430030, Hubei, People’s Republic of China, Tel +86 130 3513 3247, Fax +86 27 8369 2651, Email
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