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Mindry D, Gizaw M, Gwokyalya V, Hurley E, Finocchario-Kessler S, Beyeza-Kashesya J, Wagner GJ, Wanyenze RK, Goggin K. Provider Perspectives on Navigating Relationship Challenges in Assisting HIV-Affected Couples to Meet Their Reproductive Goals: Lessons Learned from a Safer Conception Counseling Intervention in Uganda. AIDS Behav 2022; 26:425-433. [PMID: 34324071 DOI: 10.1007/s10461-021-03397-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 12/01/2022]
Abstract
In Uganda, 60% of HIV-affected couples are serodiscordant, many of whom want children. There is a need to assess their reproductive intentions and provide appropriate services that limit transmission risks while meeting reproductive goals. Our Choice intervention engaged male and female HIV-infected clients and their partners in safer conception counseling (SCC) or family planning based on their childbearing decision. We report findings of provider experiences and recommendations for engaging couples in SCC. The intervention was implemented in four clinics offering either SCC1, an intensive training and supervision arm, or SCC2, utilizing the Ministry of Health's standard approach. Qualitative interviews were conducted at 12 (N = 23) and 24 months (N = 25) after initiation of the intervention. Many partners attended at least some SCC sessions, although engaging male partners was more challenging. Providers reported partner involvement improved understanding and facilitated successful implementation of SCM, whereas confusion and challenges were common when the client participated alone. Providers shared successful strategies for engaging male partners.
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Affiliation(s)
- Deborah Mindry
- Center for Womens Health and Empowerment, University of California Global Health Institute, San Francisco, CA, USA.
| | | | - Violet Gwokyalya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Emily Hurley
- Schools of Medicine and Pharmacy, Childrens Mercy Research Institute, University of Missouri, Kansas, MO, USA
| | - Sarah Finocchario-Kessler
- Department of Family Medicine & Community Health, University of Kansas Medical Center, Kansas, MO, USA
| | - Jolly Beyeza-Kashesya
- Department of Reproductive Medicine, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | | | - Rhoda K Wanyenze
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kathy Goggin
- Schools of Medicine and Pharmacy, Childrens Mercy Research Institute, University of Missouri, Kansas, MO, USA
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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Life loaded with threat and vulnerability: a qualitative inquiry into the experiences of HIV negative married women in serodiscordant heterosexual relationships. BMC Womens Health 2021; 21:402. [PMID: 34876115 PMCID: PMC8650320 DOI: 10.1186/s12905-021-01546-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 11/19/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Violence against women is a major, complex, multidimensional and widespread public health concern worldwide. The current qualitative study was conducted to understand the experience of violence among HIV negative married women in heterosexual serodiscordant relationships.
Methods
A qualitative description (QD) was conducted from October 2018 to January 2020 in Mashhad, Iran. The participants were 15 HIV negative women, who married and lived with HIV positive men, through purposive sampling method. The data were collected using semi-structured interviews. Data analyzed using conventional content analysis adopted by Graneheim and Lundman.
Results
The main overarching theme emerged entitled: life loaded with threat and vulnerability. This theme consisted of four categories of self-directed violence, intimate partner violence, cultural violence and structural violence. The violence began soon after awareness of husband's infection with acts such as suicide attempts and a sense of abhorrence for living with an infected person, and continued with confrontation with various types of violence in the family and society, which put women in constant threat and vulnerability.
Conclusions
This study provided an insight into different aspects of violence in Iranian women in HIV serodiscordant relationships. Considering the role of men in the occurrence of violence, policymakers must create and execute family-centered interventions to address attitudes and behaviors that lead to marital conflicts and spousal abuse in order to prevent violence. Health care professionals should also be trained to screen women for violence and refer those who require care to specialists to reduce vulnerability.
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"I did not know about all these": Perceptions regarding safer conception methods by women living with HIV in Gaborone, Botswana. PLoS One 2020; 15:e0242992. [PMID: 33259505 PMCID: PMC7707558 DOI: 10.1371/journal.pone.0242992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022] Open
Abstract
Various safer conception methods to limit HIV transmission risks can be offered in resource-constrained settings. However, implementation of safer conception services remains limited in many countries, including Botswana. Understanding perceptions about safer conception methods and the benefits and challenges to use can help with the development of policies, interventions, and service delivery models. Forty-five women living with HIV in the greater Gaborone, Botswana area participated in focus group discussions. Themes were analyzed using interpretive phenomenology. Despite low knowledge of specific safer conception methods that can be used to prevent transmission of HIV when trying to achieve pregnancy, there was noted interest in pre-exposure prophylaxis and vaginal insemination. Challenges to greater uptake were noted including a lack of knowledge about a range of SC methods, limited partner support and communication, provider stigma, health systems barriers, current policies, and the cultural acceptability of methods. Interventions will need to address these challenges and be responsive to the needs and reflect the realities of WLHIV who desire pregnancy in order for safer conception uptake to become a common practice.
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Yam EA, Kahabuka C, Mbita G, Winani K, Apicella L, Casalini C, Mbuguni Z. Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services. PLoS One 2020; 15:e0235739. [PMID: 32692777 PMCID: PMC7373272 DOI: 10.1371/journal.pone.0235739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 06/23/2020] [Indexed: 11/29/2022] Open
Abstract
Background With the advent of effective treatment, women living with HIV can plan for pregnancy while minimizing risk of transmission to infants and seronegative partners. Family planning (FP) services tend to focus solely on addressing contraceptive need, but HIV-positive women—including female sex workers—often plan to have children someday. Various “safer conception” strategies are now available to support women living with HIV achieve fertility intentions, and integrated HIV/FP services may be a promising platform to offer these services. Methods At integrated community-based HIV/FP service delivery sites operated by Jhpiego’s Sauti project in Dar es Salaam, we conducted exit interviews with 300 HIV-positive female sex workers. Descriptive analyses were conducted to describe their desire for children, use of condoms and other modern contraceptive methods, self-reported viral suppression, and knowledge of and interest in safer conception strategies. We conducted bivariate and multivariate logistic regression analysis to examine correlates of fertility desire among respondents. Results Median age of participants was 32. Nearly one-third wished to have a child within two years. Seventy-two percent had heard of having the HIV-positive partner taking ART to reduce sexual transmission during pregnancy attempts. Thirty-one percent felt the amount of FP content covered in the consultation was “too little.” Factors significantly associated with desire for children were having a nonpaying partner (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI]1.13–4.20) and having fewer children (AOR 0.65, 95% CI 0.48–0.87). Viral suppression was not associated with fertility desire. Conclusions Sex workers living with HIV attending integrated HIV/FP services have need for both contraception as well as safer conception counseling. This integrated service delivery modality is a promising platform for providing safer conception services. FP counseling for HIV-positive women should be broadened to broach the topic of safer pregnancy, as well as explicit counseling on strategies to minimize risk of sexual transmission to partners.
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Affiliation(s)
- Eileen A. Yam
- Population Council, Washington, DC, United States of America
- * E-mail:
| | | | | | - Koheleth Winani
- Reproductive and Child Health Section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | | | | | - Zuhura Mbuguni
- Reproductive and Child Health Section, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
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Gutin SA, Harper GW, Amico KR, Bitsang C, Moshashane N, Harries J, Ramogola-Masire D, Morroni C. 'I'm waiting for that': Interest in the use of PrEP for safer conception in Botswana. Glob Public Health 2020; 15:1200-1211. [PMID: 32175819 DOI: 10.1080/17441692.2020.1741663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Safe and effective low-cost safer conception (SC) methods are increasingly available and being integrated into national guidelines in sub-Saharan African contexts. Sero-different couples of childbearing age can benefit from such services and the routine provision of SC counselling. Pre-exposure prophylaxis (PrEP) to prevent HIV acquisition to uninfected partners can reduce the chances of HIV transmission when trying to achieve pregnancy. Botswana has a strong commitment to reducing new HIV infections but PrEP is not yet widely available and little guidance has been offered on counselling sero-different couples. We conducted qualitative in-depth interviews in Gaborone, Botswana with 10 HIV healthcare providers and 10 women living with HIV of childbearing age because they act as a key conduit for reaching sero-different partners with information about PrEP. We examined knowledge and attitudes towards PrEP to assess the viability and develop a deeper understanding of this SC option. Interviews were analysed using an interpretive phenomenological approach. Three themes emerged: (1) awareness of PrEP is limited, (2) providers and women overwhelmingly showed interest in PrEP and (3) women living with HIV and providers have concerns about PrEP use. With the correct support, PrEP could be a useful SC option for sero-different couples in Botswana and other sub-Saharan contexts.
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Affiliation(s)
- Sarah A Gutin
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | | | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, UK
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Treatment as Prevention-Provider Knowledge and Counseling Lag Behind Global Campaigns. J Acquir Immune Defic Syndr 2020; 83:e9-e12. [PMID: 31929409 DOI: 10.1097/qai.0000000000002197] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Davies N, Heffron R. Global and national guidance for the use of pre-exposure prophylaxis during peri-conception, pregnancy and breastfeeding. Sex Health 2018; 15:501-512. [PMID: 30447703 PMCID: PMC6790372 DOI: 10.1071/sh18067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 09/15/2018] [Indexed: 12/30/2022]
Abstract
Pre-exposure prophylaxis (PrEP) is a well-established biomedical HIV prevention strategy and recommended to reduce HIV risk during peri-conception, pregnancy and breastfeeding. Efforts are needed to translate global recommendations into national guidelines and implementation strategies. This article presents the current status of policy guidance for the use of PrEP during peri-conception, pregnancy and breastfeeding, with a particular focus on high prevalence countries, including those in sub-Saharan Africa. PrEP clinical guidelines released by ministries of health or other national-level health bodies, with a particular focus on recommendations for PrEP use during peri-conception, pregnancy and breastfeeding, were reviewed and summarised. Among countries with PrEP guidelines and/or policy, pregnancy is recognised as a period with increased HIV vulnerability, and some recommend PrEP use specifically during pregnancy. Only one country notes that PrEP is contraindicated during pregnancy, recognising a gap in complete safety data from women using PrEP throughout pregnancy. PrEP is not contraindicated as a peri-conception HIV prevention strategy in any country, but only three countries have specific guidance for peri-conception HIV prevention. Multiple barriers to the implementation of PrEP during pregnancy and breastfeeding are discussed, including barriers at the policy, health systems, social and personal levels. Although pregnancy is a period of heightened risk and fertility rates are high in many settings with high HIV burden, few PrEP policies have included guidance for PrEP use specific to peri-conception, pregnancy and breastfeeding periods. This gap can be overcome by the development or adoption of national clinical guidelines and implementation strategies from exemplary countries.
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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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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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Greener R, Milford C, Bajunirwe F, Mosery FN, Ng CK, Rifkin R, Kastner J, Pillay L, Kaida A, Bangsberg DR, Smit JA, Matthews LT. Healthcare providers' understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2018; 17:137-144. [PMID: 29745290 DOI: 10.2989/16085906.2018.1462217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.
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Affiliation(s)
- Ross Greener
- a MatCH Research (Maternal, Adolescent, and Child Health Research) Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Cecilia Milford
- a MatCH Research (Maternal, Adolescent, and Child Health Research) Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Francis Bajunirwe
- b Mbarara University of Science and Technology , Faculty of Development Studies , Mbarara , Uganda
| | - Faith N Mosery
- a MatCH Research (Maternal, Adolescent, and Child Health Research) Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Claudia K Ng
- c Harvard T.H. Chan School of Public Health , Boston , Massachusetts , USA
| | - Rachel Rifkin
- d Massachusetts General Hospital, Center for Global Health and Division of Infectious Disease , Boston , Massachusetts , USA
| | - Jasmine Kastner
- e McGill University Research Centre , Montreal , Quebec , Canada
| | - Lavanya Pillay
- a MatCH Research (Maternal, Adolescent, and Child Health Research) Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Angela Kaida
- f Simon Fraser University , Faculty of Health Sciences , Burnaby , British Columbia , Canada
| | - David R Bangsberg
- d Massachusetts General Hospital, Center for Global Health and Division of Infectious Disease , Boston , Massachusetts , USA
| | - Jennifer A Smit
- a MatCH Research (Maternal, Adolescent, and Child Health Research) Unit, Department of Obstetrics and Gynaecology, Faculty of Health Sciences , University of the Witwatersrand , Durban , South Africa
| | - Lynn T Matthews
- d Massachusetts General Hospital, Center for Global Health and Division of Infectious Disease , Boston , Massachusetts , USA
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Inambao M, Kilembe W, Canary LA, Czaicki NL, Kakungu-Simpungwe M, Chavuma R, Wall KM, Tichacek A, Pulerwitz J, Thior I, Chomba E, Allen SA. Transitioning couple's voluntary HIV counseling and testing (CVCT) from stand-alone weekend services into routine antenatal and VCT services in government clinics in Zambia's two largest cities. PLoS One 2017; 12:e0185142. [PMID: 29036208 PMCID: PMC5642897 DOI: 10.1371/journal.pone.0185142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/30/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Most HIV infections in Africa are acquired by married/cohabiting adults and WHO recommends couple's voluntary HIV counseling and testing (CVCT) for prevention. The handover from NGO-sponsored weekend CVCT to government-sponsored services in routine weekday antenatal care (ANC) and individual voluntary testing and counseling (VCT) services in Zambia's two largest cities from 2009-2015 is described. METHODS Government clinic counselors were trained to provide CVCT, and along with community health workers they promoted CVCT services in their clinic and surrounding areas. When client volume exceeded the capacity of on-duty staff in ANC and VCT, non-governmental organization (NGO) subsidies were offered for overtime pay. RESULTS Implementation of routine CVCT services varied greatly by clinic and city. The 12 highest volume clinics were examined further, while 13 clinics had CVCT numbers that were too low to warrant further investigation. In Lusaka, the proportion of pregnant women whose partners were tested rose from 2.6% in 2009 to a peak of 26.2% in 2012 and 24.8% in 2015. Corresponding reports in Ndola were 2.0% in 2009, 17.0% in 2012 and 14.5% in 2015. Obstacles to CVCT included: limited space and staffing, competing priorities, record keeping not adapted for couples, and few resources for promotion and increasing male involvement. Conflicting training models for 'partner testing' with men and women separately vs. CVCT with joint post-test counseling led to confusion in reporting to district health authorities. DISCUSSION A focused and sustained effort will be required to reach a meaningful number of couples with CVCT to prevent heterosexual and perinatal HIV transmission. Establishing targets and timelines, funding for dedicated and appropriately trained staff, adoption of standardized data recording instruments with couple-level indicators, and expansion of community and clinic-based promotions using proven models are recommended.
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Affiliation(s)
- Mubiana Inambao
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Zambia Emory HIV Research Project (ZEHRP), Ndola, Zambia
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Zambia Emory HIV Research Project (ZEHRP), Lusaka, Zambia
| | - Lauren A. Canary
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Nancy L. Czaicki
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Matilda Kakungu-Simpungwe
- District Health Management team (DHMT), Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Roy Chavuma
- District Health Management team (DHMT), Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | | | - Ibou Thior
- PATH, Washington, DC, United States of America
| | - Elwyn Chomba
- Ministry of Community Development, Maternal and Child Health (MCDMCH), Lusaka, Zambia
| | - Susan A. Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
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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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Matthews LT, Burns BF, Bajunirwe F, Kabakyenga J, Bwana M, Ng C, Kastner J, Kembabazi A, Sanyu N, Kusasira A, Haberer JE, Bangsberg DR, Kaida A. Beyond HIV-serodiscordance: Partnership communication dynamics that affect engagement in safer conception care. PLoS One 2017; 12:e0183131. [PMID: 28880892 PMCID: PMC5589112 DOI: 10.1371/journal.pone.0183131] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/31/2017] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION We explored acceptability and feasibility of safer conception methods among HIV-affected couples in Uganda. METHODS We recruited HIV-positive men and women on antiretroviral therapy (ART) ('index') from the Uganda Antiretroviral Rural Treatment Outcomes cohort who reported an HIV-negative or unknown-serostatus partner ('partner'), HIV-serostatus disclosure to partner, and personal or partner desire for a child within two years. We conducted in-depth interviews with 40 individuals from 20 couples, using a narrative approach with tailored images to assess acceptability of five safer conception strategies: ART for the infected partner, pre-exposure prophylaxis (PrEP) for the uninfected partner, condomless sex timed to peak fertility, manual insemination, and male circumcision. Translated and transcribed data were analyzed using thematic analysis. RESULTS 11/20 index participants were women, median age of 32.5 years, median of 2 living children, and 80% had HIV-RNA <400 copies/mL. Awareness of HIV prevention strategies beyond condoms and abstinence was limited and precluded opportunity to explore or validly assess acceptability or feasibility of safer conception methods. Four key partnership communication challenges emerged as primary barriers to engagement in safer conception care, including: (1) HIV-serostatus disclosure: Although disclosure was an inclusion criterion, partners commonly reported not knowing the index partner's HIV status. Similarly, the partner's HIV-serostatus, as reported by the index, was frequently inaccurate. (2) Childbearing intention: Many couples had divergent childbearing intentions and made incorrect assumptions about their partner's desires. (3) HIV risk perception: Participants had disparate understandings of HIV transmission and disagreed on the acceptable level of HIV risk to meet reproductive goals. (4) Partnership commitment: Participants revealed significant discord in perceptions of partnership commitment. All four types of partnership miscommunication introduced constraints to autonomous reproductive decision-making, particularly for women. Such miscommunication was common, as only 2 of 20 partnerships in our sample were mutually-disclosed with agreement across all four communication themes. CONCLUSIONS Enthusiasm for safer conception programming is growing. Our findings highlight the importance of addressing gendered partnership communication regarding HIV disclosure, reproductive goals, acceptable HIV risk, and commitment, alongside technical safer conception advice. Failing to consider partnership dynamics across these domains risks limiting reach, uptake, adherence to, and retention in safer conception programming.
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Affiliation(s)
- Lynn T. Matthews
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Infectious Disease, Massachusetts General Hospital, Boston, MA, United States of America
| | - Bridget F. Burns
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | | | | | - Mwebesa Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Courtney Ng
- Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Jasmine Kastner
- Research Institute McGill University Health Centre, Montreal, Canada
| | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Naomi Sanyu
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adrine Kusasira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
- Division of General Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - David R. Bangsberg
- OHSU-PSU School of Public Health, Portland, OR, United States of America
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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Mindry D, Wanyenze RK, Beyeza-Kashesya J, Woldetsadik MA, Finocchario-Kessler S, Goggin K, Wagner G. Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda. AIDS Behav 2017; 21:2488-2496. [PMID: 28597343 DOI: 10.1007/s10461-017-1816-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.
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Bhatia DS, Harrison AD, Kubeka M, Milford C, Kaida A, Bajunirwe F, Wilson IB, Psaros C, Safren SA, Bangsberg DR, Smit JA, Matthews LT. The Role of Relationship Dynamics and Gender Inequalities As Barriers to HIV-Serostatus Disclosure: Qualitative Study among Women and Men Living with HIV in Durban, South Africa. Front Public Health 2017; 5:188. [PMID: 28824897 PMCID: PMC5534462 DOI: 10.3389/fpubh.2017.00188] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 07/11/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This qualitative study investigated gender power inequalities as they contribute to relationship dynamics and HIV-serostatus disclosure among men and women living with HIV in Durban, South Africa. HIV serodiscordance among men and women within stable partnerships contributes to high HIV incidence in southern Africa, yet disclosure rates remain low. Given the emphasis on prevention for HIV-serodiscordant couples, this research supports the urgent need to explore how best to support couples to recognize that they are part of this priority population and to access appropriate prevention and treatment. METHODS Thirty-five in-depth individual interviews were conducted with 15 HIV-positive men and 20 HIV-positive women (not couples) receiving care at public-sector clinics near Durban. A structured coding scheme was developed to investigate men's and women's attitudes toward HIV-serostatus disclosure and behaviors of sharing (or not sharing) HIV serostatus with a partner. Narratives were analyzed for barriers and facilitators of disclosure through the lens of sociocultural gender inequality, focusing on reasons for non-disclosure. RESULTS Among 35 participants: median age was 33 years (men) and 30 years (women); average years since HIV diagnosis was 1 (men) and 1.5 (women). Four themes related to gender inequality and HIV-serostatus disclosure emerged: (1) Men and women fear disclosing to partners due to concerns about stigma and relationship dissolution, (2) suspicions and mistrust between partners underlies decisions for non-disclosure, (3) unequal, gendered power in relationships causes differential likelihood and safety of disclosure among men and women, and (4) incomplete or implicit disclosure are strategies to navigate disclosure challenges. Findings illustrate HIV-serostatus disclosure as a complex process evolving over time, rather than a one-time event. CONCLUSION Partner communication about HIV serostatus is infrequent and complicated, with gender inequalities contributing to fear, mistrust, and partial or implicit disclosure. Relationship dynamics and gender roles shape the environment within which men and women can engage successfully in the HIV-serostatus disclosure process. Integrated interventions to reduce barriers to trustful and effective communication are needed for HIV-affected men and women in partnerships in which seeking couples-based HIV counseling and testing (CHCT) is challenging or unlikely. These data offer insights to support HIV-serostatus disclosure strategies within relationships over time.
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Affiliation(s)
- Divya S Bhatia
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States
| | - Abigail D Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States
| | - Muriel Kubeka
- Maternal Adolescent and Child Health Research Unit, Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
| | - Cecilia Milford
- Maternal Adolescent and Child Health Research Unit, Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Christina Psaros
- Behavioral Medicine Program, Massachusetts General Hospital, Department of Psychiatry, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Steven A Safren
- Department of Psychology, University of Miami, Miami, FL, United States
| | - David R Bangsberg
- Oregon Health Sciences University, Portland, OR, United States.,Portland State University School of Public Health, Portland, OR, United States
| | - Jennifer A Smit
- Maternal Adolescent and Child Health Research Unit, Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa.,Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Lynn T Matthews
- Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Division of Global Health, Boston, MA, United States.,Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, United States
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18
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Mantell JE, Cooper D, Exner TM, Moodley J, Hoffman S, Myer L, Leu CS, Bai D, Kelvin EA, Jennings K, Stein ZA, Constant D, Zweigenthal V, Cishe N, Nywagi N. Emtonjeni-A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study. AIDS Behav 2017; 21:905-922. [PMID: 27807792 PMCID: PMC5552040 DOI: 10.1007/s10461-016-1562-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies, perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners. We conducted a Phase II randomized futility trial of a multi-level intervention to increase adherence to safer sex guidelines among those wishing to avoid pregnancy and adherence to safer conception guidelines among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town. Clinics were pair-matched and the two clinics within each pair were randomized to either a three-session provider-delivered enhanced intervention (EI) (onsite contraceptive services and brief milieu intervention for staff) or standard-of-care (SOC) provider-delivered intervention. The futility analysis showed that we cannot rule out the possibility that the EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC (p = 0.573), indicating that the intervention holds merit, and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit.
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Affiliation(s)
- J E Mantell
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA.
| | - D Cooper
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - T M Exner
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
| | - J Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - S Hoffman
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - L Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - C-S Leu
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Biostatistics and Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, NY, USA
| | - D Bai
- Department of Biostatistics and Epidemiology, Joseph Mailman School of Public Health, Columbia University, New York, NY, USA
| | - E A Kelvin
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Epidemiology and Biostatistics Department, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - K Jennings
- City of Cape Town Department of Health, Cape Town, South Africa
| | - Z A Stein
- Division of Gender, Sexuality and Health, Department of Psychiatry, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - D Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - V Zweigenthal
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - N Cishe
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - N Nywagi
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa
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Crankshaw TL, Smit JA, Beksinska ME. Placing contraception at the centre of the HIV prevention agenda. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2017; 15:157-62. [PMID: 27399045 DOI: 10.2989/16085906.2016.1204330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the past decade, the global response to the HIV epidemic has been unprecedented, and enormous progress has been made. Significant investment in the roll out of antiretroviral treatment (ART) and efforts to increase treatment coverage have greatly reduced the number of AIDS-related deaths worldwide. There are a growing number of promising innovations to expand the HIV prevention mix. However, the reach of these interventions is still very limited in adolescent girls and young women (15-24 years) and the full realisation of the intervention mandates has not yet been achieved. The HIV prevention field has been criticised for the tendency to adopt a narrow focus. The Fast-Track Strategy offers a unique opportunity for the HIV prevention field to broaden its gaze and to begin to identify synergies (and efficiencies) with prevention approaches from other global development priorities, namely sexual and reproductive health and rights (SRHR). This paper applies a SRHR lens to HIV prevention by highlighting the critical relationship between unintended pregnancy and HIV, and seeks to expand on earlier debates that prevention of HIV and prevention of unintended pregnancy are inextricably linked, complementary activities with interrelated and common goals. We call for the prioritisation of prevention of unintended pregnancy amongst two overlapping population groups - girls and young women (15-24 years old) and women living with HIV - as a key tactic to accomplish the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track Strategy and as a way to fully realise existing HIV prevention efforts. We discuss the intersecting pathways between HIV prevention and unintended pregnancy prevention and build a case for contraception to be placed at the centre of the HIV prevention agenda.
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Affiliation(s)
- Tamaryn L Crankshaw
- a Health Economics and HIV and AIDS Research Division (HEARD) , University of KwaZulu-Natal , Durban , South Africa
| | - Jennifer A Smit
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
| | - Mags E Beksinska
- b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa
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Brown J, Njoroge B, Akama E, Breitnauer B, Leddy A, Darbes L, Omondi R, Mmeje O. A Novel Safer Conception Counseling Toolkit for the Prevention of HIV: A Mixed-Methods Evaluation in Kisumu, Kenya. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2016; 28:524-538. [PMID: 27925487 PMCID: PMC5292923 DOI: 10.1521/aeap.2016.28.6.524] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Safer conception strategies can prevent HIV transmission between HIV-discordant partners while allowing them to conceive. However, HIV care providers in sub-Saharan Africa report they are not trained in safer conception, and patients are not routinely offered safer conception services. This mixed-methods pilot study evaluated the impact, acceptability, and feasibility of a novel Safer Conception Counseling Toolkit among providers and patients in Kenya. We enrolled 20 HIV-positive women, 10 HIV-discordant couples, and 10 providers from HIV care and treatment clinics. Providers completed questionnaires before/after training, and then counseled HIV-affected patients. Change in patient knowledge was assessed before/after counseling. Qualitative interviews were conducted among providers and patients. The Toolkit was associated with large, significant increases in patient knowledge, and provider confidence, knowledge, and favorable attitudes toward safer conception counseling; 20% felt confident before versus 100% after training (p < 0.01).
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Affiliation(s)
- Joelle Brown
- Department of Epidemiology and Biostatistics and the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Betty Njoroge
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Brooke Breitnauer
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Anna Leddy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lynae Darbes
- School of Nursing and the Center for Sexuality and Health Disparities, Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Okeoma Mmeje
- Department of Obstetrics and Gynecology, University of Michigan Medical School, and the Department of Health Education and Health Behavior, School of Public Health, University of Michigan
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The risks of partner violence following HIV status disclosure, and health service responses: narratives of women attending reproductive health services in Kenya. J Int AIDS Soc 2016; 19:20766. [PMID: 27037140 PMCID: PMC4819069 DOI: 10.7448/ias.19.1.20766] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/25/2016] [Accepted: 03/02/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction For many women living with HIV (WLWH), the disclosure of positive status can lead to either an extension of former violence or new conflict specifically associated with HIV status disclosure. This study aims to explore the following about WLWH: 1. the women's experiences of intimate partner violence (IPV) risks following disclosure to their partners; 2. an analysis of the women's views on the role of health providers in preventing and addressing IPV, especially following HIV disclosure. Methods Thirty qualitative interviews were conducted with purposively selected WLWH attending clinics in Kenya. Data were coded using NVivo 9 and analyzed thematically. Results Nearly one third of the respondents reported experiencing physical and/or emotional violence inflicted by their partners following the sero-disclosure, suggesting that HIV status disclosure can be a period of heightened risk for partner stigma and abuse, and financial withdrawal, and thus should be handled with caution. Sero-concordance was protective for emotional and verbal abuse once the partner knew his positive status, or knew the woman knew his status. Our results show acceptance of the role of the health services in helping prevent and reduce anticipated fear of partner stigma and violence as barriers to HIV disclosure. Some of the approaches suggested by our respondents included couple counselling, separate counselling sessions for men, and facilitated disclosure. The women's narratives illustrate the importance of integrating discussions on risks for partner violence and fear of disclosure into HIV counselling and testing, helping women develop communication skills in how to disclose their status, and reducing fear about marital separation and break-up. Women in our study also confirmed the key role of preventive health services in reducing blame for HIV transmission and raising awareness on HIV as a chronic disease. However, several women reported receiving no counselling on safe disclosure of HIV status. Conclusion Integration of partner violence identification and care into sexual, reproductive and HIV services for WLWH could be a way forward. The health sector can play a preventive role by sensitizing providers to the potential risks for partner violence following disclosure and ensuring that the women's decision to disclose is fully informed and voluntary.
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Mindry DL, Milford C, Greener L, Greener RM, Maharaj P, Letsoalo T, Munthree C, Crankshaw TL, Smit JA. Client and provider knowledge and views on safer conception for people living with HIV (PLHIV). SEXUAL & REPRODUCTIVE HEALTHCARE 2016; 10:35-40. [PMID: 27938871 DOI: 10.1016/j.srhc.2016.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/22/2016] [Accepted: 03/28/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE(S) The childbearing needs of people living with HIV (PLHIV) and the experiences of healthcare providers serving them are explored. We examine provider and client knowledge and views on safer conception methods. METHODS The study uses exploratory qualitative research to understand provider and client perspectives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers. RESULTS Clients had little knowledge and providers had limited knowledge of safer conception methods. While clients were eager to receive counseling on safer conception, providers had some hesitations but were eager to receive training in delivering safer conception services. Clients and providers noted that biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods to have biological children but some expressed concerns about potential risks associated with timed unprotected intercourse. Male clients required access to reproductive health information. CONCLUSIONS Providers need to routinely initiate discussions with clients about childbearing intentions. Providers need to be enabled with approved guidelines and training to support client access to safer conception methods.
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Affiliation(s)
- Deborah L Mindry
- Center for Culture and Health, Semel Institute, University of California, Los Angeles, USA.
| | - Cecilia Milford
- MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Letitia Greener
- MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Ross M Greener
- MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa
| | - Pranitha Maharaj
- School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
| | - Thabo Letsoalo
- School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
| | - Chantal Munthree
- School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
| | - Tamaryn L Crankshaw
- Health Economics HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Jennifer A Smit
- MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa; School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa
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Yang Y, Lewis FM, Wojnar D. Culturally Embedded Risk Factors for Cambodian Husband-Wife HIV Transmission: From Women's Point of View. J Nurs Scholarsh 2016; 48:154-62. [PMID: 26841093 DOI: 10.1111/jnu.12193] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to use interview data to examine the validity of a recently published theoretical model of HIV transmission between husband and virginal wives in rural Cambodia. DESIGN This study used a qualitative description method with a sample of women diagnosed with HIV/AIDS in Phnom Penh, Cambodia. METHODS Data were collected through in-depth interviews conducted with 15 women who self-identified as having contracted HIV from their HIV-positive husbands. Interviews were conducted in Khmer, translated and back-translated for accuracy, and then coded using deductive content analysis. Trustworthiness of study results was protected through peer debriefing, coding to consensus, and maintaining an audit trail. FINDINGS Each conceptual domain of the prior published theoretical model of HIV transmission was validated and further elaborated by current study data: wives' acceptance of their husbands' involvement with commercial sex workers, the common practice of unprotected sex between HIV-infected spouses and uninfected wives, and wives' beliefs about the value of the ideal Khmer woman. In addition, the current study findings identified a new domain that substantially distinguished between the beliefs and attitudes held about marriage and sex by wives and spouses. CONCLUSIONS Women were not passive recipients of HIV transmission; they reciprocated with behaviors that were consistent with being a good Khmer woman in rural Cambodia, all of which increased their vulnerability to HIV transmission from their HIV-infected spouses. Future interventions or programs should consider all these factors and not overly rely on simplistic educational messages about wearing barriers for HIV transmission during sex. CLINICAL RELEVANCE The refined theoretical model of HIV transmission from this qualitative research can be used to formulate culturally sensitive and embedded programs for curbing intramarital HIV transmission in Cambodia among the rural poor.
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Affiliation(s)
- Youngran Yang
- Assistant Professor, School of Nursing, Research Institute of Nursing Science, Chonbuk National University, Jeonju, Republic of Korea
| | - Frances Marcus Lewis
- School of Nursing, University of Washington Medical Center Endowed Professor in Nursing, Family and Child Nursing, Seattle, WA, USA
| | - Danuta Wojnar
- Associate Professor, College of Nursing, Seattle University, Seattle, WA, USA
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Narasimhan M, Loutfy M, Khosla R, Bras M. Sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015; 18:20834. [PMID: 28326129 PMCID: PMC4813610 DOI: 10.7448/ias.18.6.20834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Goggin K, Finocchario-Kessler S, Staggs V, Woldetsadik MA, Wanyenze RK, Beyeza-Kashesya J, Mindry D, Khanakwa S, Wagner GJ. Attitudes, Knowledge, and Correlates of Self-Efficacy for the Provision of Safer Conception Counseling Among Ugandan HIV Providers. AIDS Patient Care STDS 2015; 29:651-60. [PMID: 26588429 PMCID: PMC4684655 DOI: 10.1089/apc.2015.0089] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
- Schools of Medicine and Pharmacy, University of Missouri – Kansas City, Missouri
| | | | - Vincent Staggs
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
- School of Medicine, University of Missouri – Kansas City, Missouri
| | | | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala, Uganda
| | - Jolly Beyeza-Kashesya
- Mulago Hospital Department of Obstetrics and Gynaecology, Kampala, Uganda
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Deborah Mindry
- University of California, Los Angeles Center for Culture and Health, Los Angeles, California
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A discussion of key values to inform the design and delivery of services for HIV-affected women and couples attempting pregnancy in resource-constrained settings. J Int AIDS Soc 2015; 18:20272. [PMID: 26643454 PMCID: PMC4672397 DOI: 10.7448/ias.18.6.20272] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/28/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022] Open
Abstract
Introduction HIV-affected women and couples often desire children and many accept HIV risk in order to attempt pregnancy and satisfy goals for a family. Risk reduction strategies to mitigate sexual and perinatal HIV transmission include biomedical and behavioural approaches. Current efforts to integrate HIV and reproductive health services offer prime opportunities to incorporate strategies for HIV risk reduction during pregnancy attempts. Key client and provider values about services to optimize pregnancy in the context of HIV risk provide insights for the design and implementation of large-scale “safer conception” programmes. Discussion Through our collective experience and discussions at a multi-disciplinary international World Health Organization–convened workshop to initiate the development of guidelines and an algorithm of care to support the delivery of services for HIV-affected women and couples attempting pregnancy, we identified four values that are key to the implementation of these programmes: (1) understanding fertility care and an ability to identify potential fertility problems; (2) providing equity of access to resources enabling informed decision-making about reproductive choices; (3) creating enabling environments that reduce stigma associated with HIV and infertility; and (4) creating enabling environments that encourage disclosure of HIV status and fertility status to partners. Based on these values, recommendations for programmes serving HIV-affected women and couples attempting pregnancy include the following: incorporation of comprehensive reproductive health counselling; training to support the transfer and exchange of knowledge between providers and clients; care environments that reduce the stigma of childbearing among HIV-affected women and couples; support for safe and voluntary disclosure of HIV and fertility status; and increased efforts to engage men in reproductive decision-making at times that align with women's desires. Conclusions Programmes, policies and guidelines that integrate HIV treatment and prevention, sexual and reproductive health and fertility care services in a manner responsive to user values and preferences offer opportunities to maximize demand for and use of these services. For HIV-affected women and couples attempting pregnancy, the provision of comprehensive services using available tools – and the development of new tools that are adaptable to many settings and follow consensus recommendations – is a public health imperative. The impetus now is to design and deliver value-driven inclusive programming to achieve the greatest coverage and impact to reduce HIV transmission during pregnancy attempts.
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Matthews LT, Smit JA, Moore L, Milford C, Greener R, Mosery FN, Ribaudo H, Bennett K, Crankshaw TL, Kaida A, Psaros C, Safren SA, Bangsberg DR. Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa. AIDS Behav 2015; 19:2291-303. [PMID: 26080688 PMCID: PMC4926315 DOI: 10.1007/s10461-015-1050-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.
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Affiliation(s)
- L T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
| | - J A Smit
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- School of Pharmacy and Pharmacology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - L Moore
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - C Milford
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - R Greener
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - F N Mosery
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - H Ribaudo
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA, USA
| | - K Bennett
- Bennett Statistical Consulting, Inc., Ballston Lake, NY, USA
| | - T L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - A Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - C Psaros
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S A Safren
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - D R Bangsberg
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA
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West N, Schwartz S, Phofa R, Yende N, Bassett J, Sanne I, Van Rie A. "I don't know if this is right … but this is what I'm offering": healthcare provider knowledge, practice, and attitudes towards safer conception for HIV-affected couples in the context of Southern African guidelines. AIDS Care 2015; 28:390-6. [PMID: 26445035 DOI: 10.1080/09540121.2015.1093596] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The 2011 guidelines for safer conception for HIV-affected individuals and couples were adopted by the South African Department of Health in December 2012. We assessed implementation gaps and facilitators and barriers to delivering safer conception services through examining patient and healthcare provider (HCP) experiences. At Witkoppen Health and Welfare Centre, a primary care clinic in Johannesburg, we conducted in-depth interviews (IDIs) with nine HCPs (doctors, nurses, and counselors) and IDIs and focus group discussions with 42 HIV-affected men and women interested in having a child. Data were analyzed using a grounded theory approach. HCPs were supportive of fertility intentions of HIV-affected couples and demonstrated some knowledge of safer conception methods, especially ART initiation to suppress viral load in infected partners. Unfortunately, HCPs did not follow the key recommendation that HCPs initiate conversations on fertility intentions with HIV-affected men and women. Providers and clients reported that conversations about conception only occur when client-initiated, placing the onus on HIV-affected individuals. Important barriers underlying this were the misconception held by some HCPs that uninfected partners in serodiscordant partnerships are "latently" infected and the desire by most HCPs to protect or control knowledge around fertility and safer conception methods out of concern over what clients will do with this knowledge before they are virally suppressed or ready to conceive. Almost all participants who had conceived or attempted conception did so without safer conception methods knowledge. HCP concern over conception readiness, perception of what clients will do with safer conception knowledge, and gaps in safer conception knowledge prevent HCPs from initiating conversations with HIV-affected patients on the issue of childbearing. Examining these findings in the context of existing South African guidelines illuminates areas that need to be addressed to facilitate implementation of the guidelines.
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Affiliation(s)
- Nora West
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Sheree Schwartz
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.,c Department of Epidemiology , Johns Hopkins School of Public Health , Baltimore , MD , USA
| | - Rebecca Phofa
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | | | - Jean Bassett
- a Witkoppen Health and Welfare Centre , Johannesburg , South Africa
| | - Ian Sanne
- d Department of Medicine , Clinical HIV Research Unit, University of the Witwatersrand , Johannesburg , South Africa.,e Right to Care, ThembaLethu Wing, Helen Joseph Hospital , Johannesburg , South Africa
| | - Annelies Van Rie
- b Department of Epidemiology , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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Conserve DF, Groves AK, Maman S. Effectiveness of interventions promoting HIV serostatus disclosure to sexual partners: a systematic review. AIDS Behav 2015; 19:1763-72. [PMID: 25645328 DOI: 10.1007/s10461-015-1006-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disclosure of HIV serostatus to sexual partners is mandated within certain states in the United States and other countries. Despite these laws implemented and public health efforts to increase disclosure, rates of disclosure to sexual partners among people living with HIV (PLWH) remain low, suggesting the need for interventions to assist PLWH with the disclosure process. We conducted a systematic review of studies testing whether HIV serostatus disclosure interventions increase disclosure to sexual partners. We searched six electronic databases and screened 484 records. Five studies published between 2005 and 2012 met inclusion criteria and were included in this review. Results showed that three of the HIV serostatus disclosure-related intervention studies were efficacious in promoting disclosure to sexual partners. Although all three studies were conducted in the United States the intervention content and measurements of disclosure across the studies varied, so broad conclusions are not possible. The findings suggest that more rigorous HIV serostatus disclosure-related intervention trials targeting different populations in the United States and abroad are needed to facilitate disclosure to sexual partners.
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Affiliation(s)
- Donaldson F Conserve
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27509, USA.
| | - Allison K Groves
- Department of Sociology, Center on Health, Risk and Society, American University, Washington, DC, USA
| | - Suzanne Maman
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27509, USA
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30
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"If I don't use a condom … I would be stressed in my heart that I've done something wrong": Routine Prevention Messages Preclude Safer Conception Counseling for HIV-Infected Men and Women in South Africa. AIDS Behav 2015; 19:1666-75. [PMID: 25711300 DOI: 10.1007/s10461-015-1026-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.
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SURPRISING RESULTS: HIV TESTING AND CHANGES IN CONTRACEPTIVE PRACTICES AMONG YOUNG WOMEN IN MALAWI. J Biosoc Sci 2015; 48:174-91. [PMID: 26160156 DOI: 10.1017/s002193201500022x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This study uses eight waves of data from the population-based Tsogolo la Thanzi study (2009-2011) in rural Malawi to examine changes in young women's contraceptive practices, including the use of condoms, non-barrier contraceptive methods and abstinence, following positive and negative HIV tests. The analysis factors in women's prior perceptions of their HIV status that may already be shaping their behaviour and separates surprise HIV test results from those that merely confirm what was already believed. Fixed-effects logistic regression models show that HIV testing frequently affects the contraceptive practices of young Malawian women, particularly when the test yields an unexpected result. Specifically, women who are surprised to test HIV positive increase their condom use and are more likely to use condoms consistently. Following an HIV-negative test (whether a surprise or expected), women increase their use of condoms and decrease their use of non-barrier contraceptives; the latter may be due to an increase in abstinence following a surprise negative result. Changes in condom use following HIV testing are robust to the inclusion of potential explanatory mechanisms, including fertility preferences, relationship status and the perception that a partner is HIV positive. The results demonstrate that both positive and negative tests can influence women's sexual and reproductive behaviours, and emphasize the importance of conceptualizing of HIV testing as offering new information only insofar as results deviate from prior perceptions of HIV status.
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Mindry DL, Crankshaw TL, Maharaj P, Munthree C, Letsoalo T, Milford C, Greener RM, Rambally L, Carpenter S, Smit JA. "We have to try and have this child before it is too late": missed opportunities in client-provider communication on reproductive intentions of people living with HIV. AIDS Care 2014; 27:25-30. [PMID: 25202986 DOI: 10.1080/09540121.2014.951311] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception.
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Affiliation(s)
- D L Mindry
- a Center for Culture and Health , Semel Institute, University of California , Los Angeles , CA , USA
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