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Anand P, Wu L, Mugwanya K. Integration of sexually transmitted infection and HIV pre-exposure prophylaxis services in sub-Saharan Africa: a scoping review. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:944372. [PMID: 37457431 PMCID: PMC10338918 DOI: 10.3389/frph.2023.944372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/31/2023] [Indexed: 07/18/2023] Open
Abstract
Background Persons living in sub-Saharan Africa (SSA) face disproportionate risk from overlapping epidemics of HIV and bacterial sexually transmitted infections (STIs). Pre-exposure prophylaxis (PrEP) for prevention is gradually being scaled up globally including in several settings in SSA, which represents a key opportunity to integrate STI services with HIV pre-exposure prophylaxis (PrEP). However, there is limited literature on how to successfully integrate these services, particularly in the SSA context. Prior studies and reviews on STI and PrEP services have largely focused on high income countries. Methods We conducted a scoping review of prior studies of integration of STI and PrEP services in SSA. We searched PubMed, EMBASE, Cochrane, and CINAHL, in addition to grey literature to identify studies that were published between January 2012 and December 2022, and which provided STI and PrEP services in SSA, with or without outcomes reported. Citations and abstracts were reviewed by two reviewers for inclusion. Full texts were then retrieved and reviewed in full by two reviewers. Results Our search strategy yielded 1951 records, of which 250 were retrieved in full. Our final review included 61 reports of 45 studies. Most studies were conducted in Southern (49.2%) and Eastern (24.6%) Africa. Service settings included public health clinics (26.2%), study clinics (23.0%), sexual and reproductive care settings (23.0%), maternal and child health settings (8.2%), community based services (11.5%), and mobile clinics (3.3%). A minority (11.4%) of the studies described only syndromic STI management while most (88.6%) included some form of etiological laboratory STI diagnosis. STI testing frequency ranged from baseline testing only to monthly screening. Types of STI tested for was also variable. Few studies reported outcomes related to implementation of STI services. There were high rates of curable STIs detected by laboratory testing (baseline genitourinary STI rates ranged from 5.6-30.8% for CT, 0.0-11.2% for GC, and 0.4-8.0% for TV). Discussion Existing studies have implemented a varied range of STI services along with PrEP. This range reflects the lack of specific guidance regarding STI services within PrEP programs. However, there was limited evidence regarding implementation strategies for integration of STI and PrEP services in real world settings.
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Affiliation(s)
- Priyanka Anand
- Department of Medicine, University of Washington School of Medicine, Seattle, WAUnited States
| | - Linxuan Wu
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Kenneth Mugwanya
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Epidemiology, University of Washington, Seattle, WA, United States
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Ukoha WC, Mtshali NG. Preconception care practices among primary health care nurses working in public health facilities in KwaZulu-Natal. Glob Health Action 2022; 15:2112395. [PMID: 36161863 PMCID: PMC9542517 DOI: 10.1080/16549716.2022.2112395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Preconception care (PCC) is necessary to identify and deal with all the risk factors before conception. Some aspects of PCC, like folic acid supplementation, would be relevant to people desiring a pregnancy. Alternatively, PCC could provide contraceptive support to those with no pregnancy intention. In South Africa, primary healthcare nurses provide a comprehensive package of essential services in public health facilities to about 90% of the population at no cost. Therefore, they are the key providers of promotive, preventive, and curative services, including PCC. OBJECTIVE This study aimed to determine the level of PCC practice among primary healthcare nurses and identify determinants of effective practice. METHODS This cross-sectional descriptive survey was conducted among 196 nurses undertaking a specialisation Primary HealthCare program in a selected higher education institution. A pretested questionnaire was used to collect data that were analysed with SPSS version 27 software. RESULTS The overall practice of PCC was 87.8%. Older participants were significantly less likely to exhibit good PCC practice than their younger counterparts. Female participants were also less likely to have good PCC practices than their male counterparts. Married participants were significantly more likely to practice PCC than their unmarried counterparts. Participants practicing in rural areas were also less likely to have good PCC practices than their urban counterparts. CONCLUSION The PCC practice of most primary healthcare nurses in the study is relatively high. The study also identified the determinants of good PCC practice that can enhance its practice. There is a need to revisit the PCC training of healthcare workers, as most indicated the need for further training.
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Affiliation(s)
- Winifred Chinyere Ukoha
- School of Nursing and Public Health, Howard College, University of KwaZulu-Natal, Durban, South Africa
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3
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Mathenjwa M, Khidir H, Milford C, Mosery N, Rambally Greener L, Pratt MC, O'Neil K, Harrison A, Bangsberg DR, Safren SA, Smit JA, Psaros C, Matthews LT. Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings. AIDS Behav 2022; 26:1-12. [PMID: 34097209 PMCID: PMC8786780 DOI: 10.1007/s10461-021-03278-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/15/2023]
Abstract
Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.
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Affiliation(s)
- Mxolisi Mathenjwa
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Cecilia Milford
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Letitia Rambally Greener
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- Population Services International, South Africa, Johannesburg, South Africa
| | - Madeline C Pratt
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA
| | | | | | | | | | - Jennifer A Smit
- MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | | | - Lynn T Matthews
- University of Alabama at Birmingham (UAB), Division of Infectious Disease, Birmingham, Alabama, USA.
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4
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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Gutin SA, Harper GW, Moshashane N, Bitsang C, Harries J, Ramogola-Masire D, Morroni C. "What if they are pre-conception? What should we do?": Knowledge, practices, and preferences for safer conception among women living with HIV and healthcare providers in Gaborone, Botswana. Front Glob Womens Health 2021; 1. [PMID: 33693437 PMCID: PMC7943178 DOI: 10.3389/fgwh.2020.582463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Safer conception interventions that address HIV care, treatment, and prevention for HIV-affected couples are increasingly available in sub-Saharan Africa. Botswana, an HIV endemic country, is yet to offer formal safer conception services although universal test-and-treat approaches mean that increasing numbers of young, sexually active people living with HIV will start treatment and likely desire childbearing. In order to advance the safer conception discussion in Botswana, it is necessary to understand the current safer conception knowledge, practices, and preferences of healthcare providers and women living with HIV (WLHIV). We conducted qualitative in-depth interviews with 10 HIV healthcare providers and 10 WLHIV in Gaborone. Interviews were analyzed using a phenomenological approach. Safer conception knowledge was limited and safer conception discussions were rare. Healthcare provider and WLHIV preferences were at odds, with providers preferring WLHIV to initiate safer conception discussions, and WLHIV desiring providers to initiate safer conception discussions. Quotes from women and providers highlight deeper issues about power dynamics, concerns about stigma among women, and provider fears about promoting pregnancy. Providers emphasized the need for guidelines and training in order to improve the provision of safer conception counseling. These findings point to areas where safer conception in Botswana can be improved. Both WLHIV and providers would benefit from having information about a range of safer conception methods and approaches. In addition, since WLHIV felt hesitant about initiating safer conception conversations and feared stigma, and because putting the onus for starting safer conception discussions on women is a reversal of normal roles and power structures, providers must take the lead and routinely initiate fertility desire and safer conception discussions. Assisting healthcare providers with clear safer conception guidelines and training would improve the provision of accurate safer conception counseling and facilitate reproductive choice.
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Affiliation(s)
- Sarah A Gutin
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for AIDS Prevention Studies, Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Gary W Harper
- Dept. of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Christina Bitsang
- Career and Counseling Services, University of Botswana, Gaborone, Botswana
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Botswana U-Penn Partnership, Gaborone, Botswana.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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6
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Rucinski KB, Powers KA, Pettifor AE, Black V, Pence BW, Chi BH, Rees H, Schwartz SR. Trajectories of fertility intentions among women living with HIV in South Africa. AIDS Care 2021; 33:180-186. [PMID: 32008361 PMCID: PMC7395884 DOI: 10.1080/09540121.2020.1719969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
Fertility intentions are thought to be dynamic among women of reproductive age, yet few studies have assessed fertility intentions over time among women with HIV. We examine temporal patterns of fertility intentions in women with HIV to assess the extent to which fertility intentions - and the corresponding need for safer conception and judicious antiretroviral therapy (ART) regimen selection - vary over time. 850 non-pregnant HIV-positive women aged 18-35 on or being initiated onto ART in Johannesburg, South Africa were enrolled into a prospective cohort study (2009-2010). Fertility intentions were assessed at enrollment and at 30-day intervals via an interviewer-administered questionnaire. We used group-based trajectory modelling to identify longitudinal patterns of fertility intentions over 12 months. We identified four patterns of fertility intentions, which we labelled "consistently low" (representing ∼60% of the population), "low and increasing" (∼23%), "high and increasing" (∼12%), and "high and decreasing" (∼5%). Our findings suggest that a single family-planning assessment at one time point is insufficient to fully identify and meet the reproductive needs of women with HIV. As HIV testing and treatment evolve in South Africa, routine screening for fertility intentions can offer important opportunities to optimize HIV treatment, prevention, and maternal and child health.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Vivian Black
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
- Faculty of Health Sciences, Clinical Microbiology and Infectious Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
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"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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Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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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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10
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Khidir H, Mosery N, Greener R, Milford C, Bennett K, Kaida A, Psaros C, Safren SA, Bangsberg DR, Smit JA, Matthews LT. Sexual Relationship Power and Periconception HIV-Risk Behavior Among HIV-Infected Men in Serodifferent Relationships. AIDS Behav 2020; 24:881-890. [PMID: 31165395 PMCID: PMC6891132 DOI: 10.1007/s10461-019-02536-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gender norms affect HIV risk within serodifferent partnerships. We assessed how the sexual relationship power described by men living with HIV (MLWH) associates with periconception HIV-transmission risk behavior. Quantitative surveys were conducted with 82 MLWH reporting a recent pregnancy with an HIV-negative or unknown-serostatus partner in KwaZulu-Natal, South Africa. Surveys assessed decision-making dominance (DMD) using the Pulerwitz et al. sexual relationship power scale; partnership characteristics; and HIV-risk behaviors. Multivariable logistic regression models evaluated associations between DMD score and HIV-risk behaviors. Higher male decision-making dominance was associated with non-disclosure of HIV-serostatus to pregnancy partner (aRR 2.00, 95% CI 1.52, 2.64), not knowing partner's HIV-serostatus (aRR 1.64, 95% CI 1.27, 2.13), condomless sex since pregnancy (aRR 1.92, 95% CI 1.08, 3.43), and concurrent relationships (aRR 1.50, 95% CI 1.20, 1.88). Efforts to minimize periconception HIV-risk behavior must address gender norms and power inequities.
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Affiliation(s)
| | - Nzwakie Mosery
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Ross Greener
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, GT, South Africa
| | - Cecilia Milford
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Kara Bennett
- Bennett Statistical Consulting Inc., Ballston Lake, NY, USA
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Christina Psaros
- Harvard Medical School, Boston, MA, USA
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Steve A Safren
- Department of Psychology, University of Miami, Miami, FL, USA
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Jennifer A Smit
- Maternal Adolescent and Child Health Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, KZN, South Africa
| | - Lynn T Matthews
- Harvard Medical School, Boston, MA, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
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11
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Kaida A, Kabakyenga J, Bwana M, Bajunirwe F, Muyindike W, Bennett K, Kembabazi A, Haberer JE, Boum Y, Martin JN, Hunt PW, Bangsberg DR, Matthews LT. High Incidence of Intended Partner Pregnancy Among Men Living With HIV in Rural Uganda: Implications for Safer Conception Services. J Acquir Immune Defic Syndr 2019; 81:497-507. [PMID: 30973545 PMCID: PMC6625849 DOI: 10.1097/qai.0000000000002053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many men with HIV express fertility intentions and nearly half have HIV-uninfected sexual partners. We measured partner pregnancy among a cohort of men accessing antiretroviral therapy in Uganda. METHODS Self-reported partner pregnancy incidence and bloodwork (CD4, HIV-RNA) were collected quarterly. Interviewer-administered questionnaires assessed men's sexual and reproductive health annually and repeated at time of reported pregnancy (2011-2015). We measured partner pregnancy incidence overall, by pregnancy intention and by reported partner HIV serostatus. We assessed viral suppression (≤400 copies/mL) during the periconception period. Cox proportional hazard regression with repeated events identified predictors of partner pregnancy. RESULTS Among 189 men, the baseline median age was 39.9 years (interquartile range: 34.7-47.0), years on antiretroviral therapy was 3.9 (interquartile range: 0.0-5.1), and 51% were virally suppressed. Over 530.2 person-years of follow-up, 63 men reported 85 partner pregnancies (incidence = 16.0/100 person-years); 45% with HIV-serodifferent partners. By 3 years of follow-up, 30% of men reported a partner pregnancy, with no difference by partner HIV serostatus (P = 0.75). Sixty-nine percent of pregnancies were intended, 18% wanted but mistimed, and 8% unwanted. Seventy-eight percent of men were virally suppressed before pregnancy report. Men who were younger [adjusted hazard ratio (aHR): 0.94/yr; 95% confidence interval (CI): 0.89 to 0.99], had incomplete primary education (aHR: 2.95; 95% CI: 1.36 to 6.40), and reported fertility desires (aHR: 2.25; 95% CI: 1.04 to 4.85) had higher probability of partner pregnancy. CONCLUSIONS A high incidence of intended partner pregnancy highlights the need to address men's reproductive goals within HIV care. Nearly half of pregnancy partners were at-risk for HIV, and one-quarter of men were not virally suppressed during periconception. Safer conception care provides opportunity to support men's health and reproductive goals, while preventing HIV transmission to women and infants.
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Affiliation(s)
- Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Jerome Kabakyenga
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Mwebesa Bwana
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Francis Bajunirwe
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Winnie Muyindike
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Department of Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, New York, USA
| | - Annet Kembabazi
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
| | - Jessica E. Haberer
- Massachusetts General Hospital (MGH) Global Health and Department of General Medicine, Boston, USA
| | - Yap Boum
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Epicentre, Médicins sans Frontières (MSF), Yaoundé, Cameroon
| | - Jeffrey N. Martin
- Department of Medicine, University of California at San Francisco (UCSF), San Francisco, USA
| | - Peter W. Hunt
- Department of Medicine, University of California at San Francisco (UCSF), San Francisco, USA
| | - David R. Bangsberg
- Faculty of Medicine, Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- School of Public Health, Oregon Health Sciences University, Portland, USA
| | - Lynn T. Matthews
- MGH Global Health and Division of Infectious Diseases, Boston, USA
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Iliyasu Z, Galadanci HS, Oladimeji AI, Babashani M, Gajida AU, Aliyu MH. Predictors of Safer Conception Practices Among HIV-Infected Women in Northern Nigeria. Int J Health Policy Manag 2019; 8:480-487. [PMID: 31441288 PMCID: PMC6706964 DOI: 10.15171/ijhpm.2019.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 05/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background: Persons living with HIV often face discrimination in safe sex and reproductive choices, especially in lowresource settings. This study assessed fertility desires and intentions, risk perception and correlates of ever use of at least one safer conception method among HIV-infected women attending a tertiary health facility in Kano, Nigeria.
Methods: Structured questionnaires were administered to a cross section of 328 of 427 eligible HIV-infected women. Fertility desires and intentions, risk perception and safer conception practice were analyzed. Logistic regression was employed to assess for predictors.
Results: Of the 328 respondents, 150 respondents (45.7%) wanted more children. The proportions of respondents aware of their transmission risk during pregnancy, delivery, and breastfeeding were 69.5%, 75.3%, and 78.9%, respectively. Further, 68.9% of respondents were aware of the prospects of bearing HIV-negative children without infecting their partners. About 64.8% of women were aware of at least one safer conception method. Safer conception methods everused by the participants include: antiretroviral therapy (ART) (36.7%), timed unprotected intercourse with (10.9%), and without pre-exposure prophylaxis (PrEP) (17.2%), intravaginal insemination (7.3%) and intrauterine insemination (4.7%). Safer conception practice was predicted by marital status (married versus single, adjusted odds ratio [AOR]=1.50, 95% CI =1.10-3.55), parity (2-4 versus 0, AOR=12.1, 95% CI=3.7-39.8), occupation (civil servants versus traders, AOR=0.37, 95% CI=0.16-0.86), husband’s serostatus (seroconcordant versus serodiscordant) (AOR=1.51, 95% CI=1.13-4.64), couple contraceptive use (users versus non-users) (AOR=1.62, 95% CI=1.16-5.83) and transmission risk perception (high risk versus low/no risk) (AOR=2.14, 95% CI=1.18-3.90).
Conclusion: We found high levels of fertility desires and intentions and moderate risk perception among a cohort of HIV-infected women in urban Kano, Nigeria. The use of safer conception practices was not common. Our findings underscore the need for healthcare provider capacity building to enhance safer conception counseling and service delivery.
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Affiliation(s)
- Zubairu Iliyasu
- Department of Community Medicine, Bayero University, Kano, Nigeria.,Centre for Infectious Diseases Research, Bayero University, Kano, Nigeria
| | - Hadiza S Galadanci
- Department of Obstetrics and Gynecology, Bayero University, Kano, Nigeria
| | - Alfa I Oladimeji
- Department of Community Medicine, Bayero University, Kano, Nigeria
| | - Musa Babashani
- Department of Medicine, Bayero University, Kano, Nigeria
| | - Auwalu U Gajida
- Department of Community Medicine, Bayero University, Kano, Nigeria
| | - Muktar H Aliyu
- Department of Health Policy & Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
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13
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Matthews LT, Jaggernath M, Kriel Y, Smith PM, O'Neil K, Haberer JE, Hendrix C, Baeten JM, Ware NC, Wirth K, Psaros C, Bangsberg DR, Smit JA. Protocol for a longitudinal study to evaluate the use of tenofovir-based PrEP for safer conception and pregnancy among women in South Africa. BMJ Open 2019; 9:e027227. [PMID: 31350241 PMCID: PMC6661571 DOI: 10.1136/bmjopen-2018-027227] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 03/06/2019] [Accepted: 06/12/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Women who choose to conceive a baby with a partner living with HIV or a partner whose HIV serostatus is unknown in HIV-endemic settings need prevention strategies to mitigate HIV acquisition during conception and pregnancy. METHODS AND ANALYSIS We are conducting a single-arm longitudinal study offering oral tenofovirdisoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis (PrEP) for periconception use to 350 HIV-uninfected women in KwaZulu-Natal, South Africa. PrEP is offered as part of woman-centred safer conception programme that promotes couples-based HIV counselling and testing, antiretroviral therapy for partners who are HIV-infected, treatment for sexually transmitted infections and safer conception strategies, such as limiting condomless sex to peak fertility. We enrol HIV-uninfected women who are not currently pregnant, in a stable relationship (≥6 months) with a partner living with HIV or of unknown serostatus, and personal or partner plans for pregnancy in the next 12 months. We follow enrolled women for 12 months. Women who become pregnant are followed through pregnancy outcome, independent of their decisions regarding PrEP use. The primary objective of the study is to evaluate the uptake of and adherence to PrEP during the periconception period and pregnancy. Secondary outcomes include the uptake of other safer conception strategies. We also measure clinical outcomes including HIV seroconversion rates and pregnancy and infant outcomes. Finally, we will explore conduct and evaluate qualitative interviews in 25 participants to further inform our conceptual framework for periconception PrEP uptake and adherence among HIV-exposed women in South Africa. ETHICS AND DISSEMINATION The protocol has been approved by the Human Research Ethics Committee at the University of the Witwatersrand (Johannesburg, South Africa) and the Institutional Review Board of Partners Healthcare (Boston, Massachusetts, USA). Study findings will be made available to interested participants. Results will be presented to local health officials and stakeholders at meetings. Investigators will share the results at meetings and in manuscripts. De-identified quantitative data will be made available. TRIAL REGISTRATION NUMBER The protocol is registered with the South African Health Products Regulatory Agency (SAHPRA, formerly known as the Medicine Controls Council, MCC#20170131) and ClinicalTrials.gov (NCT03194308); Pre-results.
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Affiliation(s)
- Lynn T Matthews
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Manjeetha Jaggernath
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Yolandie Kriel
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
| | - Patricia M Smith
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Kasey O'Neil
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig Hendrix
- Division of Clinical Pharmacology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Wirth
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - David R Bangsberg
- Dean's Office, Portland State University School of Public Health, Oregon Health and Science University, Portland, Oregon, USA
| | - Jennifer A Smit
- Department of Gynecology and Obstetrics, Faculty of Health Sciences, MatCH Research Unit, University of Witwatersrand, Durban, South Africa
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Iyer JR, Van Rie A, Haberlen SA, Mudavanhu M, Mutunga L, Bassett J, Schwartz SR. Subfertility among HIV-affected couples in a safer conception cohort in South Africa. Am J Obstet Gynecol 2019; 221:48.e1-48.e18. [PMID: 30807762 PMCID: PMC6592765 DOI: 10.1016/j.ajog.2019.02.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Subfertility among couples affected by HIV has an impact on the well-being of couples who desire to have children and may prolong HIV exposure. Subfertility in the antiretroviral therapy era and its determinants have not yet been well characterized. OBJECTIVE The objective of the study was to investigate the burden and determinants of subfertility among HIV-affected couples seeking safer conception services in South Africa. STUDY DESIGN Nonpregnant women and male partners in HIV seroconcordant or HIV discordant relationships desiring a child were enrolled in the Sakh'umndeni safer conception cohort at Witkoppen Clinic in Johannesburg between July 2013 and April 2017. Clients were followed up prospectively through pregnancy (if they conceived) or until 6 months of attempted conception, after which they were referred for infertility services. Subfertility was defined as not having conceived within 6 months of attempted conception. Robust Poisson regression was used to assess the association between baseline characteristics and subfertility outcomes; inverse probability weighting was used to account for missing data from women lost to safer conception care before 6 months of attempted conception. RESULTS Among 334 couples enrolled, 65% experienced subfertility (inverse probability weighting weighted, 95% confidence interval, 0.59-0.73), of which 33% were primary subfertility and 67% secondary subfertility. Compared with HIV-negative women, HIV-positive women not on antiretroviral therapy had a 2-fold increased risk of subfertility (weighted and adjusted risk ratio, 2.00; 95% confidence interval, 1.19-3.34). Infertility risk was attenuated in women on antiretroviral therapy but remained elevated, even after ≥2 years on antiretroviral therapy (weighted and adjusted risk ratio, 1.63; 95% confidence interval, 0.98-2.69). Other factors associated with subfertility were female age (weighted and adjusted risk ratio, 1.03, 95% confidence interval, 1.01-1.05 per year), male HIV-positive status (weighted and adjusted risk ratio, 1.31; 95% confidence interval, 1.02-1.68), male smoking (weighted and adjusted risk ratio, 1.29; 95% confidence interval, 1.05-1.60), and trying to conceive for ≥1 year (weighted and adjusted risk ratio, 1.38; 95% confidence interval, 1.13-1.68). CONCLUSION Two in 3 HIV-affected couples experienced subfertility. HIV-positive women were at increased risk of subfertility, even when on antiretroviral therapy. Both male and female HIV status were associated with subfertility. Subfertility is an underrecognized reproductive health problem in resource-limited settings and may contribute to prolonged HIV exposure and transmission within couples. Low-cost approaches for screening and treating subfertility in this population are needed.
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Affiliation(s)
- Jessica R Iyer
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerpen, Belgium
| | - Sabina A Haberlen
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Mutsa Mudavanhu
- Witkoppen Health and Welfare Centre, Fourways, Johannesburg, South Africa
| | - Lillian Mutunga
- Witkoppen Health and Welfare Centre, Fourways, Johannesburg, South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Fourways, Johannesburg, South Africa
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
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15
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Schwartz S, Davies N, Naidoo N, Pillay D, Makhoba N, Mullick S. Clients' experiences utilizing a safer conception service for HIV affected individuals: implications for differentiated care service delivery models. Reprod Health 2019; 16:65. [PMID: 31138252 PMCID: PMC6538560 DOI: 10.1186/s12978-019-0718-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Safer conception services promote the reproductive health and rights of families, while minimizing HIV transmission risks between partners trying to conceive, as well vertical transmission risks. Implementation data, including clients’ experiences utilizing safer conception services in sub-Saharan Africa are limited. Methods Hillbrow Community Health Centre began offering safer conception services for individuals and couples affected by HIV in Johannesburg, South Africa in June 2015. A stratified sub-sample of safer conception clients were consecutively recruited from April 2016–August 2017 for a cross-sectional interview assessing clients’ perceptions of service acceptability and value, as well as perceived safer conception knowledge and self-efficacy. Visual analog scales from 0 to 100 were used to measure clients’ experiences; scores were classified as low, moderate and high acceptance/value/knowledge/self-efficacy if they were < 50, 50–79 and ≥ 80 respectively. Comparisons of scores were made across safer conception visits attended. Results Among 692 clients utilizing safer conception services, 120 (17%) were sampled for the process evaluation; sub-sample participant characteristics were similar to the overall cohort. Clients gave a mean score of ≥90-points for each question assessing service acceptability and 96% (114/119) indicated a high perceived value (scores ≥80) for regular safer conception attendance until conception. Fifty-eight percent (n = 70) of clients reported learning something new during the visit completed the day of the survey, though acquisition of new information tended to decrease as visits increased (p = 0.09). In terms of safer conception strategies, 80% of clients reported high levels of knowledge on the impact of antiretroviral treatment (ART) and viral suppression on HIV transmission, 67% reported high levels of knowledge of the importance of STI screening and 56% regarding limiting condomless sex to days of peak fertility; 34% in sero-different relationships reported high pre-exposure prophylaxis (PrEP) knowledge. Self-efficacy varied by safer conception methods and was similar across study visits. Conclusions Clients perceived high value from their safer conception visits and preferred regular attendance until conception, however we observed a plateau in knowledge and self-efficacy across subsequent visits after initially attending safer conception care. More intensive services may be appropriate for certain clients based on clinical circumstances, but many couples may potentially receive a ‘lighter touch’ approach while still minimizing HIV transmission risks. Electronic supplementary material The online version of this article (10.1186/s12978-019-0718-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA. .,Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa.
| | - Natasha Davies
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicolette Naidoo
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Diantha Pillay
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Nokuthula Makhoba
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Saiqa Mullick
- Wits Reproductive Health Institute, University of the Witwatersrand, Johannesburg, South Africa
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Patwa MC, Bassett J, Holmes L, Mutunga L, Mudavanhu M, Makhomboti T, Van Rie A, Schwartz SR. Integrating safer conception services into primary care: providers' perspectives. BMC Public Health 2019; 19:532. [PMID: 31072352 PMCID: PMC6507034 DOI: 10.1186/s12889-019-6904-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022] Open
Abstract
Background In 2012, South Africa adopted the Contraception and Fertility Planning guidelines to incorporate safer conception services into care for HIV-affected couples trying to conceive. These guidelines lacked clear implementation and training recommendations. The objective of this study was to investigate factors influencing integration of safer conception services in a clinical setting. Methods Twenty in-depth interviews were conducted between October–November 2017 with providers and staff at Witkoppen Clinic in Johannesburg, where the Sakh’umndeni safer conception demonstration project had enrolled patients from July 2013–July 2017. Semi-structured interview guides engaged providers on their perspectives following the Sakh’umndeni project and possible integration plans to inform the translation of the stand-alone Sakh’umndeni services into a routine service. A grounded theory approach was used to code interviews and an adaptation of the Atun et al. (2010) ‘Integration of Targeted Interventions into Health Systems’ conceptual framework was applied as an analysis tool. Results Five themes emerged: (1) The need for safer conception training; (2) The importance of messaging and demand generation; (3) A spectrum of views around the extent of integration of safer conception services; (4) Limitations of family planning services as an integration focal point; and (5) Benefits and challenges of a “couples-based” intervention. In-depth interviews suggested that counselors, as the first point of contact, should inform patients about safer conceptions services, followed by targeted reinforcement of safer conception messaging by all clinicians, and referral to more intensively trained safer conception providers. Conclusion A safer conception counseling guide would facilitate consultations. While many providers felt that the services belonged in family planning, lack of HIV management skills, men and women trying to conceive within family planning may pose barriers.
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Affiliation(s)
- Mariya C Patwa
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Leah Holmes
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA
| | - Lillian Mutunga
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | - Mutsa Mudavanhu
- Witkoppen Health and Welfare Centre, Johannesburg, South Africa
| | | | - Annelies Van Rie
- Department of Epidemiology and Social Medicine, University of Antwerp, Antwerpen, Belgium
| | - Sheree R Schwartz
- Johns Hopkins Bloomber School of Public Health, 615 N Wolfe St. E7136, Baltimore, MD, USA.
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Saleem HT, Surkan PJ, Kerrigan D, Kennedy CE. "If I don't have children, they will know that I'm sick": fertility desires of women and men living with HIV in Iringa, Tanzania. AIDS Care 2019; 31:908-911. [PMID: 30712359 DOI: 10.1080/09540121.2019.1576844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
As safer conception services are expanded and integrated into HIV care systems, these services will need to address cultural, social, economic and medical concerns of women and men living with HIV. We conducted interviews with 30 HIV-positive women, 30 HIV-positive men, and 30 healthcare providers that examined factors specific to the experience of living with HIV that influence fertility desires in Iringa, Tanzania. HIV-related factors fell under five themes: knowing one could prevent mother-to-child transmission; reaching an ideal family size in the context of HIV-related infant mortality; concealing one's HIV status; being able to provide for children; and managing HIV disease progression. Integration of safer conception counseling that includes locally-tailored messaging around desired family size, health risks, stigma and financial considerations into safer conception services will help people living with HIV reach their reproductive goals, while reducing the risks of HIV transmission.
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Affiliation(s)
- Haneefa T Saleem
- a Department of International Health , Johns Hopkins University , Baltimore , USA
| | - Pamela J Surkan
- a Department of International Health , Johns Hopkins University , Baltimore , USA
| | - Deanna Kerrigan
- b Department of Sociology , American University , Washington , USA
| | - Caitlin E Kennedy
- a Department of International Health , Johns Hopkins University , Baltimore , USA
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Velloza J, Ngure K, Kiptinness C, Quame-Amaglo J, Thuo N, Dew K, Kimani M, Gakuo S, Unger JA, Kolko B, Baeten JM, Celum C, Mugo N, Heffron R. A clinic-based tablet application to support safer conception among HIV serodiscordant couples in Kenya: feasibility and acceptability study. Mhealth 2019; 5:4. [PMID: 30976596 PMCID: PMC6414336 DOI: 10.21037/mhealth.2019.01.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND HIV serodiscordant couples are at heightened risk of HIV transmission when attempting to conceive, yet reproductive goals can outweigh concerns about HIV exposure. Safer conception strategies support fertility desires while minimizing HIV transmission risk and novel mHealth tools can optimize their use. The objective of this analysis is to examine the feasibility and usability of short message service (SMS) messages and a mobile application to support safer conception for HIV serodiscordant couples. METHODS We enrolled 74 heterosexual HIV serodiscordant couples with immediate pregnancy desires into a pilot safer conception intervention study in Thika, Kenya. Prior to pregnancy, women received daily 6-item SMS surveys to capture fertility indicators (e.g., menses, basal body temperature) and sexual behavior. The intervention also provided daily oral pre-exposure prophylaxis (PrEP) for the HIV-negative partner and in-depth counseling to accompany publicly-provided antiretroviral therapy (ART) for the HIV-infected partner. Couples attended monthly visits until pregnancy occurred. We measured PrEP use with medication event monitoring system (MEMS) caps and ART use via quarterly viral load quantification. We imported SMS, MEMS, and viral load data into an Android tablet application designed specifically for this setting for couples to view during clinic visits and included predictions of peak fertility days using SMS data. We used descriptive statistics to summarize SMS response data and developed a Google Analytics platform to monitor tablet application usage during follow-up. We also conducted semi-structured interviews with a purposive sample of 5 healthcare providers and 19 couples. Qualitative data were analyzed using a modified constant comparative approach to identify themes related to mHealth intervention feasibility and acceptability. RESULTS In our sample, 34 (45.9%) couples had an HIV-infected female partner. The median age of the female partner was 30 years [interquartile range (IQR), 27-35 years], education was 10 years (IQR, 8-12 years), and partnership duration was 3 years (IQR, 2-7 years). Couples were followed for a median of 218 days (IQR, 116-348 days) prior to pregnancy. Participants completed 13,181 of 16,905 (78.0%) SMS surveys surveys sent with a median of 167 completed surveys (IQR, 74-299) per participant. Most participants completed at least 75% of the total SMS messages received (N=58; 77.3%). The tablet application was opened by counselors 1,806 times during the study period (March 2016 through April 2018). In qualitative interviews, the SMS messages were reportedly easy to respond to and "part of the daily routine". Few participants had concerns about message confidentiality. mHealth tools were also found to be acceptable for tracking fertility indicators and enhancing provider-patient communication. CONCLUSIONS mHealth strategies are feasible to use and acceptable to support the delivery of safer conception intervention services among HIV serodiscordant couples in Kenya.
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Affiliation(s)
- Jennifer Velloza
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kenneth Ngure
- Department of Community of Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | - Nicholas Thuo
- Partners in Health and Research Development, Nairobi, Kenya
| | - Kristin Dew
- Department of Human Centered Design & Engineering, University of Washington, Seattle, WA, USA
| | - Mary Kimani
- Partners in Health and Research Development, Nairobi, Kenya
| | - Stephen Gakuo
- Partners in Health and Research Development, Nairobi, Kenya
| | - Jennifer A. Unger
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Beth Kolko
- Department of Human Centered Design & Engineering, University of Washington, Seattle, WA, USA
| | - Jared M. Baeten
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nelly Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Partners in Health and Research Development, Nairobi, Kenya
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Renee Heffron
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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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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Tenofovir and tenofovir-diphosphate concentrations during pregnancy among HIV-uninfected women using oral preexposure prophylaxis. AIDS 2018; 32:1891-1898. [PMID: 29894385 DOI: 10.1097/qad.0000000000001922] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Pregnancy is a time of increased HIV acquisition risk and pregnancy reduces concentrations of antiretrovirals used for treatment. We assessed whether pregnancy lowers concentrations of tenofovir (TFV) and tenofovir-diphosphate (TFV-DP) among HIV-uninfected women using oral preexposure prophylaxis (PrEP). METHODS We analyzed data from an open-label PrEP study, comparing concentrations of TFV in plasma and TFV-DP in dried blood spots (DBS) among 37 pregnant women and 97 nonpregnant women. Analyses controlled for adherence from daily electronic monitoring. RESULTS The average plasma concentration of TFV among pregnant women was 34.7 ng/ml with 22.2 average recorded doses over the prior month versus 86.5 ng/ml with 23.1 doses among nonpregnant women. After controlling for adherence, TFV concentrations were 58% lower among pregnant women, a statistically significant difference of -50.4 ng/ml (95% CI -68.3 to -32.5). The average TFV-DP concentration was 450.3 fmol/punch among pregnant women and 636.7 fmol/punch among nonpregnant women. This difference was not statistically significant after adjusting for adherence; however, among those with quantifiable TFV-DP, concentrations were 27% lower during pregnancy [-202 fmol/punch (95% CI -384 to -19)]. Among participants with samples before and during pregnancy, there were significant decreases during pregnancy, controlling for adherence: -28.1 ng/ml TFV (95% CI -52.3 to -4.0) and -289.2 fmol/punch TFV-DP (95% CI -439.0 to -139.3). CONCLUSION Consistent with studies among HIV-infected women on ART, we found TFV and TFV-DP concentrations were lower during pregnancy. There is no established TFV concentration threshold to achieve HIV prevention. Additional pharmacokinetic studies and studies of PrEP efficacy in pregnancy are needed.
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Difficult decisions: Evaluating individual and couple-level fertility intentions and HIV acquisition among HIV serodiscordant couples in Zambia. PLoS One 2018; 13:e0189869. [PMID: 29364895 PMCID: PMC5783339 DOI: 10.1371/journal.pone.0189869] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 12/04/2017] [Indexed: 11/19/2022] Open
Abstract
Introduction Attempts to conceive and pregnancy may increase HIV transmission to sex partners and infants. Our study evaluated the association between fertility intentions and HIV acquisition among Zambian HIV-serodiscordant couples. Methods We collected demographic, behavioral, clinical exposures, and data on fertility intentions in a cohort of HIV-serodiscordant couples in Lusaka, Zambia from 2005 to 2012. We evaluated factors associated with fertility intentions stratified by gender using multivariable logistic regression. Multivariable Cox proportional hazard models were used to evaluate the associations between fertility intentions and HIV acquisition controlling for a priori confounders and covariates that substantially (>10%) changed the effect estimates in univariate analyses. Results Among 1,029 serodiscordant couples, 311 agreed that they wanted children in the future (30%), 368 agreed they did not want children (36%), and 344 couples disagreed about having children (34%), with men more likely than women to want children. Women wanting child(ren) was associated with increased odds of baseline pregnancy (adjusted odds ratio [aOR] = 4.80 (95% confidence interval [CI] = 2.93, 7.85)), fewer previous pregnancies (aOR = 0.85 per additional pregnancy (95% CI = 0.78, 0.93)), and partner fertility intention (aOR = 2.89 (95% CI = 2.14, 3.91)) adjusting for woman’s age, literacy, years cohabiting and HIV status. Men wanting child(ren) was associated with younger age (aOR = 0.96 per year (95% CI = 0.93, 0.99)), fewer years cohabiting (aOR = 0.95 (95% CI = 0.92, 0.98)), number of previous partners’ pregnancies (aOR = 0.90 (95% CI = 0.82, 0.98)), and partner fertility intention (aOR = 3.00 (95% CI = 2.21, 4.07)) adjusting for partner’s age, literacy, HIV status and partner’s baseline pregnancy. In adjusted survival analyses, HIV-negative women were more likely to seroconvert if they themselves wanted children (aHR = 2.36 (95% CI = 1.41, 3.96)) vs. did not want children, or if their partner wanted children (aHR = 2.34 (95% CI = 1.33, 4.11)) vs. did not want children, or if the couple agreed that they wanted children (aHR = 2.08 (95% CI = 1.01, 4.30)), adjusting for women’s age, women’s literacy, previous pregnancies and time in study. HIV-negative men were more likely to seroconvert if their female partner wanted a child in the next 12-months (aHR = 1.94 (95% CI = 1.02, 3.68)) vs. did not want children, and when both partners wanted children (aHR = 2.02 (CI = 1.09, 3.73)) vs. they did not want children, adjusting for men’s age and literacy, couple income, number of live children, male circumcision status and time in study. Conclusion Women had increased risk of HIV acquisition if they and/or their partner wanted a child, while men had increased risk of HIV acquisition when their partner or if both partners agreed that they wanted children. Safer-conception interventions are needed to protect HIV uninfected women and men from HIV acquisition in HIV-serodiscordant couples who want children.
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Narasimhan M, Celum C, Askew I, Kiarie J, van der Poel S. Supporting people living with HIV in serodiscordant partnerships to attempt a desired pregnancy by integrating sexual and reproductive health and HIV interventions. J Int AIDS Soc 2017; 20:21829. [PMID: 28361499 PMCID: PMC5461117 DOI: 10.7448/ias.20.2.21829] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Manjulaa Narasimhan
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Connie Celum
- International Clinical Research Center, School of Public Health, University of Washington, Seattle, WA, USA
| | - Ian Askew
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - James Kiarie
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Sheryl van der Poel
- Independent Researcher, Geneva, Switzerland
- Population Council, Washington, DC, USA
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