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C-Channel Issue 10

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C-Channel header  June 2009

Dear Colleagues,

C-Channel 10, the monthly e-newsletter from C-Change, connects readers with current research findings in the peer-reviewed literature on social and behavior change communication in the health sector. Topics include family planning and reproductive health, HIV prevention, malaria, and maternal health and antenatal care—areas where C-Change is implementing programs and conducting research.

This month’s issue includes journal articles that examine the problems and concerns around the integration of family planning/reproductive health services with HIV prevention and treatment services and related communication issues. Articles look at vertical organization in government agencies and medical facilities that provide HIV and family planning services and the separate funding streams for these activities that limit coordination of such services; support for the reproductive rights of people with HIV; improving provision of PMTCT; the fertility-related needs of men and women living with HIV; linking VCT with contraceptive counseling, family planning services, and post-abortion care; and the reproductive health concerns of women on ART, some of whom desire children while others have unmet family planning needs. Of the final three articles, two look at HIV and AIDS and VCT and the third examines malaria and use of ITNs.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit www.c-changeprogram.org/c-channel


Family Planning/Reproductive Health and HIV/AIDS - Integration of Services

1. From effectiveness to impact: Contraception as an HIV prevention intervention

2. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: A prospective cohort study

3. Reproductive choice for women and men living with HIV: Contraception, abortion and fertility

4. HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

5. Post-abortion care and voluntary HIV counselling and testing—an example of integrating HIV prevention into reproductive health services

6. Sexual behavior, fertility desires and unmet need for family planning among home-based care clients and caregivers in Kenya

7. An evaluation of awareness: Attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV

 


HIV and AIDS

8. Influencing factors for seeking HIV voluntary counseling and testing among tuberculosis patients in Cambodia

9. Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention

 


Malaria

10. High retention and appropriate use of insecticide-treated nets distributed to HIV-affected households in Rakai, Uganda: Results from interviews and home visits

 


Family Planning/Reproductive Health and HIV/AIDS - Integration of Services

1. From effectiveness to impact: Contraception as an HIV prevention intervention

Authors: Wilcher, R; Petruney, T; Reynolds, HW; Cates, W
Source: Sexually Transmitted Infections Oct 2008, 84 Suppl 2:ii54-60.

ABSTRACT

BACKGROUND: Most efforts to date to prevent mother-to-child transmission of HIV have focused on provision of antiretroviral prophylaxis to HIV-infected pregnant women. Increasing voluntary contraceptive use has been an underused approach, despite clear evidence that preventing pregnancies in HIV-infected women who do not wish to become pregnant is an effective strategy for reducing HIV-positive births. This paper reviews international, country and service delivery level opportunities for and obstacles to translating contraceptive efficacy into interventions that will have an impact on the effectiveness of HIV prevention.

METHODS: The integration of family planning services and HIV programmes as a potential intervention were specifically reviewed.

RESULTS AND CONCLUSIONS: Despite substantial policy support for the integration of family planning and HIV programmes, burgeoning resources for HIV ignore the potential impact of contraception on HIV prevention. Moreover, separate funding for these two programmes and the resulting vertical organisation of health ministries and service facilities undermine coordination between departments and limit providers' ability to address the contraceptive needs of HIV-positive clients. Projects integrating family planning and HIV services are being implemented, allowing for documentation of factors that facilitate or impede integrated service delivery. However, few have been evaluated to demonstrate impact on contraceptive uptake and HIV-positive births averted.

To link to the website containing this article, click here.

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2. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: A prospective cohort study

Authors: Homsy, J; Bunnell, R; Moore, D; King, R; Malamba, S; Nakityo, R; Glidden, D; Tappero, J; Mermin, J
Source: PLoS ONE 8 Jan 2009, 4(1): e4149.

ABSTRACT

BACKGROUND: Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa.

METHODOLOGY /PRINCIPAL FINDINGS: Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women's desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p<0.0001). This was paralleled by an increase in the proportion of women reporting sexual activity in the past 3 months, from 24.4% at baseline to 32.5% over 24 months of follow-up (p = 0.001). Only 14% of women used permanent or semi-permanent family planning methods by their second year on ART. In the multivariate model, younger age (HR = 2.71 per 10-year decrease, 95% CI: 2.95-3.78), having a BMI>18.5 (HR = 1.09, CI: 1.01-1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02-3.13) were independently associated with pregnancy.

CONCLUSION/SIGNIFICANCE: Women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.

To link to the website containing this article, click here. Full Text is freely available.

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3. Reproductive choice for women and men living with HIV: Contraception, abortion and fertility

Authors: Delvaux, T; Nöstlinger, C
Source: Reproductive Health Matters May 2007, 15(29 Suppl): 46-66.

ABSTRACT

From a policy and programmatic point of view, this paper reviews the literature on the fertility-related needs of women and men living with HIV and how the entry points represented by family planning, sexually transmitted infection and HIV-related services can ensure access to contraception, abortion and fertility services for women and men living with HIV. Most contraceptive methods are safe and effective for HIV positive women and men. The existing range of contraceptive options should be available to people living with HIV, along with more information about and access to emergency contraception. Potential drug interaction must be considered between hormonal contraception and treatment for tuberculosis and certain antiretroviral drugs. Couples living with HIV who wish to use a permanent contraceptive method should have access to female sterilisation and vasectomy in an informed manner, free of coercion. How to promote condoms and dual protection and how to make them acceptable in long term-relationships remains a challenge. Both surgical and medical abortion are safe for women living with HIV. To reduce risk of vertical transmission of HIV and in cases of infertility, people with HIV should have access to sperm washing and other assisted conception methods, if these are available. Simple and cost-effective procedures to reduce risk of vertical transmission should be part of counselling for women and men living with HIV who intend to have children. Support for the reproductive rights of people with HIV is a priority. More operations research on best practices is needed.

To link to the website containing this article, click here.

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4. HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

Authors: Bradley, H; Bedada, A; Tsui, A; Brahmbhatt, H; Gillespie, D; Kidanu, A
Source: AIDS Care Jan 2008, 20(1): 61-71.

ABSTRACT

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.

To link to the website containing this article, click here.

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5. Post-abortion care and voluntary HIV counselling and testing—an example of integrating HIV prevention into reproductive health services

Authors: Rasch, V; Yambesi, F; Massawe, S
Source: Tropical Medicine and International Health May 2006, 11(5): 697-704.

SUMMARY

OBJECTIVE: To assess the acceptance and outcome of voluntary HIV counselling and testing (VCT) among women who had an unsafe abortion.

METHOD: 706 women were provided with post-abortion contraceptive service and offered VCT. We collected data on socioeconomic characteristics and contraceptive use and determined the HIV status of those who accepted VCT. Using a nested case-control design, we compared women who accepted HIV testing with women who did not. To study the association between socioeconomic factors, HIV testing acceptance and condom use in more detail, we did stratified analyses based on age and marital status.

RESULTS: 58% of the women who had an unsafe abortion accepted HIV testing. Women who earned an income were more likely to accept testing than housewives. Women who accepted testing were more likely to accept using a condom. The HIV prevalence rate was 19% among single women aged 20-24 years and 25% among single women aged 25-45 years.

CONCLUSION: HIV testing and condoms were accepted by most women who had an unsafe abortion. The poor reproductive health of these women could be improved by good post-abortion care that includes contraceptive counselling, VCT and condom promotion.

To link to the website containing this article, click here. Full Text is freely available.

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6. Sexual behavior, fertility desires and unmet need for family planning among home-based care clients and caregivers in Kenya

Authors: McCarraher, D; Cuthbertson, C; Kung'u, D; Otterness, C; Johnson, L; Magiri, G
Source: AIDS Care Oct 2008, 20(9): 1057-65.

ABSTRACT

As antiretroviral treatment becomes more available, community home-based care (CHBC) clients may begin to resume normal daily activities including the resumption of sexual relationships. This study examines sexual behavior, contraceptive use, unmet need for family planning and attitudes toward pregnancy in the context of HIV among CHBC participants (clients and caregivers), many of whom are HIV-positive or at risk for HIV, of the COPHIA project in Kenya. The COPHIA project was implemented by Pathfinder International with support from USAID/Kenya. We interviewed 171 CHBC clients and 183 CHBC caregivers and conducted four focus groups with caregivers. Data were collected from randomly selected COPHIA-affiliated CHBC programs in Western Province and in Nairobi between September and November 2004. Forty-four percent of clients and 55% of caregivers had been sexually active in the past six months. The reproductive health needs of this population are complex; a significant percentage of study participants have an unmet need for family planning and some desire more children. A small proportion of study participants were pregnant during the time of the interview. The majority of those who use contraception reported relying solely on the male condom to prevent pregnancy. While vital for HIV prevention and easily distributed by CHBC programs, the male condom is not as effective as other methods in preventing pregnancy. Community home-based care program participants need counseling related to contraception, fertility desires and pregnancy. The promotion of dual method use is crucial to this population. Besides referring participants to family planning services, CHBC programs need to consider how and if they can meet the family planning and other reproductive health needs of their participants.

To link to the website containing this article, click here.

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7. An evaluation of awareness: Attitudes and beliefs of pregnant Nigerian women toward voluntary counseling and testing for HIV

Authors: Okonkwo, KC; Reich, K; Alabi, AI; Umeike, N; Nachman, SA
Source: AIDS Patient Care and STDs April 2007, 21(4): 252-260.

The rate of HIV seroprevalence in Nigeria is troublesome because it is one of the highest prevalence rates worldwide. As in most developing countries, vertical transmission from mother to child accounts for most of the HIV infections in Nigerian children. The purpose of this study was to determine the awareness, attitudes, and beliefs of pregnant Nigerian women toward voluntary counseling and testing (VCT) for HIV. Two hundred forty pregnant women in Awka, Nigeria, completed questionnaires aimed at determining their willingness to accept or reject VCT. Furthermore, participants where questioned about their knowledge of HIV infection, routes of transmission, and treatment options. The majority of the women (87%) approved of VCT; of those who approved, 93% were aware that VCT could reduce the risk of transmission of HIV to their babies. All respondents who accepted VCT were willing to be tested if results remained confidential and 89% would accept if they were tested simultaneously with their partners. 69% of the women who refused VCT attribute their refusal to the social and cultural stigmatization associated with HIV. Overall, the acceptance of VCT appears to depend on the understanding that VCT has proven benefits for the unborn child. Sociocultural factors such as stigmatization of HIV-infected individuals appears to be the major barrier toward widespread acceptance of VCT in Nigeria, thus the development of innovative health education strategies is essential for providing women with information regarding the benefits of VCT and other means of prevention of mother-to-child transmission of HIV (PMTCT).

To link to the website containing this article, click here.

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HIV and AIDS

8. Influencing factors for seeking HIV voluntary counseling and testing among tuberculosis patients in Cambodia

Authors: Yi, S; Poudel, KC; Yasuoka, J; Ichikawa, M; Tan, V; Jimba, M
Source: AIDS Care Apr 2009, 21(4): 529-34.

We explored the factors influencing voluntary counseling and testing (VCT) utilization among tuberculosis patients attending two referral hospitals in Cambodia. We conducted face-to-face interviews using a structured questionnaire. We compared HIV/AIDS knowledge, HIV testing attitudes, risks for exposure to HIV, and AIDS stigma between VCT users and non-users. Compared to VCT non-users, VCT users had significantly higher risks for HIV and were more likely to have used condoms. Regarding stigma, VCT non-users demonstrated significantly greater AIDS stigmatizing beliefs compared to VCT users. To increase VCT utilization among TB patients, we need effective strategies to reduce AIDS stigma among them. Moreover, initiation of routine HIV testing in TB facilities might be another effective solution.

To link to the website containing this article, click here.

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9. Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention

Authors: Bwambale, FM; Ssali, SN; Byaruhanga, S; Kalyango, JN; Karamagi, CAS
Source: BMC Public Health 30 Jul 2008, 8:263.

ABSTRACT

BACKGROUND: Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV/AIDS in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. We therefore conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district.

METHODS: A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men.

RESULTS: Overall VCT use among men was 23.3% (95% CI 17.2-29.4). Forty six percent (95% CI 40.8-51.2) had pre-test counselling and 25.9% (95%CI 19.9-31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77-4.07), the non-subsistence farmers (OR = 2.37, 95%CI 2.37), the couple testing (OR = 2.37, 95%CI 1.02-8.83) and men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04-2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services.

CONCLUSION: VCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.

To link to the website containing this article, click here. Full Text is freely available.

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Malaria

10. High retention and appropriate use of insecticide-treated nets distributed to HIV-affected households in Rakai, Uganda: Results from interviews and home visits

Authors: Cohee, L; Mills, LA; Kagaayi, J; Jacobs, I; Galiwango, R; Ludigo, J; Ssekasanvu, J; Reynolds, SJ
Source: Malaria Journal 22 Apr 2009, 8(1):76.

ABSTRACT

BACKGROUND: Distribution of insecticide-treated nets (ITNs) has recently been incorporated into comprehensive care strategies for HIV-positive people in malaria-endemic areas. WHO now recommends free or low-cost distribution of ITNs to all persons in malaria-endemic areas, regardless of age, pregnancy and HIV status. Knowledge about and appropriate use of ITNs among HIV-positive ITN recipients and their household members has not been well characterized.

METHODS: 142 randomly selected adults were interviewed in July-August 2006 to assess knowledge, retention, and appropriate use of ITNs they had received through a PEPFAR-funded comprehensive HIV care programme in rural Uganda.

RESULTS: Among all participants, 102 (72%, CI: 65%-79%) reported they had no ITNs except those provided by the programme. Of 131 participants who stated they were given [greater than or equal to]1 ITN, 128 (98%, CI: 96%-100%) stated they still possessed at least one programme-provided ITN. Reported programme-ITN (pITN) use by participants was high: 119 participants (91%, CI: 86%-96%) reported having slept under pITN the night prior to the survey and 115 (88%, CI: 82%-94%) reported sleeping under pITN seven days per week. Being away from home and heat were the most common reasons given for not sleeping under an ITN. A sub-study of thirteen random home visits demonstrated concordance between participants' survey reports and actual use of ITNs in homes.

CONCLUSIONS: There was excellent self-reported retention and appropriate use of ITNs distributed as a part of a community-based outpatient HIV care programme. Participants perceived ITNs as useful and were unlikely to have received ITNs from other sources.

To link to the website containing this article, click here. Full Text is freely available.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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