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C-Channel Issue 13

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C-Channel header  October 2009

Dear Colleagues,

C-Channel No. 13, the monthly e-newsletter from C-Change, connects readers to current research findings in the peer-reviewed literature on social and behavior change communication (SBCC) in the health sector, particularly in the areas of family planning and reproductive health, HIV prevention and care, malaria prevention, antenatal care, maternal health, and gender norms. C‑Change implements programs and conducts research in Africa, Asia, and Eastern Europe on SBCC in these health areas.

C-Channel No. 13 highlights research on SBCC around the integration of family planning and reproductive health programs with HIV and AIDS programs. Articles cover research carried out in Argentina, India, Mozambique, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe.

Visit the C-Change website for information about how C-Change is using social and behavior change communication to address HIV prevention, to prevent malaria transmission, and to assist women and couples to make informed choices about modern and traditional contraceptive methods.

Thank you,
The Knowledge Management Team at C-Change


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


HIV and AIDS, FAMILY PLANNING and REPRODUCTIVE HEALTH

1. Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa

2. Knowledge, use, and concerns about contraceptive methods among sero-discordant couples in Rwanda and Zambia

3. Potential of dual-use policies to meet family planning and HIV prevention needs: A case study of Zimbabwe and Mozambique

4. Repeated pregnancy among women with known HIV status in Pune, India

5. The virus stops with me: HIV-infected Ugandans' motivations in preventing HIV transmission

6. The influence of motivational messages on future planning behaviors among HIV concordant positive and discordant couples in Lusaka, Zambia

7. Manifestations and reduction strategies of stigma and discrimination on people living with HIV/AIDS in Tanzania

8. Missed opportunities to address reproductive health care needs among HIV-infected women in antiretroviral therapy programmes

9. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases

10. The reproductive needs and rights of people living with HIV in Argentina: Health service users' and providers' perspectives

11. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

OTHER RESOURCES

To view the video Silent Partner and learn about the issues around HIV within marriage in sub-Saharan Africa, please click here. The video, prepared by Population Action International, was filmed in Kenya and specifically addresses the challenges faced by married women whose sexual and reproductive rights are restricted due to gender and societal norms. The length of the video is 12 minutes.
 


HIV and AIDS, FAMILY PLANNING and REPRODUCTIVE HEALTH

1. Policy maker and health care provider perspectives on reproductive decision-making amongst HIV-infected individuals in South Africa

Authors: Harries J; Cooper D; Myer L; Bracken H; Zweigenthal V; Orner P
Institution: Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Source: BMC Public Health 5 Oct 2007; 7:282.

ABSTRACT

BACKGROUND: Worldwide there is growing attention paid to the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-infected women continue to desire children despite knowledge of their HIV status. Despite the increasing attention to the health care needs of HIV-infected individuals in low resource settings, little attention has been given to reproductive choice and intentions. Health care providers play a crucial role in determining access to reproductive health services and their influence is likely to be heightened in delivering services to HIV-infected women. We examined the attitudes of health care policy makers and providers towards reproductive decision-making among HIV-infected individuals.

METHODS: In-depth interviews were conducted with 14 health care providers at two public sector health care facilities located in Cape Town, South Africa. In addition, 12 in-depth interviews with public sector policy makers and managers, and managers within HIV/AIDS and reproductive health NGOs were conducted. Data were analyzed using a grounded theory approach.

RESULTS: Providers and policy makers approached the issues related to being HIV-infected and child bearing differently. Biomedical considerations were paramount in providers' approaches to HIV infection and reproductive decision-making, whereas, policy makers approached the issues more broadly recognizing the structural constraints that inform the provision of reproductive health care services and the possibility of "choice" for HIV-infected individuals.

CONCLUSION: The findings highlight the diversity of perspectives among policy makers and providers regarding the reproductive decisions taken by HIV-infected people. There is a clear need for more explicit policies recognizing the reproductive rights and choices of HIV-infected individuals.

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2. Knowledge, use, and concerns about contraceptive methods among sero-discordant couples in Rwanda and Zambia

Authors: Grabbe K; Stephenson R; Vwalika B; Ahmed Y; Vwalika C; Chomba E; Karita E; Kayitenkore K; Tichacek A; Allen S
Institution: Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
Source: J Womens Health Sept 2009; 18(9): 1449-56.

ABSTRACT

OBJECTIVE: The unique needs of sero-discordant couples are largely missing from many current family planning efforts, which focus on the prevention of pregnancies in absence of the reduction of the risk of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). Conversely, HIV testing and programs focus exclusively on condom use without discussion of more effective contraceptive methods. In order to provide information to inform the development of family planning services tailored to the unique needs of sero-discordant couples, this study examined the contraceptive knowledge, use, and concerns among sero-discordant couples in urban Rwanda and Zambia.

METHODS: This article presents a comparison of family planning knowledge, use, and concerns about contraception among two cohorts of HIV sero-discordant study participants in Rwanda and Zambia.

RESULTS: The results reveal an interesting profile of contraceptive knowledge and use among sero-discordant couples; in both settings, despite high levels of knowledge of contraception, use of contraceptive methods remains relatively low. There is a clear gender difference in both the reporting of knowledge and use of contraceptive methods, and there is evidence of clandestine contraceptive use by women.

CONCLUSIONS: Including information on family planning in voluntary counseling and testing (VCT) services in addition to tailoring the delivery of family planning information to meet to needs and concerns of HIV-positive women or those with HIV positive partners is an essential step in the delivery of services and prevention efforts to reduce the transmission of HIV. Family planning and HIV prevention programs should integrate counseling on "dual method use," combining condoms for HIV/STI prevention with a long-acting contraceptive for added protection against unplanned pregnancy.

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3. Potential of dual-use policies to meet family planning and HIV prevention needs: A case study of Zimbabwe and Mozambique

Authors: Prata N; Sreenivas A; Bellows B
Institution: School of Public Health, University of California, Berkeley, CA
Source Journal of Family Planning and Reproductive Health Care Oct 2008; 34(4): 219-26.

ABSTRACT

BACKGROUND AND METHODOLOGY: The fight against the HIV epidemic in many high-prevalence countries is a struggle to motivate culturally relevant risk reduction in general populations that have been educated to associate HIV risk with commercial sex, injection drug use and other stigmatised behaviours. Common concurrent partnerships, which facilitate transmission of HIV in many high-prevalence countries, are only beginning to receive the attention they deserve. This has made the promotion of dual-use methods, such as condoms, for individuals who require both HIV protection and contraception very difficult. Recent research on concurrent partnerships and the implications for high HIV risk in sexually networked but sexually modest general populations is forcing another assessment of the response to HIV. In the light of the epidemic, it is important to better understand which policies will better meet HIV prevention and family planning (FP) needs. This article explores the potential of dual-use policies by examining Zimbabwe and Mozambique.

RESULTS: Zimbabwe, with a vertically driven, stronger FP programme predating the HIV epidemic, has not yet seen an increase in condom use to the level desired by their moderately strong HIV prevention programme - one that has adopted a primarily single-use condom policy. Mozambique, however, continues to have a much weaker FP programme, but is witnessing a significant increase in condom use driven by their strong HIV programme - one that is further integrated with FP content.

DISCUSSION: Integration of HIV and FP programmes has the potential to meet the need for HIV and pregnancy prevention more efficiently. By themselves, these programmes are unable to meet the need for condoms. The poorest of the poor are feeling the brunt of this inadequacy. Countries such as Zimbabwe and Mozambique have the potential to tremendously improve their efforts in increasing condom use. We suggest that thoughtful and detailed integration of HIV and FP programmes will work synergistically to reach common goals. Until a more promising method besides condoms is commercially available for protection against unintended pregnancy and sexually transmitted infections such as HIV, effective strategies must include dual-use policies as well as counselling on all available contraceptive methods so that women can maximise the benefits of mixing methods.

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4. Repeated pregnancy among women with known HIV status in Pune, India

Authors: Suryavanshi N; Erande A; Pisal H; Shankar AV; Bhosale RA; Bollinger RC; Phadke M; Sastry J
Institution: Byramjee Jeejeebhoy Medical College-MIT Study, Pune, India
Source: AIDS Care Oct 2008; 20(9): 1111-8. [PubMed]

ABSTRACT

HIV-positive women of reproductive age face challenges in decision making related to pregnancy. Understanding factors influencing repeat pregnancies in women with known HIV status are necessary to guide interventions and counseling strategies to better inform and support them. We compared three groups of women attending a large antenatal clinic in Pune, India. They include: Group A--63 HIV-positive women coming for care for a repeat pregnancy after being diagnosed in a previous pregnancy; Group B--64 HIV-negative (repeat) pregnant women attending this antenatal clinic; and Group C--63 HIV-positive non-pregnant women currently enrolled in an ongoing clinical trial. Comparisons of Group A and B indicate that the likelihood of unplanned repeat pregnancies was significantly higher in HIV-positive (70%) than HIV-negative (36%) women (OR=4.1, CI: 2.0-8.7). Inability to terminate the pregnancy (31%) and familial obligations (40%) appear to be important for continuing the unplanned repeat pregnancy. Despite high reported contraceptive use by HIV-positive women, pregnancies still occurred. Death of their youngest child is an important factor as 21% of HIV-positive pregnant women lost their youngest child compared with 3% of HIV-negative women and 3% of HIV-positive non-pregnant women (p<0.001). Repeat pregnancies were more likely to occur for women who did not disclose their HIV status to their spouse. Thus the majority of the repeat pregnancies for HIV-positive women were both unplanned and unwanted.

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5. The virus stops with me: HIV-infected Ugandans' motivations in preventing HIV transmission 

Authors: King R; Lifshay J; Nakayiwa S; Katuntu D; Lindkvist P; Bunnell R
Institution: CDC-Uganda, Entebbe, Uganda
Source: Social Science and Medicine Feb 2009; 68(4): 749-57.

ABSTRACT

Few Positive Prevention interventions have been implemented in Africa; however, greater attention is now being paid to interventions that include messages of personal responsibility or altruism that may motivate HIV-infected individuals towards HIV prevention behaviors in Africa. We conducted 47 in-depth interviews in 2004 with HIV-infected men and women purposefully sampled to represent a range of sexual activities among clients of an AIDS support organization in Uganda. Qualitative interviews were selected from a cross-sectional survey of 1092 HIV-infected men and women. Clients were interviewed about their concerns around sexual HIV transmission, feelings of responsibility and reasons for these feelings, as well as about the challenges and consequences of actions to prevent HIV transmission. The reasons they provided for their sense of prevention responsibility revolved around ethical and practical themes. Responsibility toward sexual partners was linked to the belief that conscious transmission of HIV equals murder, would cause physical and emotional harm, and would leave children orphaned. The primary reason specific to preventing HIV transmission to unborn children was the perception that they are 'innocent'. Most participants felt that HIV-infected individuals held a greater responsibility for preventing HIV transmission than did HIV-uninfected individuals. Respondents reported that their sense of responsibility lead them to reduce HIV transmission risk, encourage partner testing, disclose HIV test results, and assume an HIV/AIDS educator role. Challenges to HIV preventive behavior and altruistic intentions included: sexual desire; inconsistent condom use, especially in long term relationships; myths around condom use; fear of disclosure; gender-power dynamics; and social and financial pressure. Our finding that altruism played an important role in motivating preventive behaviors among HIV-infected persons in Uganda supports the inclusion of altruistic prevention and counseling messages within Positive Prevention interventions.

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6. The influence of motivational messages on future planning behaviors among HIV concordant positive and discordant couples in Lusaka, Zambia

Authors: Stephenson R; Mendenhall E; Muzizi L; Vwalika B; Chomba E; Ahmed Y; Clark L; Roth D; Telfair J; Haworth A; Allen S
Institution: Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
Source: AIDS Care Feb 2008; 20(2): 150-60. [PubMed]

ABSTRACT

In Zambia the HIV/AIDS epidemic has resulted in many single female-headed households. Strong patriarchal laws and customs prevent widows and children from maintaining economic assets. This study examines the impact of a video-based motivational intervention promoting future planning in 1,504 HIV-infected couples in Lusaka, Zambia. Following a group video session, couples randomized to the motivational arm could choose to write a will, identify a guardian for their children and make financial plans. Desirable behaviours modelled in the motivational video were measured at quarterly intervals for a year and compared in intervention and control arms. Demographic measures including age, income and educational status were not associated with planning behaviours. Participation in the intervention was associated with will writing (23% versus 5%) and naming a guardian (32% versus 17%) but not with other planning behaviours. The study demonstrates the ability of motivational messages integrated into HIV VCT to encourage future planning behaviour and points to the need to expand existing HIV and VCT services to meet other non-health needs of those living with HIV.

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7. Manifestations and reduction strategies of stigma and discrimination on people living with HIV/AIDS in Tanzania

Authors: Mutalemwa P; Kisoka W; Nyigo V; Barongo V; Malecela MN; Kisinza WN
Institution: National Institute for Medical Research, Dar es Salaam, Tanzania
Source: Tanzania Journal of Health Research Oct 2008; 10(4): 220-5.

ABSTRACT

HIV/AIDS-related stigma, and its associated discrimination, is known to negatively affect all aspects of HIV prevention, care and treatment. Studies have revealed the extent to which individuals are stigmatized and discriminated against the health care system. However, there has been limited information on stigma manifestations and reduction interventions. The main objective of the study was to determine the magnitude and factors influencing HIV/AIDS-related stigma and discrimination with a specific focus on the manifestations and reduction interventions. In-depth interviews, exit interviews and focus group discussions were deployed in the study. Results have shown that HIV/AIDS is increasingly conceptualized as a continuum between prevention and care, effects of stigma and discrimination are from both health facilities and communities. While religious leaders isolate people living with HIV/AIDS (PLWHAs) and consider them as most promiscuous, health workers also have strong negative attitudes and feelings and as a result PLWHAs refrain from counselling and testing services. A stigmatizing social environment was found to pose barriers to all strategies and/or interventions that are aimed at reducing this situation. Because of stigma and discrimination, people living with HIV/AIDS receive inadequate treatment, as such they decline to divulge their status to partners or change their behaviour avoiding depressing reactions. Basing on that therefore, adequate outreach services at both community and health facility levels be established and line up in the fight against stigma and discrimination facing people living with HIV/AIDS.

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8. Missed opportunities to address reproductive health care needs among HIV-infected women in antiretroviral therapy programmes

Authors: Myer L; Rebe K; Morroni C
Institution: Infectious Diseases Epidemiology Unit, School of Public Health & Family Medicine, University of Cape Town, South Africa
Source: Tropical Medicine and International Health Dec 2007; 12(12): 1484-9.

ABSTRACT

OBJECTIVES: To investigate the delivery of reproductive health care services in an antiretroviral therapy (ART) programme in Cape Town, South Africa.

METHODS: A cross-sectional survey was conducted among 227 consecutive women attending a hospital-based ART outpatient service who had been on ART for at least one month. Semi-structured interviews investigating reproductive health issues and services received were conducted in participants' home language by a trained interviewer.

RESULTS: Sixty-seven per cent of the women were younger than 30 years and 75% were sexually active. The use of both condoms (70%) and hormonal contraceptives (31%) decreased with age, while the prevalence of sterilization (13%) increased with age. Few women knew about emergency contraception (EC) (7%) or termination of pregnancy (TOP) (13%). Approximately 45% of women had had a Papanicolau smear, and this was constant across all age groups. One in 10 women had experienced verbal or physical abuse by an intimate partner since their HIV diagnosis. More than 80% of women had discussed the use of condoms and other forms of contraception with a health care provider since their HIV diagnosis, but less than 5% had discussed EC or TOP, and no woman had discussed issues of partner violence. Discussion These data delineate the large unmet need for reproductive health services among HIV-infected women receiving ART in this setting. While issues related to condom and contraceptive use are relatively well addressed, reproductive health services related to unintended pregnancy and partner violence appear to be neglected. The integration of a broad range of reproductive health services into ART programmes requires urgent attention in both research and policy-making circles.

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9. Empowering sex workers in India to reduce vulnerability to HIV and sexually transmitted diseases

Authors: Swendeman D; Basu I; Das S; Jana S; Rotheram-Borus MJ
Institution: Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles
Source: Social Science and Medicine Oct 2009; 69(8): 1157-66.

ABSTRACT

The Sonagachi Project was initiated in Kolkata, India in 1992 as a STD/HIV intervention for sex workers. The project evolved to adopt strategies common to women's empowerment programs globally (i.e., community mobilization, rights-based framing, advocacy, micro-finance) to address common factors that support effective, evidence-based HIV/STD prevention. The Sonagachi model is now a broadly diffused evidence-based empowerment program. We previously demonstrated significant condom use increases among female sex workers in a 16 month replication trial of the Sonagachi empowerment intervention (n=110) compared to a control community (n=106) receiving standard care of STD clinic, condom promotion, and peer education in two randomly assigned rural towns in West Bengal, India (Basu et al., 2004). This article examines the intervention's impacts on 21 measured variables reflecting five common factors of effective HIV/STD prevention programs to estimate the impact of empowerment strategies on HIV/STD prevention program goals. The intervention which was conducted in 2000-2001 significantly: 1) improved knowledge of STDs and condom protection from STD and HIV, and maintained STD/HIV risk perceptions despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This study's results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs.

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10. The reproductive needs and rights of people living with HIV in Argentina: Health service users' and providers' perspectives

Authors: Gogna ML; Pecheny MM; Ibarlucía I; Manzelli H; López SB
Institution: CEDES, Center for the Study of State and Society and CONICET (National Research Council) Sánchez, Health, Economy and Society, Buenos Aires, Argentina
Source: Social Science and Medicine Sept 2009; 69(6): 813-20.

ABSTRACT

This article focuses on the contraceptive and reproductive experiences and needs of people living with HIV and on public health services' responses to them in Argentina. Data collected through a national survey amongst people living with HIV (N=841) and semi-structured interviews (N=89) explored the perspectives of both health-care users and HIV/AIDS program coordinators and providers. The survey revealed that 55% of women and 30% of men had had children after their HIV diagnosis and that half of those pregnancies had been unintended. At the time of the survey in 2006, 73% of men and 64% of women did not want a (new) pregnancy. The vast majority report systematic condom use, but acknowledge difficulties complying with this recommendation. Dual protection (i.e., condom use plus another method) is low among those who do not want children or another pregnancy (8% of women and 9% of men reported using it). Mostly women and heterosexual men without children either expressed their wish or were seeking to be parents. Institutional and cultural barriers to friendly and/or effective contraceptive and reproductive counselling were identified. Most physicians encourage only condom use while a minority refers patients to family planning providers or talk with them about contraception. A lack of updated information about interactions between antiretroviral drugs and hormonal contraception and/or intrauterine devices was not infrequent among providers. Users reported having being discouraged or blamed by health professionals when they revealed they wanted to have (or were expecting) a baby. Professionals and program directors' attitudes regarding reproduction range from not acknowledging people's wishes, to providing useful information or referral. Whether wanted or unexpected, parenthood is a challenge for many of the people living with HIV. Social and biomedical responses still need to be refined in order to fully respect people's rights and succeed in preventing (re)infection as well as unwanted pregnancies. Drawing on study results, recommendations to enhance the provision of adequate information and services to help people prevent unwanted pregnancies or reproduce as safely as possible are discussed.

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11. Couple-centred testing and counselling for HIV serodiscordant heterosexual couples in sub-Saharan Africa

Authors: Desgrées-du-Loû A; Orne-Gliemann J
Institution: Institut de Recherche pour le Développement, Centre Population Développement (CEPED), Paris, France
Source: Reproductive Health Matters Nov 2008; 16(32): 151-61.

ABSTRACT

In Africa, a large proportion of HIV infections occur within stable relationships, either because of prior infection of one of the partners or because of infidelity. In five African countries at least two-thirds of couples with at least one HIV-positive partner were HIV serodiscordant; in half of them, the woman was the HIV-positive partner. Hence, there is an urgent need to define strategies to prevent HIV transmission within couple relationships. HIV counselling and testing have largely been organised on an individual and sex-specific basis, for pregnant women in programmes for prevention of mother-to-child transmission of HIV and in STI consultations and recently male circumcision for men. A couple-centred approach to HIV counselling and testing would facilitate communication about HIV status and adoption of preventive behaviours within couples. This paper reviews what is known about HIV serodiscordance in heterosexual couples in sub-Saharan Africa and what has been published about couple-centred initiatives for HIV counselling and testing since the early 1990s. Despite positive outcomes, couple-oriented programmes have not been implemented on a large scale. In order to stimulate and strengthen HIV prevention efforts, increased attention is required to promote prevention and testing and counselling for couples in stable relationships.

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