Date Published: May 2, 2013
Publisher: Hindawi Publishing Corporation
Author(s): Sara J. Newmann, Kavita Mishra, Maricianah Onono, Elizabeth A. Bukusi, Craig R. Cohen, Olivia Gage, Rose Odeny, Katie D. Schwartz, Daniel Grossman.
Objective. To inform an intervention integrating family planning into HIV care, family planning (FP) knowledge, attitudes and practices, and perspectives on integrating FP into HIV care were assessed among healthcare providers in Nyanza Province, Kenya. Methods. Thirty-one mixed-method, structured interviews were conducted among a purposive sample of healthcare workers (HCWs) from 13 government HIV care facilities in Nyanza Province. Structured questions and case scenarios assessed contraceptive knowledge, training, and FP provision experience. Open-ended questions explored perspectives on integration. Data were analyzed descriptively and qualitatively. Results. Of the 31 HCWs interviewed, 45% reported previous FP training. Few providers thought long-acting methods were safe for HIV-positive women (19% viewed depot medroxyprogesterone acetate as safe and 36% viewed implants and intrauterine contraceptives as safe); fewer felt comfortable recommending them to HIV-positive women. Overall, providers supported HIV and family planning integration, yet several potential barriers were identified including misunderstandings about contraceptive safety, gendered power differentials relating to fertility decisions, staff shortages, lack of FP training, and contraceptive shortages. Conclusions. These findings suggest the importance of considering issues such as patient flow, provider burden, commodity supply, gender and cultural issues affecting FP use, and provider training in FP/HIV when designing integrated FP/HIV services in high HIV prevalence areas.
Unmet need for contraception and unintended pregnancy are prevalent among the estimated 13 million HIV-positive women in sub-Saharan Africa [1–3]. Unintended pregnancies account for 14–58% of all births in countries where the burden of HIV is the greatest . In South Africa, a recent cohort study of women attending antiretroviral (ART) clinics found that 62% of pregnancies were unintended , while a cross-sectional study of pregnant women obtaining services for prevention of mother-to-child transmission (PMTCT) reported that 84% of pregnancies were unintended . In a cohort of Ugandan women starting ART, 17% became pregnant over the two-year follow-up period, despite 93% not wanting or planning pregnancy .
We conducted a mixed-method study between November 2007 and October 2008 at thirteen government-run HIV care and treatment clinics “patient support centers” in the Migori, Rongo, and Suba districts of Nyanza Province, Kenya. The study sites selected were supported by Family AIDS Care and Education Services (FACES), a collaboration between the University of California San Francisco (UCSF) and the Kenyan Medical Research Institute (KEMRI). FACES provides training, clinical mentorship, and logistical support for public sector HIV care and treatment clinics in these districts in western Kenya .
Similar to other studies from sub-Saharan Africa [26, 27], we found that the majority of providers viewed pregnancy as a basic right for people living with HIV. However, they reported in their experience that HIV-positive women more commonly wanted to limit or end childbearing rather than conceive. They stated that HIV-positive people should have access to all contraceptives. Providers were enthusiastic about integrating family planning into HIV care and felt integration could improve access to contraception and reduce stigma related to both family planning and HIV. However, we found that the providers interviewed had extremely limited knowledge and uncertainty about the safety of contraceptive methods, hormonal and nonhormonal, and whether or not to recommend contraception to people living with HIV. Our study findings portray the enthusiasm and hypothetical acceptability among HIV providers for FP/HIV integration. Our findings also reveal the dire need to comprehensively educate HIV providers about the safety of FP methods with respect to HIV and to increase their ability to incorporate sensitivity to complex gendered power differentials that influence contraceptive choice and use into their counseling. These data informed the development of the FP/HIV intervention in Nyanza, Kenya, used in the cluster randomized trial which is now being used as a model to guide national integration efforts in Kenya and will be useful in similar resource-poor settings in sub-Saharan Africa.