A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural Zambia

• Type of Material: Article
• Authors: Kalonde Malama, Aix Marseille Univ; William Kilembe, Emory University; Mubiana Inambao, Emory University; Alexandra Hoagland, Emory University; Tyronza Sharkey, Emory University; Rachel Parker, Emory University; Kristin Wall, Emory University; Amanda Tichacek, Emory University; Supriya Sarkar, Emory University; Bellington Vwalika, University of Zambia; Lisa Haddad, Emory University; Elwyn Chomba, Minist Hlth; Susan Allen, Emory University
• Language: English
• Date: 2020-04-01
• Publisher: MOSBY-ELSEVIER
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2020 Elsevier Inc. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.ajog.2020.01.007
• Title of Journal or Parent Work: AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
• Volume: 222
• Issue: 4
• Start Page: S915.e1
• End Page: S915.e10
• Grant/Funding Information: The work presented in this document was funded by the UK Department for International Development. Additional support was provided from the National Institute of Child Health and Development (NICHD R01 HD40125); National Institute of Mental Health (NIMH R01 66767; K01 MH107320); the AIDS International Training and Research Program Fogarty International Center (D43 TW001042); the Emory Center for AIDS Research (P30 AI050409); National Institute of Allergy and Infectious Diseases (NIAID R01 AI51231; NIAID R01 AI64060; NIAID R37 AI51231); and the International AIDS Vaccine Initiative. The contents do not necessarily reflect the views of the United States Government. The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
• Keywords: family planning; Science & Technology; DISCORDANT COUPLES; FEASIBILITY; IMPACT; Life Sciences & Biomedicine; Zambia; HIV; Obstetrics & Gynecology; CARE; ACCEPTABILITY; FAMILY-PLANNING-SERVICES; RWANDA; unplanned pregnancy prevention; long-acting reversible contraceptives

Abstract

Background: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. Objective: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. Study Design: A 3 year program (2013–2016) progressively integrated the promotion and provision of couples’ voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples’ family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. Results: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). Conclusion: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.