Barbara Nattabi

A Systematic Review of Factors Influencing Fertility Desires and Intentions Among People Living with HIV/AIDS: Implications for Policy and Service Delivery

With availability of antiretroviral treatments, HIV is increasingly recognised as a chronic disease people live with for many years. This paper critically reviews the current literature on fertility desires and reproductive intentions among people living with HIV/AIDS (PLHIV) and critiques the theoretical frameworks and methodologies used. A systematic review was conducted using electronic databases: ISI Web of Knowledge, Science Direct, Proquest, Jstor and CINAHL for articles published between 1990 and 2008. The search terms used were fertility desire, pregnancy, HIV, reproductive decision making, reproductive intentions, motherhood, fatherhood and parenthood. Twenty-nine studies were reviewed. Fertility desires were influenced by a myriad of demographic, health, stigma-associated and psychosocial factors. Cultural factors were also important, particularly in Sub-Saharan Africa and Asia. Future research that examines fertility desires among PLHIV should include cultural beliefs and practices in the theoretical framework in order to provide a holistic understanding and to enable development of services that meet the reproductive needs of PLHIV.

Investigating factors associated with uptake of HIV voluntary counselling and testing among pregnant women living in North Uganda

Abstract We investigated factors potentially associated with the uptake of HIV voluntary counselling and testing (VCT), which is the first step in acceding to programmes for the prevention of mother-to-child transmission of HIV infection. For the period 2001–2003, we estimated the VCT uptake among the 12,252 first-time attendees of the Antenatal Clinic (ANC) at Lacor Hospital (Gulu District, North Uganda). Associations between VCT uptake and socio-demographic characteristics and reproductive history were evaluated using log binomial regression models. VCT uptake was 55.6% for the overall study period; it increased from 51.0% in 2001 to 58.6% in 2002 and 57.7% in 2003 (P <0.001). Having some education [primary versus none, adjusted prevalence proportion ratio (PPR) =1.05, 95% confidence intervals (CI): 1.00–1.10] and being unmarried (cohabitating, PPR =1.07, 95% CI: 1.03–1.10; single/widowed/divorced, PPR =1.10, 95% CI: 1.03–1.18) were significantly associated with VCT uptake. Associations of borderline significance were found for: recent change of residence, having a partner with a modern occupation, and past use of contraceptives. VCT uptake is still low in this district of North Uganda. Although some socio-demographic factors were found to have been associated with uptake, the associations were weak and not of public-health significance.

Differences in fertility by HIV serostatus and adjusted HIV prevalence data from an antenatal clinic in northern Uganda.

Objectives  To estimate differences in fertility by HIV serostatus and to validate an adjustment method for estimating the HIV prevalence in the general female population using data from an antenatal clinic.

Using prevalence data from the programme for the prevention of mother-to-child-transmission for HIV-1 surveillance in North Uganda

Objectives:To validate the use of data from a programme for the prevention of mother-to-child transmission (PMTCT) in estimating HIV-1 prevalence in North Uganda. Methods:The study was conducted at St. Marys Hospital Lacor. We compared the estimated prevalence for 3580 attendees at the antenatal clinic who were selected for anonymous surveillance to that for 6785 pregnant women who agreed to undergo voluntary counselling and testing (VCT) for enrolment in the PMTCT programme. Log-binomial regression models were used to identify the factors associated with both VCT uptake and HIV-1 infection, which could bias the prevalence estimates based on PMTCT data. Results:In 2001–2003, the age-standardized prevalence was similar (11.1% in the anonymous surveillance group and 10.9% in the VCT group). The estimates were also similar when compared for each year tested. Analogously, no important differences were observed in age-specific prevalence. Of the factors associated with HIV-1 infection, only time of residence at current address [prevalence proportion ratio (PPR) = 1.05; 95% confidence interval (CI), 1.00–1.10], marital status (PPR = 1.05; 95% CI, 1.01–1.10) and partners occupation (PPR = 1.05; 95% CI, 1.01–1.10) were associated with VCT uptake, yet the associations were weak. Conclusions:The prevalence estimated based on the VCT data collected as part of the PMTCT programme could be used for HIV-1 surveillance in North Uganda. At the national level, however, it needs to be evaluated whether PMTCT data could replace, or instead be combined with, the data from sentinel surveillance.

Estimating HIV prevalence and the impact of HIV/AIDS on a Ugandan hospital by combining serosurvey data and hospital discharge records.

Objective To estimate the disease-specific HIV prevalence in a northern Ugandan hospital and to evaluate the impact of HIV/AIDS on hospital services. Design HIV serosurvey and analysis of routinely compiled hospital records. Methods The serosurvey was conducted among all 352 patients admitted to the medical ward of the Lacor Hospital in March 1999 (this ward consists of 3 units: general medicine, tuberculosis, and cancer). The impact on hospital services was estimated using the hospital discharge records for all 3447 patients admitted in 1999, in combination with serosurvey data, and was expressed as the percentage of bed-days attributable to HIV-positive patients. Results The overall HIV prevalence was 42.0% (52.6, 44.6, and 13.2% in the general medicine, tuberculosis, and cancer units, respectively). The disease-specific prevalence ranged from 45–65% for patients with tuberculosis, pneumonia, malaria, and enteritis. HIV-positive patients, compared with HIV-negative patients, had a higher in-hospital mortality (14.6 vs. 3.0%) and a lower average length of stay (41.4 vs. 48.9 days). AIDS cases accounted for 5.0% of hospital admissions, 4.1% of bed-days, and 11.5% of deaths. When considering all HIV-positive patients, these accounted for 37.2% of the bed-days. Conclusions Knowledge of disease-specific HIV prevalence and of the patterns of HIV-related diseases is crucial for early case management. The impact of HIV-positive patients on hospital services is quite high, accounting for >1/3 of the bed-days in 1999. Providing a continuum of care through inpatient, outpatient, and outreach home care services probably represents the only means of relieving the pressure on overloaded hospitals.

Factors Associated With Perceived Stigma Among People Living With HIV/AIDS in Post-Conflict Northern Uganda

HIV-related stigma continues to persist in several African countries including Uganda. This study quantified the burden of stigma and examined factors associated with stigma among 476 people living with HIV (PLHTV) in Gulu, northern Uganda. Data were collected between February and May 2009 using the HIV/AIDS Stigma Instrument-PLWA. Females more than males, respondents aged above 30 years, and those who had been on antiretroviral therapy for a longer time experienced higher levels of stigma. Verbal abuse and negative self-perception were more common forms of stigma. The association between antiretroviral therapy and stigma suggested that organizational aspects of antiretroviral delivery may lead to stigmatization of PLHIV. Interventions such as counseling of PLHIV, education of health workers and the community would lead to reductions in negative self-perception and verbal abuse and in turn improve the quality of life for PLHIV in northern Uganda.

Between a rock and a hard place: stigma and the desire to have children among people living with HIV in northern Uganda

HIV‐related stigma, among other factors, has been shown to have an impact on the desire to have children among people living with HIV (PLHIV). Our objective was to explore the experiences of HIV‐related stigma among PLHIV in post‐conflict northern Uganda, a region of high HIV prevalence, high infant and child mortality and low contraception use, and to describe how stigma affected the desires of PLHIV to have children in the future.

'I could never have learned this in a lecture': transformative learning in rural health education

Health indicators for rural populations in Australia continue to lag behind those of urban populations and particularly for Indigenous populations who make up a large proportion of people living in rural and remote Australia. Preparation of health practitioners who are adequately prepared to face the ‘messy swamps’ of rural health practice is a growing challenge. This paper examines the process of learning among health science students from several health disciplines from five Western Australian universities during ‘Country Week’: a one-week intensive experiential interprofessional education program in rural Western Australia. The paper weaves together strands of transformative theory of learning with findings from staff and student reflections from Country Week to explore how facilitated learning in situ can work to produce practitioners better prepared for rural health practice.

Wide variation in sexually transmitted infection testing and counselling at Aboriginal primary health care centres in Australia: analysis of longitudinal continuous quality improvement data

BackgroundChlamydia, gonorrhoea and syphilis are readily treatable sexually transmitted infections (STIs) which continue to occur at high rates in Australia, particularly among Aboriginal Australians. This study aimed to: explore the extent of variation in delivery of recommended STI screening investigations and counselling within Aboriginal primary health care (PHC) centres; identify the factors associated with variation in screening practices; and determine if provision of STI testing and counselling increased with participation in continuous quality improvement (CQI).MethodsPreventive health audits (n = 16,086) were conducted at 137 Aboriginal PHC centres participating in the Audit and Best Practice for Chronic Disease Program, 2005–2014. STI testing and counselling data were analysed to determine levels of variation in chlamydia, syphilis and gonorrhoea testing and sexual health discussions. Multilevel logistic regression was used to determine factors associated with higher levels of STI-related service delivery and to quantify variation attributable to health centre and client characteristics.ResultsSignificant variation in STI testing and counselling exists among Aboriginal PHC centres with health centre factors accounting for 43% of variation between health centres and jurisdictions. Health centre factors independently associated with higher levels of STI testing and counselling included provision of an adult health check (odds ratio (OR) 3.40; 95% Confidence Interval (CI) 3.07-3.77) and having conducted 1–2 cycles of CQI (OR 1.34; 95% CI 1.16-1.55). Client factors associated with higher levels of STI testing and counselling were being female (OR 1.45; 95% CI 1.33-1.57), Aboriginal (OR 1.46; 95% CI 1.15-1.84) and aged 20–24 years (OR 3.84; 95% CI 3.07-4.80). For females, having a Pap smear test was also associated with STI testing and counselling (OR 4.39; 95% CI 3.84-5.03). There was no clear association between CQI experience beyond two CQI cycles and higher levels of documented delivery of STI testing and counselling services.ConclusionsA number of Aboriginal PHC centres are achieving high rates of STI testing and counselling, while a significant number are not. STI-related service delivery could be substantially improved through focussed efforts to support health centres with relatively lower documented evidence of adherence to best practice guidelines.

Social and Emotional Wellbeing Screening for Aboriginal and Torres Strait Islanders within Primary Health Care: A Series of Missed Opportunities?

Background Social and emotional wellbeing (SEWB) is a critical determinant of health outcomes for Indigenous Australians. This study examined the extent to which primary healthcare services (PHSs) undertake SEWB screening and management of Aboriginal and Torres Strait Islander clients, and the variation in SEWB screening and management across Indigenous PHS. Methods Cross-sectional analysis between 2012 and 2014 of 3,407 Indigenous client records from a non-representative sample of 100 PHSs in 4 Australian states/territory was undertaken to examine variation in the documentation of: (1) SEWB screening using identified measurement instruments, (2) concern regarding SEWB, (3) actions in response to concern, and (4) follow up actions. Binary logistic regression was used to determine the factors associated with screening. Results The largest variation in SEWB screening occurred at the state/territory level. The mean rate of screening across the sample was 26.6%, ranging from 13.7 to 37.1%. Variation was also related to PHS characteristics. A mean prevalence of identified SEWB concern was 13% across the sample, ranging from 9 to 45.1%. For the clients where SEWB concern was noted, 25.4% had no referral or PHS action recorded. Subsequent internal PHS follow up after 1 month occurred in 54.7% of cases; and six-monthly follow up of referrals to external services occurred in 50.9% of cases. Conclusion Our findings suggest that the lack of a clear model or set of guidelines on best practice for screening for SEWB in Indigenous health may contribute to the wide variation in SEWB service provision. The results tell a story of missed opportunities: 73.4% of clients were not screened and no further action was taken for 25.4% for whom an SEWB concern was identified. There was no follow up for just under half of those for whom action was taken. There is a need for the development of national best practice guidelines for SEWB screening and management, accompanied by dedicated SEWB funding, and training for health service providers as well as ongoing monitoring of adherence with the guidelines. Further research on barriers to screening and follow up actions is also warranted.