Francis Obare

Acceptance of repeat population-based voluntary counselling and testing for HIV in rural Malawi.

Objective: To examine the acceptance of repeat population-based voluntary counselling and testing (VCT) for HIV in rural Malawi. Methods: Behavioural and biomarker data were collected in 2004 and 2006 from approximately 3000 adult respondents. In 2004, oral swab specimens were collected and analysed using ELISA and confirmatory Western blot tests, while finger-prick rapid testing was done in 2006. We used cross-tabulations with χ2 tests and significance tests of proportions to determine the statistical significance of differences in acceptance of VCT by year, individual characteristics and HIV risk. Results: First, over 90% of respondents in each round accepted the HIV test, despite variations in testing protocols. Second, the percentage of individuals who obtained their test results significantly increased from 67% in 2004, when the results were provided in randomly selected locations several weeks after the specimens were collected, to 98% in 2006 when they were made available immediately within the home. Third, whereas there were significant variations in the sociodemographic and behavioural profiles of those who were successfully contacted for a second HIV test, this was not the case for those who accepted repeat VCT. This suggests that variations in the success of repeat testing might come from contacting the individuals rather than from accepting the test or knowing the results. Conclusions: Repeat HIV testing at home by trained healthcare workers from outside the local area, and with either saliva or blood, is almost universally acceptable in rural Malawi and, thus, likely to be acceptable in similar contexts.

Preventive service needs of young people perinatally infected with HIV in Uganda.

Abstract The sexual and reproductive health needs of young people perinatally infected with HIV in Uganda remain largely unaddressed by existing HIV/AIDS programs mostly because, such programs encourage young HIV-positive clients to refrain from or postpone sexual activity. This study examines the sexual expressions and experiences as well as the preventive practices of 732 adolescent boys and girls aged 15–19 years who were born with HIV with a view to identifying the preventive service needs of these young people and the implications of these needs for HIV/AIDS programs. The data come from a project on the sexuality of young people perinatally infected with HIV conducted in 2007 in four districts of Uganda, that is, Kampala, Wakiso, Masaka, and Jinja. The analysis involves both quantitative and qualitative approaches: the quantitative approach entails cross-tabulations with chi-square tests as well as significance tests of proportions while the qualitative approach involves an analysis of individual case stories, in-depth probes and focus group discussions for content. The findings show disconnect between: (1) the information the service providers give to the young people and their actual needs and desires; (2) the fears of the adolescents and their actual preventive practices; and (3) the high level of reported condom use and the frequency of use. Programs will therefore need to recognize that young people perinatally infected with HIV are sexually active or anticipate being so in future. Thus, both sexually active and non-sexually active young people require information and services on prevention of unwanted pregnancies as well as avoiding infecting their sexual partners with HIV and re-infecting themselves. Programs will need to devise ways of responding to these needs which should include emphasizing the disclosure of HIV status to the partner as well as the need to accompany such disclosure with consistent condom use.

Community-level impact of the reproductive health vouchers programme on service utilization in Kenya

This paper examines community-level association between exposure to the reproductive health vouchers programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15–49 years) from voucher and comparable non-voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the programme. The results show that for births occurring after the voucher programme began, women from communities that had been exposed to the programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the programme at all. The findings suggest that the programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy.

Reducing Unmet Need by Supporting Women with Met Need

CONTEXT The 2012 London Summit on family planning set a goal of providing modern contraceptives to 120 million women with unmet need by 2020. Reducing the high rate of contraceptive discontinuation by facilitating switching among methods will play a critical role in meeting that goal. METHODS Data collected from married women in Demographic and Health Surveys conducted in 34 countries between 2005 and 2010 were used to estimate the potential contribution of contraceptive discontinuation to current and future unmet need. An indicator of relevant discontinuation was created by calculating the proportion of past users with an unmet need for modern methods among ever-users. Regression analyses identified associations between this indicator and access to and composition of methods. RESULTS Women who had discontinued method use and subsequently had unmet need at the survey accounted for 38% of the total estimated unmet need. These past users represented 19% of women who had ever used modern methods. Both the access to and composition of available methods were associated with a reduction in the relevant discontinuation rate. The level of discontinuation in Sub-Saharan Africa was significantly higher than in other regions, in part due to differences in method availability. CONCLUSIONS High contraceptive discontinuation in the past has contributed tens of millions of cases of unmet need, and discontinuation among current users will contribute even more cases in the future. Enabling past users with unmet need to resume use and encouraging current users to continue use of the same or another method could be an effective strategy to reduce future unmet need.

A policy analysis of the implementation of a reproductive health vouchers program in Kenya

BackgroundInnovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up.MethodsPolicy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi.ResultsThe OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided.ConclusionsOBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The government’s role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.

Factors associated with unintended pregnancy, poor birth outcomes and post-partum contraceptive use among HIV-positive female adolescents in Kenya

BackgroundAlthough the experiences of unintended pregnancies and poor birth outcomes among adolescents aged 15–19 years in the general population are well documented, there is limited understanding of the same among those who are living with HIV. This paper examines the factors associated with experiencing unintended pregnancies, poor birth outcomes, and post-partum contraceptive use among HIV-positive female adolescents in Kenya.MethodsData are from a cross-sectional study that captured information on pregnancy histories of HIV-positive female adolescents in four regions of Kenya: Coast, Nairobi, Nyanza and Rift Valley provinces. Study participants were identified through HIV and AIDS programs in the four regions. Out of a total of 797 female participants, 394 had ever been pregnant with 24% of them experiencing multiple pregnancies. Analysis entails the estimation of random-effects logit models.ResultsHigher order pregnancies were just as likely to be unintended as lower order ones (odds ratios [OR]: 1.2; 95% confidence interval [CI]: 0.8–2.0) while pregnancies occurring within marital unions were significantly less likely to be unintended compared to those occurring outside such unions (OR: 0.1; 95% CI: 0.1–0.2). Higher order pregnancies were significantly more likely to result in poor outcomes compared to lower order ones (OR: 2.5; 95% CI: 1.6–4.0). In addition, pregnancies occurring within marital unions were significantly less likely to result in poor outcomes compared to those occurring outside such unions (OR: 0.3; 95% CI: 0.1–0.9). However, experiencing unintended pregnancy was not significantly associated with adverse birth outcomes (OR: 1.3; 95% CI: 0.5–3.3). There was also no significant difference in the likelihood of post-partum contraceptive use by whether the pregnancy was unintended (OR: 0.9; 95% CI: 0.5–1.5).ConclusionsThe experience of repeat unintended pregnancies among HIV-positive female adolescents in the sample is partly due to inconsistent use of contraception to prevent recurrence while poor birth outcomes among higher order pregnancies are partly due to abortion. This underscores the need for HIV and AIDS programs to provide appropriate sexual and reproductive health information and services to HIV-positive adolescent clients in order to reduce the risk of undesired reproductive health outcomes.

Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: a qualitative evaluation

BackgroundFew studies in Africa have explored in detail the ability of output-based aid (OBA) voucher programs to increase access to gender-based violence recovery (GBVR) services.MethodsA qualitative study was conducted in 2010 and involved: (i) in-depth interviews (IDIs) with health managers, service providers, voucher management agency (VMA) managers and (ii) focus group discussions (FGDs) with voucher users, voucher non-users, voucher distributors and opinion leaders drawn from five program sites in Kenya.ResultsThe findings showed promising prospects for the uptake of OBA GBVR services among target population. However, a number of factors affect the uptake of the services. These include lack of general awareness of the GBVR services vouchers, lack of understanding of the benefit package, immediate financial needs of survivors, as well as stigma and cultural beliefs that undermine reporting of cases or seeking essential medical services. Moreover, accreditation of only hospitals to offer GBVR services undermines access to the services in rural areas. Poor responsiveness from law enforcement agencies and fear of reprisal from perpetrators also undermine treatment options and access to medical services. Low provider knowledge on GBVR services and lack of supplies also affect effective provision and management of GBVR services.ConclusionsThe above findings suggest that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA program to promote the GBVR services voucher, and conduct widespread community education programs aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.

Can private pharmacy providers offer comprehensive reproductive health services to users of emergency contraceptives? evidence from Nairobi Kenya.

OBJECTIVE To evaluate the provision of reproductive health information and services to users of emergency contraceptives (ECs) by private pharmacists. METHODS The study involved intervention (9) and control (8) pharmacies, with baseline and endline assessments of EC provision through the use of mystery clients. Intervention pharmacies received weekly updates on EC, fliers with three key messages on EC, and information, education, and communication materials. Logistic regression models are estimated to predict the provision of reproductive health services to EC clients. RESULTS The differences between the control and intervention pharmacies with respect to the provision of additional information on EC and regular family planning services are in the expected direction but statistically insignificant. In contrast, the likelihood of providing information or referral for counseling or testing for sexually transmitted infections or HIV was lower in the intervention than in the control pharmacies but the difference was also not statistically significant. CONCLUSION Pharmacy providers in the country face institutional challenges in providing reproductive health services to EC clients. PRACTICE IMPLICATIONS The challenges could be addressed through pre-service training, targeted in-service training, sensitization of clients, and point-of-sale materials such as brochures, posters and package inserts.

Nonresponse in Repeat Population-Based Voluntary Counseling and Testing for HIV in Rural Malawi

Despite the increasing number of population-based surveys in sub-Saharan Africa that provide testing and counseling for HIV over the past decade, understanding the nature of nonresponse in these surveys, especially panel HIV surveys, is still limited. This article uses longitudinal HIV data collected from rural Malawi in 2004 and 2006 to examine nonresponse in repeat population-based testing. It shows that nonresponse in repeat testing led to significant bias in the estimates of HIV prevalence and to inconsistent conclusions about the predictors of HIV status. In contrast, previous cross-sectional analyses found that nonresponse does not significantly bias the estimates of HIV prevalence. The difference in conclusions from cross-sectional and longitudinal analyses of nonresponse can be attributed to two factors: the different definitions of what constitutes nonresponse in both contexts, and the risk profiles of the missed populations. In particular, although refusal and temporary absence are the major sources ofnonresponse in the cross-sectional contexts, attrition attributable to mortality and out-migration are additional sources of nonresponse in repeat testing. Evidence shows that out-migrants have higher HIV prevalence than nonmigrants, which could account for significant bias in the estimates of prevalence among participants in both tests observed in this study.

The limited effect of knowing they are HIV-positive on the sexual and reproductive experiences and intentions of infected adolescents in Uganda

This paper compares the sexual and reproductive experiences and intentions of those adolescents aged 15–19 years in Uganda who are perinatally infected with HIV and know their sero-status with those of adolescents who do not know their sero-status. The analysis comprises a simple comparison of means and proportions, together with the relevant tests of significance, as well as estimation of Cox proportional hazards and random-effects logit models. The findings show that the two groups of adolescents do not differ significantly in terms of timing of sexual debut and whether they intend to have children in the future. However, adolescents who are HIV-positive and know their status are significantly more likely to use a modern method of contraception, including condoms. Nonetheless, the level of condom use among these adolescents is still limited (less than half of those sexually active) and inconsistent (less than half of those in relationships reported always using a condom).