Harriet Birungi

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.

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.

Engaging men who have sex with men in operations research in Kenya

Research on men who have sex with men (MSM) in Africa is severely constrained. This paper examines the process of engaging MSM in research in a context where same-sex relationships are criminalised and socially stigmatised. Despite difficulties in researching MSM in Kenya, a convenient sample of 500 men was enrolled into a study aimed at understanding HIV/STI risks and prevention needs. Lessons drawn from this study highlight innovative methodological approaches and processes to working with and researching MSM in homophobic communities. Researchers willing to venture into MSM research in such contexts should be prepared to deal with among others, issues such as, seeking ethical approval for a study whose subjects are considered to engage in illegal activities, assuring study participants of their privacy and confidentiality and questioning of their own integrity. This study shows that despite difficulties, research of this kind can be carried out in Kenya.

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).

HIV Infection and Schooling Experiences of Adolescents in Uganda

The increased availability of anti-retroviral treatment (ART) for HIV in parts of sub-Saharan Africa (SSA) has enabled many children who were perinatally infected to survive to schoolgoing age and even longer. For instance, a study conducted in 2007 in Uganda among adolescents aged 15-19 years who were perinatally infected with HIV found that about 70% of them were attending school at the time of the survey and many desired to be in school to avoid social isolation (Birungi et al., 2008). With an increasing number of HIV-positive young people attending school, most governments in SSA have begun to recognize the challenges this situation presents to the education sector (Kelly, 2003). Many governments have formulated Education Sector Policies on HIV/AIDS that encompass all learners, employees, managers and administrators in all learning institutions at all levels of the education system (for example, Ministry of Education and SportsUganda, 2006; Ministry of EducationKenya, 2004). The policies predominantly revolve around a legal framework that recognizes and upholds the rights of all people with a special focus on marginalized and vulnerable groups and those with special needs. They also recognize the need for universal access to HIV/AIDS information, access to treatment and care, protection from discrimination and stigma, and care for orphans and vulnerable in-school young people. In spite of the recognition of school-going HIV-positive young people as a vulnerable group, education sector responses to HIV/AIDS in the SSA region are predominantly curriculumbased. The focus is almost entirely on developing the capacity of learners in the areas of better knowledge about the diseases, skills that enhance the ability to protect oneself against infection, and approaches that acknowledge the rights and dignities of those infected and affected (Bennell et al., 2002; Cohen, 2004; Kelly, 2000; Rugalema & Khanye, 2004). Insufficient attention has been paid to ways of supporting in-school HIV-positive young people partly because their needs in school are still largely unknown given that this is an emerging issue in the region. It could also be due to the dilemma of how to tackle the issue of HIV in schools based on fears that having specific programs targeting in-school HIVpositive young people could reinforce stigma and discrimination against them. Whatever the reason for the lack of appropriate education sector responses in this area, a key issue that emerges is the need for evidence on in-school experiences of HIV-positive young people in the region. This should in turn inform appropriate interventions aimed at

Recent research on sexuality in East Africa

Unless one is particularly inattentive, it is nearly impossible not to have noticed the growth of interest in the intersection between sexuality, culture and health in the East African region over the last five years or more. One rationale for the heightened attention to this topic has to do with the limitations of conventional social science research in the region, which historically privileged a severely limited number of constructs for understanding sexual behaviour (Undie and Benaya 2006). These limitations became increasingly evident as the ‘pyrrhic victory’ of the HIV and AIDS pandemic became an undeniable reality. Attempts to address the pandemic necessarily resulted in the questioning of the traditional silence surrounding sexual matters in the region (Tamale 2003). Clearly, there was a need for a paradigm shift in the customary approach to the conceptualisation of sexuality among African peoples in the context of HIV. The incorporation of sexuality intowork on culture and health inEastAfrican countries could thus be seen as a resort to common sense. Furthermore, most scholars are on a constant quest for seemingly innovative and novel areas of inquiry – and sexuality, being ‘virgin territory’ (in the public health world at least), certainly falls into this category. Despite longstanding discussions of and research on the subject in many other fields (e.g. anthropology, sociolinguistics, history, literature, folklore, law etc.), surprisingly little was known about sexuality (in a broad sense) in the public health domain until fairly recently (Maticka-Tyndale, Tiemoko, and Makinwa-Adebusoye 2007, Undie, Izugbara and Khamasi, forthcoming), making the subject of sexuality particularly attractive, exciting and refreshing. In addition to the ‘common sense’ argument, further critical consideration of the matter suggests the existence of other forces at play in the East African region’s mounting interest in sexuality, culture and health. Undie, Izugbara, and Khamasi (forthcoming) observe a number of critical factors that have contributed to the popularity that sexuality-related research/work currently enjoys in East Africa. A major propellant was the naming and framing of sexuality by the World Health Organisation (WHO) in 2002 through its now influential working definition of the term. The 2002 WHO working definition of sexuality helped to clarify an otherwise nebulous concept and provided a framework for guiding investigations of relevance to the domain. Although this definition was still cautiously labeled by the WHO as a ‘draft’ several years later, the legitimacy that WHO’s acknowledgement represents has prompted public health scholars and practitioners to engage with an area of inquiry hitherto regarded as taboo and, indeed, as trivial. The perhaps inadvertent legitimisation of sexuality as a critical issue by the WHO was followed by the development of funding portfolios for sexuality in East Africa. The Ford Foundation and the Swedish International Development Agency, amongst other donor institutions, seem to have been at the forefront of funding sexuality-related work in the

Policy Scripts and Students' Realities Regarding Sexuality Education in Secondary Schools in Kenya.

This paper explores the sexual and reproductive health (SRH) policy context and the realities facing in-school young people in Kenya. It is based on a review of the health and education sector policy documents as well as data from self-administered questionnaires with 3624 male and female students from eight secondary schools in Nairobi. Findings show that although the policies emphasise the right to access accurate SRH information, there are restrictions on the content of messages that can be provided to in-school young people. At the same time, students continue to be exposed to the risks of undesired SRH outcomes and quest for comprehensive SRH information. The findings suggest that as policy-makers, parents, teachers, civil and faith-based organisations debate about the value and content of sexuality education in schools, it is important to consider the views and experiences of students who are the intended beneficiaries of such education.

Acceptability and Effectiveness of Linking HIV-Positive Family PlanningClients to Treatment and Care Services among Health Care Providers inKenya

Although there has been growing interest in the provision of integrated reproductive health and HIV services in sub-Saharan Africa in recent decades, there is limited evidence on effectiveness of linking family planning clients who test HIV-positive to comprehensive care centers with respect to such outcomes as uptake of care and support services as well as initiation of clients to antiretroviral therapy for those eligible. This paper examined the acceptability and effectiveness of linking HIV-positive family planning (FP) clients to treatment and care services among health care providers in Kenya. Data are from a pre- and post-intervention study without a comparison group. Intervention activities included modifying the referral system, reviewing and updating training materials and job aids, training service providers on the updated tools, and conducting support supervision. Data collection involved facility assessment, provider interviews, and record reviews. Analysis entails descriptive statistics including frequencies, percentages and scores with significant tests of means and proportions to determine if there were any significant differences between baseline and endline. The results show that although most facilities were not adequately prepared in terms of infrastructure to support linking HIV-positive family planning clients to treatment and care services, there was significant improvement in provider acceptance of referral practices after than before the interventions. For example, the proportion of providers who used a directory for referral rose from 8% at baseline to 58% at endline (p<0.01) while the proportion of providers who discussed referral of HIV-positive FP clients improved from 71% at baseline to 96% at the endline (p<0.05). In addition, whereas there was initially no referral of HIVpositive FP clients to comprehensive care centers (CCCs), most of the HIV-positive FP clients received at CCCs (93%) were from within the Maternal-Child-Health (MCH)/FP unit of the same facility during the intervention period indicating that the referral system was effective.

Do Women Find the Progesterone Vaginal Ring Acceptable? Findings from Kenya, Nigeria, and Senegal: Do Women Find the Progesterone Vaginal Ring Acceptable?

The progesterone vaginal ring (PVR) is a contraceptive designed for use by breastfeeding women in the first year postpartum. This Report presents results of an acceptability study of the PVR in Kenya, Nigeria, and Senegal. Women seeking postpartum family planning services were offered various contraceptive options including the PVR. Of the 174 participating women, 110 (63 percent) used one ring and 94 (54 percent) completed the study by using two rings over a six-month period. Women were interviewed up to three times: at the time they entered the study, at 3 months (the end of the first ring cycle), and at 6 months (the end of the second ring cycle or when they exited if they had discontinued earlier). Many participants found the ring to be acceptable, with over three-quarters reporting that it was easy to insert, remove, and reinsert. While a small proportion of women experienced ring expulsion, the majority did not. These findings suggest that even in countries with little or no use of vaginal health products, contraceptive vaginal rings offer women a new option that they are able and willing to use.

Correction to: Harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol: proceedings of a 2016 regional technical meeting in sub-Saharan Africa

In April 2016, the Population Council, in partnership with the World Health Organization (WHO) and the International Consortium for Emergency Contraception, convened a regional meeting in Lusaka, Zambia, geared toward supporting countries in East and Southern Africa in meeting their obligations under the Maputo Protocol. These obligations include expanding access to women’s reproductive health services – especially women survivors of sexual violence. Government and civil society representatives from six countries participated: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia. Countries were selected based on to their being priority settings for the projects that sponsored the meeting, coupled with the fact that they were each far enough along in addressing post-rape care to be able to develop concrete policy, programming, and/or legal action plans by the end of the meeting.The meeting was the first activity in a joint project of technical assistance by the conveners, aimed at strengthening access to comprehensive post-rape care for survivors of sexual violence. It aimed to sensitize Member States to their obligations under the Maputo Protocol to expand women’s access to emergency contraception (EC) and safe abortion services, and to inspire them to do so by providing information, research evidence, and a platform for discussion.The meeting deliberations fostered a better understanding of opportunities to broaden access to EC and safe abortion for survivors in the region. Discussions on EC in this regard centered on strengthening EC delivery in the clinical context, decentralizing EC services, increasing community awareness, and overcoming policy barriers. Safe abortion discussions focused primarily on legislation, policy, and integrating these services into existing services for sexual violence survivors. Country-specific action plans were developed to address gaps and weaknesses.The regional technical meeting concluded with a discussion of practical steps that participants could take to facilitate legal, policy, and program reform with respect to pregnancy prevention and safe abortion in their respective countries. The steps revolved around three mainly areas, namely: establishing an evidence base to inform action; creating forums for discussing the issues; and drafting action points to carry the momentum from the meeting forward. This paper details the proceedings from this regional technical meeting – proceedings that are of interest to the field of sexual and gender-based violence (and reproductive health, more broadly) as challenges faced by countries in implementing the Maputo Protocol are outlined, and evidence-informed and practice-based strategies for addressing these challenges are provided.