Laura Packel

Linking family planning with HIV/AIDS interventions: a systematic review of the evidence.

Objective:To conduct a systematic review of the literature and examine the effectiveness, optimal circumstances, and best practices for strengthening linkages between family planning and HIV interventions. Design:Systematic review of peer-reviewed articles and unpublished program reports (‘promising practices’) evaluating interventions linking family planning and HIV services. Methods:Articles were included if they reported post-intervention evaluation results from an intervention linking family planning and HIV services between 1990 and 2007. Systematic methods were used for searching, screening, and data extraction. Quality assessment was conducted using a 9-point rigor scale. Results:Sixteen studies were included in the analysis (10 peer-reviewed studies and six promising practices). Interventions were categorized into six types: family planning services provided to HIV voluntary counseling and testing (VCT) clients, family planning and VCT services provided to maternal and child health clients, family planning services provided to people living with HIV, community health workers provided family planning and HIV services, VCT provided to family planning clinic clients, and VCT and family planning services provided to women receiving postabortion care. Average study design rigor was low (3.25 out of 9). Most studies reported generally positive or mixed results for key outcomes; no negative results were reported. Conclusion:Interventions linking family planning and HIV services were generally considered feasible and effective, though overall evaluation rigor was low.

Depression and HIV in Botswana: A Population-Based Study on Gender-Specific Socioeconomic and Behavioral Correlates

Background Depression is a leading contributor to the burden of disease worldwide, a critical barrier to HIV prevention and a common serious HIV co-morbidity. However, depression screening and treatment are limited in sub-Saharan Africa, and there are few population-level studies examining the prevalence and gender-specific factors associated with depression. Methods We conducted a cross-sectional population-based study of 18–49 year-old adults from five districts in Botswana with the highest prevalence of HIV-infection. We examined the prevalence of depressive symptoms, using a Hopkins Symptom Checklist for Depression (HSCL-D) score of ≥1.75 to define depression, and correlates of depression using multivariate logistic regression stratified by sex. Results Of 1,268 participants surveyed, 25.3% of women and 31.4% of men had depression. Among women, lower education (adjusted odds ratio [AOR] 2.07, 95% confidence interval [1.30–3.32]), higher income (1.77 [1.09–2.86]), and lack of control in sexual decision-making (2.35 [1.46–3.81]) were positively associated with depression. Among men, being single (1.95 [1.02–3.74]), living in a rural area (1.63 [1.02–2.65]), having frequent visits to a health provider (3.29 [1.88–5.74]), anticipated HIV stigma (fearing discrimination if HIV status was revealed) (2.04 [1.27–3.29]), and intergenerational sex (2.28 [1.17–4.41]) were independently associated with depression. Discussion Depression is highly prevalent in Botswana, and its correlates are gender-specific. Our findings suggest multiple targets for screening and prevention of depression and highlight the need to integrate mental health counseling and treatment into primary health care to decrease morbidity and improve HIV management efforts.

An observational cohort study of Chlamydia trachomatis treatment in pregnancy

Background and Objectives: Currently, azithromycin is not considered a first-line treatment for Chlamydia trachomatis in pregnant women. We evaluated the use, efficacy, and safety of azithromycin compared with erythromycin and amoxicillin in the treatment of genital chlamydial infection during pregnancy. Methods: This was a retrospective cohort study of pregnant women with genital chlamydial infection. Data on antibiotics prescribed, test-of-cure (TOC) results, and maternal and infant complications were collected from medical records. Results: Of the 277 women in the study sample, 69% were initially prescribed azithromycin, 9% amoxicillin, and 19% erythromycin. Eight-one percent of subjects had a TOC 7 or more days after diagnosis and before delivery. Treatment efficacy, as defined by a negative TOC, was 97% (95% confidence interval [CI], 92.9–99.2) for azithromycin, 95% (95% CI, 76.2–99.9) for amoxicillin, and 64% (95% CI, 44.1–81.4) for erythromycin. The efficacy of azithromycin was significantly higher than erythromycin (P <0.0001). There were no significant differences in efficacy by age, race/ethnicity, concurrent sexually transmitted disease diagnosis, partner treatment, or substance use. Furthermore, there was no difference in complications for women or infants exposed to azithromycin compared with those treated with other regimens. Conclusion: Clinical outcome data from this study population of women and infants support both efficacy and safety of azithromycin for treatment of C. trachomatis in pregnancy.

Patient-delivered partner therapy for chlamydial infections: attitudes and practices of California physicians and nurse practitioners.

Objective: The objective of this study was to examine California clinicians’ use of and attitudes toward patient-delivered partner therapy (PDPT) to treat sexual partners of patients infected with chlamydia. Study Design: In 2002, a stratified random sample of primary care physicians and nurse practitioners completed a mailed, self-administered survey. Weighted frequencies were calculated to assess partner management practices, including PDPT, and attitudes toward PDPT. Multivariate models were constructed to determine independent predictors of PDPT use. Results: Of 708 physicians and 895 nurse practitioners, approximately half (47% and 48%, respectively) reported that they use PDPT usually or always. Over 90% agreed that PDPT protects patients from reinfection and provides better care for patients with chlamydia. However, providers reported concerns that PDPT may result in incomplete care for the partner, may be dangerous without knowing the partner’s medical or allergy history, is an activity the practice may not get paid for, and may get them sued. Obstetrics/gynecology and family practice physicians were more likely than internal medicine physicians to report routine use of PDPT. Concerns about adverse outcomes of PDPT were associated with less PDPT use. Conclusions: Although the proportion of California healthcare providers routinely using PDPT is comparatively high, further study is warranted to examine the circumstances under which this partner management strategy is used.

Sexual and reproductive health services for people living with HIV: a systematic review.

Abstract People living with HIV often have unmet needs for sexual and reproductive health (SRH) services. We present results of a systematic review of studies offering SRH services targeted to people living with HIV. Studies were selected from a broader SRH and HIV linkages review. Inclusion criteria included: (1) peer-reviewed journal articles with a pre–post or multiple-arm study design; (2) reported post-intervention evaluation data; and (3) published 1 January 1990 through 31 December 2007. Nine studies were identified with an average rigour score of 5.1 out of 9. Services included family planning (one study), sexually transmitted infection (STI) services (two studies), combined family planning and STI services (three studies) and multiple services (three studies). The review identified mostly positive effects on the outcomes measured, including condom and contraceptive use and quality of services. Yet gaps remain in the research to establish the best approaches for addressing needs and choices of people living with HIV. There is a need for high-quality intervention studies to determine the most successful and cost-effective strategies for providing SRH services to people living with HIV.

Evolving strategies, opportunistic implementation : HIV risk reduction in Tanzania in the context of an incentive-based HIV prevention intervention

Background Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection. Methods In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction. Results We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence. Conclusions Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.

Integrating Chlamydia trachomatis control services for males in female reproductive health programs.

Chlamydia trachomatis is the most commonly reported infectious disease in the United States. Although more than 700000 cases were reported in 2000 the total number of annual cases—reported and unreported—is estimated to be three million. The majority of severe consequences of untreated chlamydia occur in women. Of women who are not treated 30% will develop pelvic inflammatory disease (PID) and approximately one-third of these will become infertile have ectopic pregnancies or develop chronic pelvic pain. Prevention of these consequences is dependent upon screening to identify asymptomatic infection and effective partner management to decrease the risk of reinfection. Expanded chlamydia screening has resulted in decreases in prevalence among women in sites monitored by the Centers for Disease Control and Prevention (CDC). However these decreases have not been consistently sustained and current levels of prevalence may be associated with lack of chlamydia testing and treatment among males. Indeed case-based reported chlamydia rates among women may be 4–5 times the rates among men because women are more likely to obtain care and because guidelines exist for chlamydia screening among women. These data suggest that male sexually transmitted disease (STD) services need to be improved to ensure that partners of infected women are tested and treated. One approach is to expand strategies aimed at controlling chlamydia to males by integrating male services in programs serving women’s reproductive health needs. (excerpt)

Validation of AIDS-related mortality in Botswana

BackgroundMortality data are used to conduct disease surveillance, describe health status and inform planning processes for health service provision and resource allocation. In many countries, HIV- and AIDS-related deaths are believed to be under-reported in government statistics.MethodsTo estimate the extent of under-reporting of HIV- and AIDS-related deaths in Botswana, we conducted a retrospective study of a sample of deaths reported in the government vital registration database from eight hospitals, where more than 40% of deaths in the country in 2005 occurred. We used the consensus of three physicians conducting independent reviews of medical records as the gold standard comparison. We examined the sensitivity, specificity and other validity statistics.ResultsOf the 5276 deaths registered in the eight hospitals, 29% were HIV- and AIDS-related. The percentage of HIV- and AIDS-related deaths confirmed by physician consensus (positive predictive value) was 95.4%; however, the percentage of non-HIV- and non-AIDS-related deaths confirmed (negative predictive value) was only 69.1%. The sensitivity and specificity of the vital registration system was 55.7% and 97.3%, respectively. After correcting for misclassification, the percentage of HIV- and AIDS--related deaths was estimated to be in the range of 48.8% to 54.4%, depending on the definition.ConclusionImprovements in hospitals and within government offices are necessary to strengthen the vital registration system. These should include such strategies as training physicians and coders in accurate reporting and recording of death statistics, implementing continuous quality assurance methods, and working with the government to underscore the importance of using mortality statistics in future evidence-based planning.