Maricianah Onono

The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya : A Prospective Mixed-Methods Study

Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.

Integration of family planning services into HIV care and treatment in Kenya: a cluster-randomized trial.

Objective:To determine whether integrating family planning services into HIV care is associated with increased use of more effective contraceptive methods (sterilization, intrauterine device, implant, injectable or oral contraceptives). Design:Cluster-randomized trial. Setting:Eighteen public HIV clinics in Nyanza Province, Kenya. Participants:Women aged 18–45 years receiving care at participating HIV clinics; 5682 clinical encounters from baseline period (December 2009–February 2010) and 12 531 encounters from end-line period (July 2011–September 2011, 1 year after site training). Intervention:Twelve sites were randomized to integrate family planning services into the HIV clinic, whereas six clinics were controls where clients desiring contraception were referred to family planning clinics at the same facility. Main outcome measures:Increase in use of more effective contraceptive methods between baseline and end-line periods. Pregnancy rates during the follow-up year (October 2010–September 2011) were also compared. Results:Women seen at integrated sites were significantly more likely to use more effective contraceptive methods at the end of the study [increased from 16.7 to 36.6% at integrated sites, compared to increase from 21.1 to 29.8% at controls; odds ratio (OR) 1.81, 95% confidence interval (CI) 1.24–2.63]. Condom use decreased non-significantly at intervention sites compared to controls (OR 0.64, 95% CI 0.35–1.19). No difference was observed in incident pregnancy in the first year after integration comparing intervention to control sites (incidence rate ratio 0.90; 95% CI 0.68–1.20). Conclusions:Integration of family planning services into HIV care clinics increased use of more effective contraceptive methods with a non-significant reduction in condom use. Although no significant reduction in pregnancy incidence was observed during the study, 1 year may be too short a period of observation for this outcome.

Social context and drivers of intimate partner violence in rural Kenya: Implications for the health of pregnant women

More than half of rural Kenyan women experience intimate partner violence (IPV) in their lifetime. Beyond physical consequences, IPV indirectly worsens maternal health because pregnant women avoid antenatal care or HIV testing when they fear violent reprisal from partners. To develop an intervention to mitigate violence towards pregnant women, we conducted qualitative research in rural Kenya. Through eight focus group discussions, four with pregnant women and four with male partners, and in-depth interviews with service providers, we explored the social context of IPV using an ecological model. We found that women experienced physical and sexual IPV, but also economic violence such as forced exile from the marital home or losing material support. Relationship triggers of IPV included perceived sexual infidelity or transgressing gender norms. Women described hiding antenatal HIV testing from partners, as testing was perceived as a sign of infidelity. Extended families were sometimes supportive, but often encouraged silence to protect the family image. The broader community viewed IPV as an intractable, common issue, which seemed to normalise its use. These results resonate with global IPV research showing that factors beyond the individual – gender roles in intimate partnerships, family dynamics and community norms – shape high rates of violence.

HIV-positive status disclosure and use of essential PMTCT and maternal health services in rural Kenya

Background:In sub-Saharan Africa, womens disclosure of HIV-positive status to others may affect their use of services for prevention of mother-to-child transmission of HIV (PMTCT) of HIV and maternal and child health—including antenatal care, antiretroviral drugs (ARVs) for PMTCT, and skilled birth attendance. Methods:Using data from the Migori and AIDS Stigma Study conducted in rural Nyanza Province, Kenya, we compared the use of PMTCT and maternal health services for all women by HIV status and disclosure category (n = 390). Among HIV-infected women (n = 145), associations between disclosure of HIV-positive status and the use of services were further examined with bivariate and multivariate logistic regression analyses. Results:Women living with HIV who had not disclosed to anyone had the lowest levels of maternity and PMTCT service utilization. For example, only 21% of these women gave birth in a health facility, compared with 35% of HIV-negative women and 49% of HIV-positive women who had disclosed (P < 0.001). Among HIV-positive women, the effect of disclosure to anyone on ARV drug use [odds ratio (OR) = 5.8; 95% confidence interval (CI): 1.9 to 17.8] and facility birth (OR = 2.9; 95% CI: 1.4 to 5.7) remained large and significant after adjusting for confounders. Disclosure to a male partner had a particularly strong effect on the use of ARVs for PMTCT (OR = 7.9; 95% CI: 3.7 to 17.1). Conclusions:HIV-positive status disclosure seems to be a complex yet critical factor for the use of PMTCT and maternal health services in this setting. The design of interventions to promote such disclosure must recognize the impact of HIV-related stigma on disclosure decisions and protect womens rights, autonomy, and safety.

Cost, cost-efficiency and cost-effectiveness of integrated family planning and HIV services.

Objective:To evaluate costs, cost-efficiency and cost-effectiveness of integration of family planning into HIV services. Intervention:Integration of family planning services into HIV care and treatment clinics. Design:A cluster-randomized trial. Setting:Twelve health facilities in Nyanza, Kenya were randomized to integrate family planning into HIV care and treatment; six health facilities were randomized to (nonintegrated) standard-of-care with separately delivered family planning and HIV services. Main outcome measures:We assessed costs, cost-efficiency (cost per additional use of more effective family planning), and cost-effectiveness (cost per pregnancy averted) associated with the first year of integration of family planning into HIV care. More effective family planning methods included oral and injectable contraceptives, subdermal implants, intrauterine device, and female and male sterilization. Patients and participants:We collected cost data through interviews with study staff and review of financial records to determine costs of service integration. Results:Integration of services was associated with an average marginal cost of

Pregnancy rates in HIV-positive women using contraceptives and efavirenz-based or nevirapine-based antiretroviral therapy in Kenya: a retrospective cohort study

841 per site and

Responses to and Resources for Intimate Partner Violence Qualitative Findings From Women, Men, and Service Providers in Rural Kenya

48 per female patient. Average overall and marginal costs of integration were associated with personnel costs [initial (

Factors associated with pregnant women's anticipations and experiences of HIV-related stigma in rural Kenya

1003 vs.

Gendered power dynamics and women's negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya.

872) and refresher (

A Community-Supported Clinic-Based Program for Prevention of Violence against Pregnant Women in Rural Kenya

498 vs.