Kalonde Malama1, William Kilembe2, Mubiana Inambao3, Alexandra Hoagland4, Tyronza Sharkey2, Rachel Parker5, Kristin M Wall6, Amanda Tichacek5, Supriya Sarkar7, Bellington Vwalika8, Lisa Haddad9, Elwyn Chomba10, Susan Allen5. 1. Aix Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques and Sociales de la Santé and Traitement de l'Information Médicale, Marseille, France; ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azurr, Marseille, France. Electronic address: kalondemalama@gmail.com. 2. Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia. 3. Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University, Lusaka, Zambia; Department of Obstetrics and Gynaecology, Ndola Central Hospital, Ndola, Zambia. 4. Zambia Emory HIV Research Project, Rwanda Zambia HIV Research Group, Emory University. 5. Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA. 6. Rwanda Zambia HIV Research Group, the Department of Pathology and Laboratory Medicine, School of Medicine, Emory University, Atlanta, GA; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA. 7. Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA. 8. Department of Obstetrics and Gynaecology, University of Zambia, School of Medicine, Lusaka, Zambia. 9. Department of Obstetrics and Gynaecology, School of Medicine, Emory University, Atlanta, GA. 10. Ministry of Health, Lusaka, Zambia.
Abstract
BACKGROUND: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. OBJECTIVE: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. STUDY DESIGN: A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. RESULTS: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). CONCLUSION: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.
BACKGROUND: Zambia's total fertility rate (5 births per woman) and adult HIV prevalence (11.5%) are among the highest in the world, with heterosexual couples being the most affected group. Jointly counseling and testing couples for HIV has reduced up to 58% of new HIV infections in Zambian clinics. Married women using contraceptives in Zambia have a high (20%) unmet need for family planning and low (8.6%) uptake of cost-effective long-acting reversible contraceptives. We present an integrated counseling, testing, and family-planning program to prevent HIV and unplanned pregnancy in Zambia. OBJECTIVE: The objective of this study was to integrate effective HIV prevention and family-planning services for Zambian couples. STUDY DESIGN: A 3 year program (2013-2016) progressively integrated the promotion and provision of couples' voluntary HIV counseling and testing and long-acting reversible contraceptives. The program was based in 55 urban and 215 rural government clinics across 33 districts. In the first year, a couples' family-planning counseling training program was developed and combined with existing couples HIV counseling training materials. To avoid congestion during routine clinic hours, joint counseling services were initially provided on weekends, while nurses were trained in intrauterine device and hormonal implant insertion and removal during weekday family-planning services. Demand was created through mutual referral between weekend and weekday programs and by clinic staff, community health workers, and satisfied family-planning clients. When the bulk of integrated service training was completed, the program transitioned services to routine weekday clinic hours, ensuring access to same-day services. Performance indicators included number of staff trained, clients served, integrated service referrals, HIV infections averted, and unplanned pregnancies averted. RESULTS: A stepwise approach trained high-performing service providers to be trainers and used high-volume clinics for practicum training of the next generation. In total, 1201 (391 urban, 810 rural) counselors were trained and served 120,535 urban and 87,676 rural couples. In urban clinics, 236 nurses inserted 65,619 long-acting reversible contraceptives, while in rural clinics, 243 nurses inserted 35,703 implants and intrauterine devices. The program prevented an estimated 12,869 urban and 8279 rural adult HIV infections, and 98,626 unintended urban pregnancies. In the final year, the proportion of clients receiving joint counseling services on weekdays rose from 11% to 89%, with many referred from within clinics including HIV testing and treatment services (32%), outpatient department (31%), family planning (16%), and infant vaccination (15%). The largest group of clients requesting long-acting reversible contraceptives (45%) did so after joint fertility goal-based counseling, confirming the high impact of this couple-focused demand creation approach. Remaining family-planning clients responded to referrals from clinic nurses (34%), satisfied implant/intrauterine device users (13%), or community health workers (8%). CONCLUSION: Integrated HIV and unplanned pregnancy prevention can be implemented in low-resource public sector facilities. Combination services offered to couples mutually leverage HIV prevention and unplanned pregnancy prevention. The addition of long-acting reversible contraceptives is an important complement to the method mix available in government clinics. Demand creation in the clinic and in the community must be coordinated with a growing supply of well-trained providers.
Authors: Kristin M Wall; William Kilembe; Mubiana Inambao; Alexandra Hoagland; Tyronza Sharkey; Kalonde Malama; Bellington Vwalika; Rachel Parker; Supriya Sarkar; Ken Hunter; Gordon Streeb; Christine Mazarire; Amanda Tichacek; Susan Allen Journal: AIDS Date: 2020-09-01 Impact factor: 4.177
Authors: Dana O Sarnak; Shannon N Wood; Linnea A Zimmerman; Celia Karp; Fredrick Makumbi; Simon P S Kibira; Caroline Moreau Journal: PLoS One Date: 2021-01-12 Impact factor: 3.240
Authors: Kalonde Malama; Matt A Price; Luis Sagaon-Teyssier; Rachel Parker; Kristin M Wall; Amanda Tichacek; Tyronza Sharkey; William Kilembe; Mubiana Inambao; Bruno Spire; Susan Allen Journal: AIDS Behav Date: 2021-07-31
Authors: Jeannine Mukamuyango; Rosine Ingabire; Rachel Parker; Julien Nyombayire; Andrew Abaasa; Gershim Asiki; Sarah Rae Easter; Kristin M Wall; Laetitia Nyirazinyoye; Amanda Tichacek; Nadine Kaslow; Matt A Price; Susan Allen; Etienne Karita Journal: Reprod Health Date: 2020-08-17 Impact factor: 3.223