Abstract
Objective:
To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV.
Methods:
We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18–45 years and using antiretrovirals.
Results:
At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception.
Conclusions:
Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC.
Keywords: Botswana, contraception, family planning, HIV, service integration
1 |. INTRODUCTION
Botswana has one of the highest HIV rates in the world, with 30% of women of reproductive age (15–49 years) living with HIV.1 In addition, 44%–50% of pregnancies are unintended.2,3 Use of less effective contraceptive methods (WHO Tier 2 and 3 such as condoms and oral contraceptives), in combination with an unmet need for family planning (FP), which is estimated to be about 28%–30%, may explain these high levels of unintended pregnancy.4 Between 79% and 88% of women in Botswana who used contraception before an unintended pregnancy relied only on the male condom.3,4 Although condom use is key for sexually transmitted infection and HIV prevention, dual method use (combining condoms with highly effective contraception) should be promoted to reduce the likelihood of unintended pregnancy.5
In Botswana, the majority of FP is provided in sexual and reproductive health or general primary care clinics. Integrating contraceptive services into HIV clinics is a national priority for the Botswana Ministry of Health and Wellness (MoHW).6 Despite concerns about increasing provider burden with FP-HIV integration, the introduction of contraceptive services into HIV care has been shown to be instrumental in increasing uptake of more effective contraceptive methods in southern Africa, including long-acting reversible contraceptive methods (LARCs; i.e. intrauterine devices and implants).7–9 However, integration of FP into HIV care may be most effective in settings where FP use is already at a moderate level, indicating the need for resources and infrastructure before implementation.10
Improving effective FP use in Botswana requires convenient access to contraceptive commodities and services (including LARCs), and rights-based, patient-centered contraceptive counseling that enables women to align their method choice with their reproductive intentions. One component of the current unmet need for FP among women living with HIV (WLHIV) may be the provider perception that WLHIV cannot use many of the contraceptives available, limiting their informed choice.11 Moreover, WLHIV are affected by factors such as stigma and discrimination around reproductive decision-making12–14; to reduce these effects, it is important that FP be integrated into their HIV care.10 FP integration programs in other African countries have lacked sustainability because although methods are free for research, the contraceptive cost outside the experimental setting can be prohibitive for women.15 In Botswana, as contraceptives are provided free-of-charge by the MoHW, a well-constructed program that integrates contraceptive counseling and access into HIV care would likely be sustainable.
This study aimed to create, and test, a simple, practical model for improving patient-provider FP discussions and increasing the interest of WLHIV who want to avoid pregnancy in adopting more effective contraception methods. The specific aims were: to assess the need for and feasibility of incorporating FP care into an HIV clinic in Botswana, and to measure the effectiveness of FP provider training in stimulating interest for effective contraception among WLHIV who wished to delay or avoid pregnancy.
2 |. MATERIALS AND METHODS
This project was a prospective, hybrid type 2 clinical intervention and implementation study16 of an intervention to engage WLHIV with FP services. A strength is that the hybrid study design combines assessment of implementation outcomes (acceptability, feasibility, and adoption) with measurement of clinical efficacy (interest in FP and LARC uptake). The study site was the Infectious Disease Care Clinic (IDCC) in the Princess Marina Hospital in Gaborone, the largest public sector hospital in Botswana. The IDCC is an outpatient clinic that provides care for people living with HIV and serves people from Gaborone and outlying areas.
HIV care patients and providers were surveyed at baseline (October 2017 to March 2018), and a different cohort of patients was surveyed after intervention implementation (June 2018 to August 2018) to assess intervention impact. The HIV clinic was open every morning, Monday to Friday, and consecutive, eligible, and consenting patients were interviewed during all clinic opening hours for the duration of the study. Eligibility criteria for patients were being female, English or Setswana speaking, 18–45 years of age, and living with HIV. The eligibility criterion for providers was being a nurse or doctor providing care in the IDCC HIV clinic.
While patients were waiting for their routine HIV care appointment in the waiting room at IDCC, a brief standardized announcement was made to them to introduce the study topic in very general terms and to give women a chance to consider whether or not they would like to participate. This was done in exactly the same way for the baseline and post-intervention patients. All the women were approached after they had undergone their routine HIV consultation, and eligible women who were interested in taking part were consented. Patients took part in a survey after they saw their HIV provider. Post intervention, each woman was offered an opportunity to discuss contraception in more depth with an FP doctor in the IDCC and given a direct referral to receive contraceptive methods that were not available at the IDCC at that time (i.e., oral contraception, injectables, implants, intrauterine devices, and sterilization). If the patients met with an FP doctor after their HIV appointment, they completed a further survey regarding this discussion.
The intervention was a 2-hour training session (implemented in May and June of 2018) with three or four HIV providers attending each session led by an FP doctor. The training session was developed using the Behaviour Change Wheel17 and the Theoretical Domains Framework.18 Relevant barriers and facilitators to FP counseling and provision were identified from the baseline provider surveys to address how to motivate behavior change and improve the discussion of FP in the HIV clinic. Suggestions from the IDCC staff were incorporated into the training to maximize the potential efficacy of the intervention.
The training session included a discussion on the importance of—and the stigma associated with—FP in Botswana (including providers’ own personal, religious, and cultural beliefs) and how to overcome this in the clinical setting to best serve patients. Then, current FP methods available in Botswana were discussed; staff were made aware of the referral process for patients who desired contraception that the IDCC could not provide at the time (i.e., all methods apart from female and male condoms). The training aimed to provide the staff with strategies to effectively discuss FP with patients including effective communication techniques and how to introduce a discussion about reproductive plans and FP into their routine HIV care consultations. The training focused on the importance of providers engaging patients in active participation during their consultation. Role-play between the staff enabled providers to practice different methods of discussing confidentiality, encouraging shared decision-making, and where possible, helping the woman access her “method in mind”—the method that aligned with her needs, preferences, and values. The training session also allowed time for the providers to familiarize themselves with using the Decision Making Tool flipchart,19 designed by WHO to help improve the quality of FP counseling. By the end of the training, providers were able to describe the FP methods available in Botswana and how patients could obtain these, able to provide basic counseling on the advantages and disadvantages of each method, and equipped to introduce a discussion about reproductive plans and contraception into their routine HIV care consultations.
To ensure ongoing fidelity of the intervention, continuous support and mentorship were available to HIV providers from an FP doctor, who was present for the duration of the study and could be accessed during the HIV clinic appointments if required. This FP doctor was available to see any patients wishing to discuss contraception in more depth after their routine HIV appointment.
To evaluate clinical efficacy following the intervention, we surveyed providers to assess the impact and adoption of the intervention, measured their FP knowledge, and asked about organizational factors that could support or impede the intervention and how the providers rated the utility of the intervention and its impact. We surveyed patients to determine if FP counseling was discussed in their HIV consultation and whether their interest in discussing different contraceptive methods was enhanced.
Our sample size estimate was based upon evidence that integration of FP into HIV services caused effective FP use to increase from 32% to 65% in Kenya.20 Effective FP use in our patient population was estimated at 10% in 2014, based on IDCC clinical audit data (personal communication, clinic matron). We conservatively expected the intervention to increase interest in this to 30%. This increase required a minimum of 62 patients per group to be statistically significant (α 0.05, 80% power, two-sided test). Descriptive statistics, group and within-patient comparisons (χ2, Fisher, Wilcoxon or t tests as appropriate) were assessed using Stata 14 (StataCorp).
Ethical approvals were obtained from the University of Botswana, Princess Marina Hospital in Gaborone, Botswana, the Human Research and Development Committee at the Botswana Ministry of Health, and the University of Pennsylvania. All participants gave written informed consent.
3 |. RESULTS
At baseline, 141 women completed the survey, and 107 did so post intervention. Demographics (Table 1) were similar between the baseline group and the post-intervention group, though more women preferred to use English for survey completion in the post-intervention group than at baseline. All patients at baseline and post intervention were on antiretroviral agents for HIV treatment. Women reported a median of two living children and most women were single (73% at baseline, 80% post intervention). Table 2 shows women’s FP history, clinic visit experience, and preferences. Fifteen percent (21) of women at baseline and 34% (36) post intervention desired pregnancy in the next 6 months (P = 0.002 between the groups). At baseline, only 6% (9) of women reported discussing FP with the healthcare provider, whereas post intervention, this rose to 61% (65), indicating that adoption of the intervention was high (P < 0.001). Post intervention, 45% (48) of the women met with the FP doctor after their initial HIV consultation because they wanted to have a further, in-depth discussion regarding FP, highlighting that there was a clear desire from women for further information regarding contraception. Importantly, most women (82% at baseline and 96% post intervention) expressed a preference for FP services to be available in the HIV clinic.
TABLE 1.
Patient characteristicsa
| Baseline (n = 141) | Post intervention (n = 107) | P value | |
|---|---|---|---|
| Language preference | <0.001 | ||
| English | 2 (2) | 24 (22) | |
| Setswana | 135 (95) | 83 (78) | |
| Unknown | 4 (3) | 0 | |
| Age, y: mean (SD), n | 38.5 (5.3), 138 | 39.3 (5.0), 100 | 0.24 |
| Marital status | 0.40 | ||
| Single | 103 (73.0) | 86 (80.4) | |
| Married/in union | 32 (22.7) | 18 (16.8) | |
| Divorced | 3 (2.1) | 2 (1.9) | |
| Widowed | 2 (1.4) | 1 (0.9) | |
| Unknown | 1 (0.7) | 0 | |
| Highest education level | 0.99 | ||
| None | 2 (1.4) | 0 | |
| Non-formal | 1 (0.7) | 0 | |
| Primary | 6 (4.3) | 15 (14.0) | |
| Junior secondary | 76 (53.9) | 49 (45.8) | |
| Senior secondary | 34 (24.1) | 17 (15.9) | |
| Tertiary | 21 (14.9) | 26 (24.3) | |
| Unknown | 1 (0.7) | 0 | |
| Living children: mean (SD) | 2.2 (1.5) | 2.3 (1.4) | 0.59 |
| Median, range | 2, 0–8 | 2, 0–6 | |
| Pregnancies: mean (SD) | 2.6 (1.8) | 2.7 (1.5) | 0.64 |
| Median, range | 2, 0–10 | 2, 0–7 |
Data are given as number (percentage) or mean (standard deviation); group comparisons by χ2, Fisher, Wilcoxon or t tests
TABLE 2.
Family planning history, clinic visit experience, and preferencesa
| Question | Baseline (n = 141) | Post intervention (n = 107) | P value |
|---|---|---|---|
| Want to get pregnant in the next 6 months? | 0.002 | ||
| Yes | 21 (14.9) | 36 (33.6) | |
| No | 106 (75.2) | 65 (60.8) | |
| Unsure | 12 (8.5) | 5 (4.7) | |
| Unknown | 2 (1.4) | 1 (0.9) | |
| Did patient discuss contraception with the HIV healthcare provider today? | |||
| Yes | 9 (6.4) | 65 (60.8) | <0.001 |
| No | 132 (93.6) | 41 (38.3) | |
| Unknown | 0 | 1 (1.9) | |
| Did patient meet with family planning doctor today to discuss contraception? | |||
| Yes | N/A | 48 (44.5) | |
| No | 57 (53.3) | ||
| Unknown | 2 (1.9) | ||
| Would you like to have family planning services available in the following clinics? | |||
| HIV Clinic | 116 (82%) | 103 (96%) | 0.14 |
| Cervical Cancer Screening Clinic | 63 (45%) | 56 (52%) | |
| Maternal and Child Health Clinic | 60 (43%) | 57 (53%) | |
| None/other | 33 (23%) | 14 (13%) | |
Data are given as number (percentage).
Table 3 shows FP use and preferences at baseline and post intervention. The majority of women at baseline and post intervention reported currently using FP (86% and 88%, respectively). Of those who were using FP, 85% (100) at baseline, and 81% (73) at post intervention were using male condoms only. In the post-intervention cohort, 30% of women (32) wanted to use highly effective contraception (including female sterilization) versus only 8% (11) at baseline. Hence, there was a significant increase (P < 0.001) in the proportion of women interested in more effective contraception after the intervention. Only 3% (4) of women at baseline and 4% (5) at post intervention reported using LARC (i.e., implant or intrauterine device) before their visit. At baseline, after their HIV consultation, 6% (8) of women wanted to use a LARC method (Table 3; “very effective contraception” total includes three tubal ligations). In the post-intervention cohort, 29% (31) of women wanted to use a LARC method (P < 0.001) (Table 3; “very effective contraception” total includes one tubal ligation). The method of greatest interest to potential users in the post-intervention group was the contraceptive implant, with 26% (28) of women wanting to use it.
TABLE 3.
Contraceptive use and preferencesa
| Contraceptive methodb | Before visit | Future wishes | P valuec |
|---|---|---|---|
| Baseline (n = 141) | 0.16 | ||
| Very effective contraception | 7 (5.0) | 11 (7.8) | |
| Effective contraception | 11 (7.8) | 18 (12.7) | |
| Less effective contraception | 100 (70.9) | 92 (65.2) | |
| Not effective contraception | 20 (14.2) | 19 (13.5) | |
| Unknown | 3 (2.1) | 1 (0.7) | |
| Post intervention (n = 107) | |||
| Very effective contraception | 6 (5.6) | 32 (30.0) | <0.001 |
| Effective contraception | 11 (10.3) | 14 (13.1) | |
| Less effective contraception | 73 (68.2) | 46 (43.0) | |
| Not effective contraception | 13 (12.2) | 11 (10.3) | |
| Unknown | 4 (3.7) | 4 (3.7) |
Data are given as number (percentage).
Very effective contraception included the copper and hormonal intrauterine contraceptive device, the levonorgestrel and etonogestrel implants and tubal ligation. Effective contraception included the 3-monthly injectable (DMPA, Depo Provera) and oral contraceptive pill (both combined and progesterone only). Less effective contraception included the male and female condom. Not effective contraception included no method and abstinence. No patients in either survey indicated using natural methods, withdrawal, the patch or the ring.
P relates to within-participant comparison.
Thirteen providers were interviewed at baseline and seven were interviewed again post intervention. Fewer providers were interviewed post intervention because of staff redeployments out of the IDCC during the intervening period, which is common across Botswana MoHW services. At baseline, the providers gave a variety of reasons for why it was difficult to discuss FP with the patients; four felt that time was the main limiting factor, three believed it was a result of lack of training and of knowledge in offering FP, four felt that cultural, spiritual, and religious barriers prevented them from addressing FP, and one felt that the lack of contraceptive methods in the HIV clinic itself impeded FP discussions. When providers were asked how these barriers could be overcome in order to offer FP, seven thought continuous education for providers was essential, three wanted more staff available, and one thought a specific clinic to offer FP would be beneficial.
In both baseline and post-intervention HIV provider surveys (Table 4), all participants agreed that it would be feasible to offer FP counseling and provision in the HIV clinic. The proportion of providers who reported feeling comfortable discussing FP with patients rose from 77% at baseline to 86% post intervention. At baseline, fewer than half of the 13 providers reported feeling that they were adequately trained on counseling for LARC methods; post intervention 100% of seven providers believed that they were adequately trained to discuss the range of methods including copper intrauterine devices, implants, injectable contraception, oral contraceptive pills, male and female condoms, and the permanent methods.
TABLE 4.
Provider characteristics and perceptions of family planning in clinica
| Provider questions | Baseline (n = 13) | Post intervention (n = 7) |
|---|---|---|
| Gender | ||
| Male | 3 (23) | 3 (43) |
| Female | 10 (77) | 4 (57) |
| Position | ||
| Nurse | 8 (62) | 4 (57) |
| Midwife | 1 (8) | 0 |
| Doctor | 4 (31) | 3 (43) |
| FP clinical experience (years) | 6.1 (9.7) | 2.7 (5.3) |
| Helping patients decide on FP takes too much time | ||
| Strongly disagree/disagree | 7 (54) | 3 (43) |
| Neither agree nor disagree | 2 (15) | 3 (43) |
| Agree/strongly agree | 4 (30) | 1 (14) |
| I am comfortable discussing FP methods with patients | ||
| Strongly disagree/disagree | 2 (15) | 1 (14) |
| Neither agree nor disagree | 1 (8) | 0 |
| Agree/strongly agree | 10 (77) | 6 (86) |
| I have been adequately trained to offer the following FP methods | ||
| Copper intrauterine device | 4 (31) | 7 (100) |
| Hormonal intrauterine device | 0 | 1 (14) |
| Etonogestrel contraceptive implant | 1 (8) | 7 (100) |
| Levonorgestrel contraceptive implant | 0 | 2 (28) |
| 3-month injectable | 4 (31) | 7 (100) |
| Combined oral contraceptive pills | 8 (62) | 7 (100) |
| Progesterone-only contraceptive pills | 5 (38) | 7 (100) |
| Female condoms | 5 (38) | 7 (100) |
| Male condoms | 11 (85) | 7 (100) |
| Is it feasible to offer family planning method provision in HIV clinic? | ||
| Yes | 14 (100) | 7 (100) |
Abbreviation: FP, family planning.
Data are given as number (percentage) or mean (standard deviation).
4 |. DISCUSSION
Addressing the unmet need for contraception among WLHIV, through the successful integration of FP and HIV services, is a critical component of meeting public health goals that include reduced maternal and child mortality, fewer unintended pregnancies, and reduced risk of maternal to child transmission of HIV.21
Unsurprisingly, this study has highlighted that there is an unmet need for FP among WLHIV and that the majority of WLHIV in this setting, in Botswana, use the less-effective, shorter-acting contraceptives, mostly male condoms, despite the fact that more than 60% of patients reported wanting to postpone pregnancy for more than 6 months at both baseline and post intervention. FP is an essential component of comprehensive HIV care and WHO recommends integration of FP services within HIV care settings.22 However, pre-intervention, the majority of women were not being asked about their reproductive plans and FP needs during their HIV consultation. Following a simple intervention (engaging and educating HIV providers in FP), there was a significant increase in FP discussions with patients. There was also an increase in the number of women expressing a desire to use a LARC method. Making contraceptive services and a full range of methods, including LARCs, readily available in HIV care, in a supportive and confidential environment, is likely to increase FP uptake, as suggested by this study. These findings corroborate studies from other sub-Saharan African settings that have shown similar results.10
There are multiple reasons why providers were not asking women about FP in HIV care, including a lack of basic FP training, lack of communication skills, and lack of clarity about the referral pathways. Following this brief and simple intervention, the providers felt more confident across these domains; however, they had concerns regarding the additional time it may take to discuss FP in HIV care and the need for more staff to offer this service. Despite these concerns, all providers felt that FP could be logistically and feasibly offered in the HIV clinic. Nevertheless, it is important to recognize that ongoing uptake of integration will depend on staffing and continuous training for healthcare providers to ensure that this practice will have longevity and sustainability.
This study is limited by the fact that it was done in only one clinic located at the main hospital for the country, and patients and providers at this clinic may not be fully representative of patients and providers at other clinics in the country, and/or the region. However, the study population is likely to be representative of approximately 70% of the people living with HIV in Botswana.23 Language preferences for interview were different between the baseline and post-intervention cohorts, which likely reflects the fact that the clinic population is generally bilingual and that most patients would use Setswana and English interchangeably throughout a consultation or interview as opposed to any fundamental differences that could be associated with study outcomes between the two groups. There are a limited number of providers at this clinic, and the HIV providers, both doctors and nurses, change often; therefore, this training intervention would need to be repeated at regular intervals and as part of induction training for new staff, and ongoing training through regular mentoring visits24 and onsite FP specialists25 would be beneficial. More detailed qualitative assessments with providers of reasons for intervention acceptability and feasibility would be useful. Given the single time point of post-intervention measurement, this study cannot confirm whether FP interest and uptake, even if increased post intervention, would continue to be offered outside and beyond the study period.
Despite the limitations, this study provides good baseline data on the unmet need for FP information and services among WLHIV in Botswana, which did not exist previously; provides evidence that this can likely be addressed with a simple intervention; and demonstrates that both patients and providers are supportive of integrating such a service into the clinic. Given the significance of these findings, it is now essential to evaluate the effect of an integrated service on actual contraceptive uptake. This study clearly documents that most women, as expected, are currently using short-acting FP methods, mostly condoms, which are ranked among the less effective methods of contraception, despite a desire to delay pregnancy for a long period of time. The study also demonstrates that when services become available, many would consider starting a more effective and long-term method, particularly the LARC method of implant. Given that Botswana already provides free FP (including multiple LARC options) and HIV care in the public sector health services, this intervention is likely easily reproducible, and can be readily scaled up for use in other HIV clinics around the country and in other sub-Saharan African countries that offer similar services. This will be a useful step towards implementing comprehensive, patient-centered care in HIV clinics. Subsequent to this study and based on our findings, the Botswana MoHW has now implemented an integrated FP service in the Princess Marina Hospital IDCC and most methods of contraception are now provided on site in the clinic as part of routine HIV care (i.e., implants, injectables, oral contraception, and condoms); referrals are made for intrauterine devices and sterilization.
ACKNOWLEDGEMENTS
Arden McAllister and Rebecca Howett contributed to study coordination and to revising the manuscript. We would also like to acknowledge the Botswana MoHW for their support of this research, in particular Lesego Mokganya and Sifelani Malima. Finally thanks to Dr Helena Spector for her editing assistance. This work was supported by the University of Pennsylvania Center for AIDS Research. AMG’s time was supported by the Fogarty International Center and the National Institute of Mental Health, Award Number D43 TW010543, and the Afya Bora Consortium Fellowship program.
Funding information
University of Pennsylvania Center for AIDS Research; Fogarty International Center; National Institute of Mental Health, Grant/Award Number: D, 43 and TW010543; Afya Bora Consortium Fellowship
Footnotes
CONFLICT OF INTEREST
The authors have no conflicts of interest.
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