A couple-focused, integrated unplanned pregnancy and HIV prevention program in urban and rural 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 costeffective 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 (2013e2016) 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 sameday 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...

Uptake of long acting reversible contraception following integrated couples HIV and fertility goal-based family planning counselling in Catholic and non-Catholic, urban and rural government health centers in Kigali, Rwanda

“…While some would argue that this approach is not sustainable, we found during the nationwide expansion of CVCT that new skills transition into day to day practice and – when supported by MoH mandates – eventually become the standard of care [ 59 ]. We also implemented our integrated HIV-FP model in 55 urban and 215 rural government clinics across 33 districts in Zambia: the program provided HIV-FP counseling to 208,211 couples and performed 101,322 LARC insertions [ 69 ].…”

The role of partner influence in contraceptive adoption, discontinuation, and switching in a nationally representative cohort of Ugandan women

“…Programs that support spousal communication around family planning, avoiding or planning for a pregnancy, and fertility intentions could be key in achieving reproductive goals [39][40][41].…”

Impact of a Group-Based Video and Interactive Group Session Addressing Diarrheal Disease, Helminthic and Schistosomiasis Infections, Hypertension and Diabetes on Short and Long-Term Improvement in Knowledge and Healthy Behaviors in Seroconcordant HIV-Negative Zambian Couples

“…Other studies have highlighted male involvement in traditionally women-oriented household roles in the context of maternal and child health [74][75][76][77][78]. We have worked extensively with Zambian couples on HIV and unplanned pregnancy prevention, and collaboration between spouses is strongly associated with success in those domains [18,79,80]. We noted an increase in shared household responsibilities relating to collecting and treating water, food purchasing and preparation and taking care of sick persons.…”