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      Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

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          Abstract

          Background

          Unwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda.

          Methods and findings

          We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm 3 (SD = 61) for those enrolled in the control group versus 393 cells/mm 3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67–13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65–12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31–4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66–9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40–9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control ( P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with <10% in each arm selecting condoms, oral contraception, or intrauterine devices (IUDs). Similar proportions of women changed contraceptive methods over the 6-month follow-up in the voucher and control groups (N = 8, 5% versus N = 5, 4%; P = 0.467). More women in the control group discontinued contraception for 1 to 2 weeks (N = 19, 13% versus N = 7, 5%; P = 0.008) or more than 4 weeks (N = 15, 10% versus N = 3, 2%; P = 0.002) compared to those given a family planning voucher. The main limitation of this study is that its findings may not be generalized to settings without improved availability of contraceptives in publicly funded facilities.

          Conclusion

          These findings indicate that a well-structured, time-bound family planning voucher program appeared to increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services. Further work should clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time.

          Trial registration

          ClinicalTrials.gov NCT02964169.

          Abstract

          Esther Cathyln Atukunda and colleagues reveal the uptake of contraceptive care for postpartum women living with HIV when offered family planning vouchers.

          Author summary

          Why was this study done?
          • Unwanted pregnancies remain a burden for women living with HIV (WLWH).

          • Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health.

          • To date, previous studies have not compared whether family planning vouchers are as effective in driving differences in modern contraceptive method uptake or discontinuation by a common follow-up point postpartum. The studies also do not report on WLWH enrolled immediately postpartum in a public health facility and subject to standard limitations of public sector healthcare facilities in the region.

          What did the researchers do and find?
          • We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis included adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). We intended to document the rate and time of initiation, continuation, and change of a modern family planning method postpartum.

          • By 8 weeks postpartum, more women initiated family planning in the voucher group (144 [91%]) than in the control group (83 [52%]). The family planning uptake rates were also high for both groups, with higher rates among the intervention group at 12, 14, 16, and 20 weeks postpartum.

          • The average time to family planning initiation was substantially reduced from 9.3 weeks to 5.9 weeks for those in the voucher compared to control arms, respectively.

          • Method mix did not differ by group: injectables were selected by most women (50%), for which 52% of this proportion were in the experimental arm. The proportion of women using implants was 20% (N = 60), with more women (60% versus 40%) opting for implants in the control arm than in the experimental arm. Less than 10% in each arm selected condoms, oral contraception, or IUDs.

          • Similar proportions of women changed contraceptive methods over the 6-month follow-up period in the voucher and control groups. More women in the control group discontinued contraception for 1 to 2 weeks or more than 4 weeks compared to those given a family planning voucher.

          What do these findings mean?
          • These findings indicate that a well-structured, time-bound family planning voucher program could increase early postpartum contraceptive uptake and continuation in a setting in which users are faced with financial, knowledge, and structural barriers to contraceptive services.

          • The increased family planning uptake observed in this study may have been due to improved availability of contraceptives at the referral hospital, plus one-on-one postpartum counseling provided by a well-trained nurse as recommended versus routine care practiced at similar public facilities.

          • Further work needs to clarify the role of vouchers in empowering WLWH to avoid unintended pregnancies over time.

          Related collections

          Most cited references 39

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          The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients.

          A 14-item, self-administered, multidimensional, functional social support questionnaire was designed and evaluated on 401 patients attending a family medicine clinic. Patients were selected from randomized time-frame sampling blocks during regular office hours. The population was predominantly white, female, married, and under age 45. Eleven items remained after test-retest reliability was assessed over a 1- to 4-week follow-up period. Factor analysis and item remainder analysis reduced the remaining 11 items to a brief and easy-to-complete two-scale, eight-item functional social support instrument. Construct validity, concurrent validity, and discriminant validity are demonstrated for the two scales (confidant support--five items and affective support--three items). Factor analysis and correlations with other measures of social support suggest that the three remaining items (visits, instrumental support, and praise) are distinct entities that may need further study.
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            Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale.

            AIDS stigmas create significant barriers to HIV prevention, testing, and care and can become internalized by people living with HIV/AIDS. We developed a psychometric scale to measure internalized AIDS-related stigmas among people infected with HIV. Items were adapted from a psychometrically sound test of AIDS-related stigmas in the general population. Six items reflecting self-defacing beliefs and negative perceptions of people living with HIV/AIDS were responded to dichotomously, Agree/Disagree. Data collected from people living with HIV/AIDS in Cape Town South Africa (n=1068), Swaziland (n=1090), and Atlanta US (n=239) showed that the internalized AIDS Stigma Scale was internally consistent (overall alpha coefficient=0.75) and time stable (r=0.53). We also found evidence in support of the scale's convergent, discriminant, and criterion-related validity. The Internalized AIDS-Related Stigma Scale appears reliable and valid and may be useful for research and evaluation with HIV-positive populations across southern African and North American cultures.
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              Reproductive Intentions and Outcomes among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study

              Background Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa. Methodology /Principal Findings Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women's desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p 18.5 (HR = 1.09, CI: 1.01–1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02–3.13) were independently associated with pregnancy. Conclusion/Significance Women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: Writing – review & editing
                Role: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: InvestigationRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                21 June 2019
                June 2019
                : 16
                : 6
                Affiliations
                [1 ] Mbarara University of Science and Technology, Mbarara, Uganda
                [2 ] Faculty of Health Sciences, Simon Fraser University, Burnaby, Vancouver, Canada
                [3 ] Division of Infectious Diseases and Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
                [4 ] Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
                FHI360, UNITED STATES
                Author notes

                All the authors have declared that no competing interests exist.

                Article
                PMEDICINE-D-19-00081
                10.1371/journal.pmed.1002832
                6588214
                31226123

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                Page count
                Figures: 3, Tables: 3, Pages: 20
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000002, National Institutes of Health;
                Award ID: D43 TW010128
                Award Recipient :
                This publication was supported by the Fogarty International Center (National Institutes of Health [NIH] Common Fund, Office of Strategic Coordination, Office of the Director [OD/OSC/CF/NIH]; Office of AIDS Research, Office of the Director (OAR/NIH); National Institute of Mental Health [NIMH/NIH]; National Institute of Neurological Disorders and Stroke [NINDS/NIH]) of the NIH under award number D43 TW010128. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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