Motivational interviewing experiences from a community health worker-led HIV prevention and care intervention in rural Uganda: a qualitative study.

Motivational Interviewing (MI) and Community Health Workers (CHWs) are increasingly utilized in global settings to improve HIV outcomes, yet research exploring implementation strategies using MI and CHWs is lacking. We examined the experiences of CHWs and their clients in a counseling intervention which used MI-informed counseling to increase engagement in HIV prevention and treatment. This study was nested within the mLAKE cluster-randomized trial in a high HIV prevalence fishing community in rural Rakai District, Uganda. We conducted in-depth interviews with purposively-sampled CHWs (n = 8) and clients (n = 51). Transcripts were analyzed thematically to characterize CHWs' implementation of the intervention. Main themes identified included use of specific MI strategies (including evocation, guidance towards positive behavior change, active listening, and open-ended questions), and MI spirit (including collaboration, power-sharing, trust, and non-judgmental relationship building). Through these specific MI mechanisms, CHWs supported client behavior change to facilitate engagement with HIV services. This study provides evidence from a low-resource setting that CHWs with no previous experience in MI can successfully implement MI-informed counseling that is well-received by clients. CHW-led MI-informed counseling appears to be a feasible and effective approach to increase uptake of HIV prevention and care services in low-resource, HIV endemic regions.

The Impact of Needle and Syringe Exchange Programs on HIV-Related Risk Behaviors in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis Examining Individual- Versus Community-Level Effects.

We conducted a systematic review and meta-analysis of the impact of needle and syringe exchange programs (NSP) on both individual- and community-level needle-sharing behaviors and other HIV-related outcomes in low- and middle-income countries (LMIC). A search of five databases for peer-reviewed trial or quasi-experimental studies reported through July 2021 identified 42 interventions delivered in 35 studies, with a total of 56,751 participants meeting inclusion criteria. Random-effects meta-analysis showed a significant protective association between NSP exposure and needle-sharing behaviors at the individual-level (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.16-0.39, 8 trials, n = 3947) and community-level (OR 0.39, CI 0.22-0.69, 12 trials, n = 6850), although with significant heterogeneity. When stratified by needle-sharing directionality, NSP exposure remained associated with reduced receptive sharing, but not distributive sharing. NSP exposure was also associated with reduced HIV incidence and increased HIV testing but there were no consistent associations with prevalence of bloodborne infections. Current evidence suggests positive impacts of NSPs in LMICs.

RESUMEN: Realizamos una revisión sistemática y un metanálisis del impacto de los programas de intercambio de agujas y jeringas (NSP, por sus siglas en inglés) de los comportamientos de uso compartido de agujas tanto a nivel individual como comunitario y otros resultados relacionados con el VIH en países de ingresos bajos y medianos (LMIC, por sus siglas en inglés). Realizamos búsquedas sistemáticas en cinco bases de datos hasta julio de 2021 en busca de ensayos revisados por pares o estudios cuasiexperimentales. En general, 42 intervenciones informadas en 35 estudios entre 56 751 participantes cumplieron los criterios de inclusión. El metanálisis de efectos aleatorios de ocho estudios a nivel individual y 12 a nivel comunitario con 11 075 participantes en total mostró una asociación protectora significativa entre la exposición a NSP y los comportamientos de compartir agujas (individual: OR 0,25, IC95%: 0,16­0,39; comunidad: OR 0,39, IC95%:0,22­0,69), aunque con una heterogeneidad importante. Cuando se estratificó por la direccionalidad del intercambio de agujas, la exposición a NSP permaneció asociada con un intercambio receptivo reducido, pero no con un intercambio distributivo. La exposición a NSP también se asoció con una incidencia reducida del VIH y un aumento de las pruebas del VIH, pero no hubo asociaciones consistentes para la prevalencia de infecciones transmitidas por la sangre. La evidencia actual sugiere impactos positivos de los NSP en los LMIC.

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda.

A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.

Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda.

Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.

RESUMEN: En 2017, Uganda introdujo profilaxis pre-exposición (PrEP), dirigida a las populaciones con alto riesgo de contraer al VIH (trabajadoras sexuales, pescadores, camioneros, parejas sero-discordantes). Para investigar facilitadores y barreras para la adopción y la adherencia a la PrEP, exploramos percepciones de PrEP antes y después de su introducción en Uganda. Realizamos 75 entrevistas y 12 grupos focales con miembros de la comunidad y trabajadores de salud. Analizamos las transcripciones temáticamente usando un marco de referencia. Parejas, familias, compañeros, y clientes usando PrEP apoyaron a los demás mantener adherencia. Movilidad fue una barrera para la adherencia a la PrEP para trabajadoras sexuales y pescadores. Preocupaciones sobre el entrenamiento de los distribuidores de PrEP y la especulación de precios no fueron realizadas. Percepciones del riesgo del VIH y confianza en la eficacia de PrEP facilitaron su adopción. Estigma y migración inesperada persistieron como barreras para la adopción de PrEP. Comunicaciones manejadas por clientes usando PrEP pueden motivar interés en PrEP y abordar rumores. Sistemas flexibles del entrego y la recarga de medicinas pueden permitir continuación de, y adherencia a, la PrEP.

Stigma, Facility Constraints, and Personal Disbelief: Why Women Disengage from HIV Care During and After Pregnancy in Morogoro Region, Tanzania.

Millions of children are living with HIV in sub-Saharan Africa, and the primary mode of these childhood infections is mother-to-child transmission. While existing interventions can virtually eliminate such transmission, in low- and middle-income settings, only 63 % of pregnant women living with HIV accessed medicines necessary to prevent transmission. In Tanzania, HIV prevalence among pregnant women is 3.2 %. Understanding why HIV-positive women disengage from care during and after pregnancy can inform efforts to reduce the impact of HIV on mothers and young children. Informed by the tenets of Grounded Theory, we conducted qualitative interviews with 40 seropositive postpartum women who had disengaged from care to prevent mother-to-child transmission (PMTCT). Nearly all women described antiretroviral treatment (ART) as ultimately beneficial but effectively inaccessible given concerns related to stigma. Many women also described how their feelings of health and vitality coupled with concerns about side effects underscored a desire to forgo ART until they deemed it immediately necessary. Relatively fewer women described not knowing or forgetting that they needed to continue their treatment regimens. We present a theory of PMTCT disengagement outlining primary and ancillary barriers. This study is among the first to examine disengagement by interviewing women who had actually discontinued care. We urge that a combination of intervention approaches such as mother-to-mother support groups, electronic medical records with same-day tracing, task shifting, and mobile technology be adapted, implemented, and evaluated within the Tanzanian setting.

Values and Preferences on the Use of Oral Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Multiple Populations: A Systematic Review of the Literature.

Daily oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by HIV-negative people to prevent HIV infection. WHO released new guidelines in 2015 recommending PrEP for all populations at substantial risk of HIV infection. To prepare these guidelines, we conducted a systematic review of values and preferences among populations that might benefit from PrEP, women, heterosexual men, young women and adolescent girls, female sex workers, serodiscordant couples, transgender people and people who inject drugs, and among healthcare providers who may prescribe PrEP. A comprehensive search strategy reviewed three electronic databases of articles and HIV-related conference abstracts (January 1990-April 2015). Data abstraction used standardised forms to categorise by population groups and relevant themes. Of 3068 citations screened, 76 peer-reviewed articles and 28 conference abstracts were included. Geographic coverage was global. Most studies (N = 78) evaluated hypothetical use of PrEP, while 26 studies included individuals who actually took PrEP or placebo. Awareness of PrEP was low, but once participants were presented with information about PrEP, the majority said they would consider using it. Concerns about safety, side effects, cost and effectiveness were the most frequently cited barriers to use. There was little indication of risk compensation. Healthcare providers would consider prescribing PrEP, but need more information before doing so. Findings from a rapidly expanding evidence base suggest that the majority of populations most likely to benefit from PrEP feel positively towards it. These same populations would benefit from overcoming current implementation challenges with the shortest possible delay.

Social and structural factors related to HIV risk among truck drivers passing through the Iringa region of Tanzania.

Truck drivers and their assistants have been identified as groups at higher risk for HIV infection. We sought to identify and describe the social and structural factors that may contribute to HIV risk among truck drivers who visit rest stops in Iringa, Tanzania, a region characterized by high levels of migration and mobility. This analysis was part of a comprehensive strategic assessment to examine HIV risk factors in Iringa. This analysis focuses on 11 in-depth interviews with truck drivers and a transport owner. A semi-structured interview guide was developed to elicit open-ended responses and enable probing. Interviews were conducted in Swahili, transcribed, and translated into English. Data analysis followed thematic analysis procedures that included initial reading of transcripts, development of a codebook and identification of themes through in-depth reading of transcripts. Drivers described structural risk factors for HIV including work conditions, the power imbalance between male drivers and their sexual partners and minimal perceived HIV risk with certain partners (e.g., regular partners and women selling sex). Multiple and inter-related social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, presence of sex workers, ability to purchase sex throughout their travel and alcohol consumption. These distinct social norms in truck stops and other rest points facilitated behavior that many participants said they would not engage in elsewhere. HIV prevention strategies with truck drivers should address individual, social and structural barriers to HIV prevention through partnerships with the health and transportation sectors, local government and local communities. HIV prevention services should be adapted to drivers' times and places of availability, for example, condom provision where/when drivers make decisions about or have sex. A focus on positive messaging and addressing specific challenges including the continual challenge of re-choosing and reinforcing decisions to engage in safer sexual behaviors is important.

"You have to take action": changing knowledge and attitudes towards newborn care practices during crisis in South Sudan.

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers' knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre-post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers' knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review.

Evidence on the feasibility, effectiveness, and cost-effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community-wide and HIV-specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up.

A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.

Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples.

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.

A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention.

Income generation interventions, such as microfinance or vocational skills training, address structural factors associated with HIV risk. However, the effectiveness of these interventions on HIV-related outcomes in low- and middle-income countries has not been synthesized. The authors conducted a systematic review by searching electronic databases from 1990 to 2012, examining secondary references, and hand-searching key journals. Peer-reviewed studies were included in the analysis if they evaluated income generation interventions in low- or middle-income countries and provided pre-post or multi-arm measures on behavioral, psychological, social, care, or biological outcomes related to HIV prevention. Standardized forms were used to abstract study data in duplicate and study rigor was assessed. Of the 5218 unique citations identified, 12 studies met criteria for inclusion. Studies were geographically diverse, with six conducted in sub-Saharan Africa, three in South or Southeast Asia, and three in Latin America and the Caribbean. Target populations included adult women (N = 6), female sex workers/bar workers (N = 3), and youth/orphans (N = 3). All studies targeted females except two among youth/orphans. Study rigor was moderate, with two group-randomized trials and two individual-randomized trials. All interventions except three included some form of microfinance. Only a minority of studies found significant intervention effects on condom use, number of sexual partners, or other HIV-related behavioral outcomes; most studies showed no significant change, although some may have had inadequate statistical power. One trial showed a 55% reduction in intimate partner violence (adjusted risk ratio 0.45, 95% confidence interval 0.23-0.91). No studies measured incidence/prevalence of HIV or sexually transmitted infections among intervention recipients. The evidence that income generation interventions influence HIV-related behaviors and outcomes is inconclusive. However, these interventions may have important effects on outcomes beyond HIV prevention. Further studies examining not only HIV-related outcomes but also causal pathways and intermediate variables, are needed. Additional studies among men are also needed.

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6,664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95% confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95% CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95% CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (beta: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95% CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95% CI: 1.29-7.17), regular clients (OR: 2.20, 95% CI: 1.41-3.42), and all clients (OR: 5.87, 95% CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

From 'no problem' to 'a lot of difficulties': barriers to health service utilization among migrants in Rakai, Uganda.

Migration is increasingly common in Africa, especially for employment. Migrants may face additional barriers to accessing health care, including human immunodeficiency virus (HIV) prevention and treatment, compared with long-term residents. Exploring migrants' experiences with health services can provide insights to inform the design of health programmes. In this study, we used qualitative methods to understand migrants' barriers to health service utilization in south-central Uganda. This secondary data analysis used data from in-depth semi-structured interviews with 35 migrants and 25 key informants between 2017 and 2021. Interviews were analysed thematically through team debriefings and memos. We constructed three representative migrant journeys to illustrate barriers to accessing health services, reflecting experiences of migrant personas with differing HIV status and wealth. Migrants reported experiencing a range of barriers, which largely depended on the resources they could access, their existing health needs and their ability to form connections and relationships at their destination. Migrants were less familiar with local health services, and sometimes needed more time and resources to access care. Migrants living with HIV faced additional barriers to accessing health services due to anticipated discrimination from community members or health workers and difficulties in continuing antiretroviral therapy when switching health facilities. Despite these barriers, social networks and local connections facilitated access. However, for some migrants, such as those who were poorer or living with HIV, these barriers were more pronounced. Our work highlights how local connections with community members and health workers help migrants access health services. In practice, reducing barriers to health services is likely to benefit both migrants and long-term residents.

Mixed Methods, Implementation Science Evaluation of a Community Health Worker Strategy for HIV Service Engagement in Uganda.

BACKGROUND: A trial found that a community health worker (CHW) strategy using "Health Scouts" improved HIV care uptake and ART coverage. To better understand outcomes and areas for improvement, we conducted an implementation science evaluation. METHODS: Using the RE-AIM framework, quantitative methods included analyses of a community-wide survey (n = 1903), CHW log books, and phone application data. Qualitative methods included in-depth interviews (n = 72) with CHWs, clients, staff, and community leaders. RESULTS: Thirteen Health Scouts logged 11,221 counseling sessions; 2532 unique clients were counseled. 95.7% (1789 of 1891) of residents reported awareness of the Health Scouts. Overall, reach (self-reported receipt of counseling) was 30.7% (580 of 1891). Unreached residents were more likely to be male and HIV seronegative ( P < 0.05). Qualitative themes included the following: (1) reach was promoted by perceived usefulness but deterred by busy client lifestyles and stigma, (2) effectiveness was enabled through good acceptability and consistency with the conceptual framework, (3) adoption was facilitated by positive impacts on HIV service engagement, and (4) implementation fidelity was initially promoted by the CHW phone application but deterred by mobility. Maintenance showed consistent counseling sessions over time. The findings suggested the strategy was fundamentally sound but had suboptimal reach. Future iterations could consider adaptations to improve reach to priority populations, testing the need for mobile health support, and additional community sensitization to reduce stigma. CONCLUSIONS: A CHW strategy to promote HIV services was implemented with moderate success in an HIV hyperendemic setting and should be considered for adoption and scale-up in other communities as part of comprehensive HIV epidemic control efforts. TRIAL REGISTRATION: ClinicalTrials.gov Trial Number NCT02556957.

Integration of HIV/AIDS services with maternal, neonatal and child health, nutrition, and family planning services.

BACKGROUND: The integration of HIV/AIDS and maternal, neonatal, child health and nutrition services (MNCHN), including family planning (FP) is recognized as a key strategy to reduce maternal and child mortality and control the HIV/AIDS epidemic. However, limited evidence exists on the effectiveness of service integration. OBJECTIVES: To evaluate the impact of integrating MNCHN-FP and HIV/AIDS services on health, behavioral, and economic outcomes and to identify research gaps. SEARCH METHODS: Using the Cochrane Collaboration's validated search strategies for identifying reports of HIV interventions, along with appropriate keywords and MeSH terms, we searched a range of electronic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE (via PubMed), and Web of Science / Web of Social Science. The date range was from 01 January 1990 to 15 October 2010. There were no limits to language. SELECTION CRITERIA: Included studies were published in peer-reviewed journals, and provided intervention evaluation data (pre-post or multi-arm study design).The interventions described were organizational strategies or change, process modifications or introductions of technologies aimed at integrating MNCHN-FP and HIV/AIDS service delivery. DATA COLLECTION AND ANALYSIS: We identified 10,619 citations from the electronic database searches and 101 citations from hand searching, cross-reference searching and interpersonal communication. After initial screenings for relevance by pairs of authors working independently, a total of 121 full-text articles were obtained for closer examination. MAIN RESULTS: Twenty peer-reviewed articles representing 19 interventions met inclusion criteria. There were no randomized controlled trials. One study utilized a stepped wedge design, while the rest were non-randomized trials, cohort studies, time series studies, cross-sectional studies, serial cross-sectional studies, and before-after studies. It was not possible to perform meta-analysis. Risk of bias was generally high. We found high between-study heterogeneity in terms of intervention types, study objectives, settings and designs, and reported outcomes. Most studies integrated FP with HIV testing (n=7) or HIV care and treatment (n=4). Overall, HIV and MNCHN-FP service integration was found to be feasible across a variety of integration models, settings and target populations. Nearly all studies reported positive post-integration effects on key outcomes including contraceptive use, antiretroviral therapy initiation in pregnancy, HIV testing, and quality of services. AUTHORS' CONCLUSIONS: This systematic review's findings show that integrated HIV/AIDS and MNCHN-FP services are feasible to implement and show promise towards improving a variety of health and behavioral outcomes. However, significant evidence gaps remain. Rigorous research comparing outcomes of integrated with non-integrated services, including cost, cost-effectiveness, and health outcomes such as HIV and STI incidence, morbidity and mortality are greatly needed to inform programs and policy.

Self-testing for pregnancy: a systematic review and meta-analysis.

OBJECTIVES: Urine pregnancy tests are often inaccessible in low-income settings. Expanded provision of home pregnancy testing could support self-care options for sexual and reproductive health and rights. We conducted a systematic review of pregnancy self-testing effectiveness, values and preferences and cost. DESIGN: Systematic review and meta-analysis using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. DATA SOURCES: PubMed, CINAHL, LILACS and EMBASE and four trial registries were searched through 2 November 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included trials and observational studies that compared urine self-testing for pregnancy to health worker-led pregnancy testing on effectiveness outcomes; quantitative and qualitative studies describing values and preferences of end users and health workers and costs of pregnancy self-testing. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search, screen and code included studies. Risk of bias was assessed using the Cochrane Collaboration and Evidence Project tools. Meta-analysis was conducted using random effects models. Findings were summarised in GRADE evidence profiles and synthesised qualitatively. RESULTS: For effectiveness, four randomised trials following 5493 individuals after medical abortion showed no difference or improvements in loss to follow-up with home pregnancy self-testing compared with return clinic visits. One additional trial of community health workers offering home pregnancy tests showed a significant increase in pregnancy knowledge and antenatal counselling among 506 clients. Eighteen diverse values and preferences studies found support for pregnancy self-testing because of quick results, convenience, confidentiality/privacy, cost and accuracy. Most individuals receiving pregnancy self-tests for postabortion home management preferred this option. No studies reported cost data. CONCLUSION: Pregnancy self-testing is acceptable and valued by end users. Effectiveness data come mostly from articles on postabortion care, and cost data are lacking. Greater availability of pregnancy self-tests, including in postabortion care and CHW programs, may lead to improved health outcomes. PROSPERO REGISTRATION NUMBER: CRD42021231656.

Over-the-counter provision of emergency contraceptive pills: a systematic review.

OBJECTIVE: To synthesise evidence around over-the-counter (OTC) emergency contraceptive pills (ECPs) to expand the evidence base on self-care interventions. DESIGN: Systematic review (PROSPERO# CRD42021231625). ELIGIBILITY CRITERIA: We included publications comparing OTC or pharmacy-access ECP with prescription-only ECPs and measuring ECP uptake, correct use, unintended pregnancy, abortion, sexual practices/behaviour, self-efficacy and side-effects/harms. We also reviewed studies assessing values/preferences and costs of OTC ECPs. DATA SOURCES: We searched PubMed, CINAL, LILACS, EMBASE, clinicaltrials.gov, WHO International Clinical Trials Registry Platform, Pan African Clinical Trials Registry, Australian New Zealand Clinical Trials Registry, Cochrane Fertility Regulation and International Consortium for Emergency Contraception through 2 December 2020. RISK OF BIAS: For trials, we used Cochrane Collaboration's tool for assessing risk of bias; for other studies, we used the Evidence Project risk of bias tool. DATA EXTRACTION AND SYNTHESIS: We summarised data in duplicate using Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence Profile tables, reporting findings by study design and outcome. We qualitatively synthesised values/preferences and cost data. RESULTS: We included 19 studies evaluating effectiveness of OTC ECP, 56 on values/preferences and 3 on costs. All studies except one were from high-income and middle-income settings. Broadly, there were no differences in overall ECP use, pregnancy or sexual behaviour, but an increase in timely ECP use, when comparing OTC or pharmacy ECP to prescription-only ECP groups. Studies showed similar/lower abortion rates in areas with pharmacy availability of ECPs. Users and providers generally supported OTC ECPs; decisions for use were influenced by privacy/confidentiality, convenience, and cost. Three modelling studies found pharmacy-access ECPs would lower health sector costs. CONCLUSION: OTC ECPs are feasible and acceptable. They may increase access to and timely use of effective contraception. Existing evidence suggests OTC ECPs do not substantively change reproductive health outcomes. Future studies should examine OTC ECP's impacts on user costs, among key subgroups and in low-resource settings.

Contraception values and preferences of people living with HIV: A systematic review.

OBJECTIVE: Attention to the contraception values and preferences of those living with HIV is essential to meeting their reproductive rights and health needs. We systematically reviewed the literature on contraception values and preferences among women and men living with HIV. STUDY DESIGN: We searched ten electronic databases for articles from 1 January 2005 through 27 July 2020 for qualitative and quantitative studies of the values and preferences for contraceptive methods among individuals living with HIV. RESULTS: Twenty-one studies, primarily from sub-Saharan Africa, met the inclusion criteria. Contraception values and preferences were shaped by several factors: availability, accessibility, and convenience; perceived effectiveness; safety and tolerability; dual protection; fertility desires; partnership dynamics; and provider recommendations. Male condoms were a frequently preferred contraceptive method, offering an affordable and accessible form of dual protection against HIV and unwanted pregnancy. Fears of infertility and side effects decreased interest in hormonal contraceptive methods. Financial burdens incurred by HIV management and a desire to reduce dual reproductive health and HIV care burdens influenced preferences. Healthcare providers contributed to contraceptive preferences of women living with HIV, informing perceptions of safety, tolerability, and effectiveness. CONCLUSION: Contraception values and preferences among women living with HIV are complex and influenced by factors related and unrelated to their HIV status. Considering contraception values and preferences of people living with HIV will ensure that their autonomy and right to make decisions about the contraceptive methods best for them are upheld.

Health workers' values and preferences regarding contraceptive methods globally: A systematic review.

OBJECTIVE: We sought to systematically review the literature on health workers' values and preferences related to contraceptive methods. STUDY DESIGN: As part of a larger review, we searched ten electronic databases for published articles from January 1, 2005 through July 27, 2020. We included studies that reported qualitative or quantitative data from the perspective of health workers providing family planning services globally. RESULTS: Forty-one studies met our inclusion criteria. These studies included 12,643 health workers and were conducted in 27 countries. Health worker values and preferences for contraceptive methods were affected by factors related to contraceptive method characteristics (e.g., bleeding pattern and convenience), the contraceptive user (e.g., medical history, parity), and the health worker themselves (e.g., training, environment). Differences were also noted between various professions/specialties (e.g., comfort level with contraceptive methods, depth of experience). While contraceptive counseling and provision were influenced by health worker values and preferences, they were also affected by health worker misconceptions and biases. CONCLUSION: Health worker values and preferences for contraception are affected by the client's history, medical eligibility, and the health worker context. Provision of contraception that is affected by harmful bias towards certain populations or about certain methods can negatively affect patient-centered care. Future work should address knowledge gaps and health worker biases by improving and standardizing education and training globally, to ensure high-quality, rights-based, and patient-centered contraceptive services.