Testing a counseling message for increasing uptake of self-injectable contraception in southern Malawi: A mixed-methods, clustered randomized controlled study.

OBJECTIVE: While self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) has well-documented benefits, uptake may be improved by addressing client concerns such as fear of self-injury and low self-efficacy. However, current training materials for family planning providers do not address these concerns. We used an iterative process with family planning providers and clients, male community leaders and partners, and stakeholders in Malawi to develop a counseling message addressing user-centered concerns about self-injection. We report on our testing of the effectiveness of this evidence-based message for increasing self-injection uptake in the context of full method choice. METHODS: We randomized 60 public facilities across two districts in southern Malawi to orient their providers to the message (treatment) or not (control). After strengthening data quality, we extracted routine service delivery data from the facilities six months before and after introducing the message. We compared pre- and post-orientation trends for the treatment and control groups using generalized linear mixed models. We conducted eight focus group discussions with a sample of providers oriented to the message. RESULTS: The message was feasible to implement and highly acceptable to providers. During June 2020-June 2021, 16,593 new clients used injectables in Mangochi district (52% DMPA-SC; 15% self-injected). In Thyolo district, 7,761 new clients used injectables during July 2020-July 2021 (29% DMPA-SC; 14% self-injected). We observed high variability in number of clients and self-injection uptake across facilities and over time, indicating inconsistent offering of self-injection. In both districts, we found significant increases in self-injection in treatment facilities after message introduction. However, this increase was not sustained, especially when DMPA-SC was unavailable or about to expire. CONCLUSION: Based on the study findings, we recommend the evidence-based message be used in programs offering DMPA-SC self-injection services. However, effective use of the message is contingent upon a consistent supply of DMPA-SC.

"Men can take part": examining men's role in supporting self-injectable contraception in southern Malawi, a qualitative exploration.

BACKGROUND: The male engagement framework for reproductive health, which presents men as family planning users, supportive partners, and agents of change, is being increasingly incorporated into family planning strategies worldwide. We applied this framework to understand the perspectives of and role that men play in supporting the use of self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC). METHODS: We conducted a qualitative analysis using data from a study conducted in southern Malawi to develop and test a counseling message to introduce DMPA-SC and self-injection. We conducted 4 focus group discussions (FGD) with male community leaders and partners of DMPA-SC users, 13 interviews and FGDs with public and private sector family planning providers, and 30 interviews with female clients. We explored all participant groups' perspectives on what could facilitate or prevent women from choosing self-injection, including views on men's attitudes towards DMPA-SC and self-injection. RESULTS: Overall, participants expressed ways that men could be engaged as cooperative users, supportive partners, and agents of change, and felt that this would help build a more supportive environment for DMPA-SC self-injection use. Men held favorable opinions of DMPA-SC self-injection: they felt that it is useful, described ways they could actively and emotionally support their partners in its use, and described their role in normalizing it. CONCLUSIONS: We suggest that DMPA-SC self-injection has the potential to be both a female-controlled and a cooperative method, based on the ability for women to use it autonomously and the option to encourage male partner involvement (only where the woman welcomes this). Shifting the conversation from viewing men as a barrier to men as a resource may allow us to harness the social capital of men and transform traditional power dynamics, therefore establishing more enabling environments to support autonomy and choice for DMPA-SC and self-injection use.

Self-injectable contraception (DMPA-SC) has the potential to expand family planning access. Once users are trained to self-inject, they can obtain multiple units and self-inject every three months privately, without needing to return to a health provider. Considering men's role in supporting self-injection can inform family planning programs' male engagement strategies.We conducted a study in Southern Malawi which included interviews and focus group discussions with male community leaders and partners of DMPA-SC users, family planning providers, and female family planning clients. We applied the male engagement framework to these data to understand the potential roles men can play as cooperative users, supportive partners, and agents of change. We found that men can support their partners in DMPA-SC self-injection use through actively participating in the injection process, providing emotional support and encouragement, and advocating for other men and communities to accept self-injection and family planning use.We acknowledge that encouraging male participation could potentially lead to women's autonomy being restricted, so offer concrete suggestions to create an enabling environment that keeps women's and girls' needs central. For example, we propose that program materials expand their description of DMPA-SC self-injection to include a potentially cooperative option, which may be appropriate for women who want to involve their partners. Further, we suggest that social and behavioral change programs channel men's social capital in order to normalize self-injection. When their traditional role as norm influencers is harnessed, men may encourage their communities to support women's autonomy and choice for DMPA-SC and self-injection use.

Acceptability of the contraceptive Sayana® Press when injected every four months: Results from a twelve-month trial in Brazil, Chile and the Dominican Republic.

OBJECTIVE: We assessed the acceptability of subcutaneous depot-medroxyprogesterone acetate 104 mg (Sayana® Press) when injected every 4 months for 12 months. STUDY DESIGN: We assessed acceptability using questionnaires within a clinical trial to evaluate contraceptive effectiveness of Sayana® Press when the reinjection interval was extended from 3 to 4 months. We enrolled 750 women aged 18 to 35 years and at risk of pregnancy at 3 centers in Brazil, Chile, and the Dominican Republic who agreed to use Sayana® Press every 4 months for 12 months. Acceptability outcomes included responses to questions about perception of bleeding patterns and side effects, likes, and dislikes about the regimen. We descriptively compared outcomes across study centers and between those who completed the study and those who discontinued early. RESULTS: Across the 3 centers, participants differed in age, marital status, years of schooling, and race. At the final visit, 90% reported being satisfied with Sayana® Press and 75% reported preferring to use this contraceptive every 4 months. The most common reasons women liked using Sayana® Press were for its duration of effectiveness, followed by amenorrhea. The most common dislike, when a reason was identified, was its effect on uterine bleeding, including amenorrhea reported by some participants. We also observed center-level differences in the proportion of women who liked amenorrhea. CONCLUSIONS: Satisfaction with Sayana® Press injected every 4 months was high across the 3 demographically diverse Latin-American centers. However, participants had varied feelings towards contraceptive-induced amenorrhea. IMPLICATIONS: We found that Sayana® Press when injected every 4 months was highly acceptable among women in 3 Latin American settings despite differences in their feelings toward contraceptive-induced amenorrhea. Our results suggest that there will be interest in using this method every 4 months if introduced into these settings.

Family Connections randomized controlled trial: assessing the feasibility and acceptability of an intervention with adolescents living with HIV and their caregivers in Ndola, Zambia.

Achieving the 95-95-95 UNAIDS targets requires meeting the needs of adolescents, however we lack evidenced-based approaches to improving adolescent adherence to antiretroviral therapy (ART), increasing viral suppression, and supporting general wellbeing. We developed Family Connections as a group intervention for adolescents and their adult caregivers and conducted a randomized controlled trial in Ndola, Zambia to test feasibility and acceptability. Fifty pairs (n = 100) of adolescents (15-19 years and on ART ≥ 6 months) and their caregivers were randomly assigned either to the intervention consisting of 10 group sessions over 6 months, or to a comparison group, which received the usual care. Each pair completed baseline and endline surveys, with adolescents also undergoing viral load testing. Of the 24-intervention adolescent/caregiver pairs, 88% attended at least eight group sessions. Most adolescents (96%) and all caregivers would recommend Family Connections to peers. Adolescent viral failure decreased but did not significantly differ by study group. Adolescents in the intervention group showed a greater reduction in HIV-related feelings of worthlessness and shame than the comparison group. The feasibility, acceptability, and the positive trend toward significantly reducing internalized stigma, generated by this Family Connections pilot study, contributes valuable data to support adolescent/caregiver approaches that use peer groups.

'I married when I was 16 due to poverty, I had no other way': multi-level factors influencing HIV-related sexual risk behaviours among adolescent girls in Zambézia, Mozambique.

This paper explores individual, interpersonal- and household-level factors influencing HIV-related sexual risk behaviour among adolescent girls who participated in an intervention to reduce HIV risk in a rural setting in Mozambique. Twenty-eight adolescent girls ages 13-19, 30 heads of household, and 53 influential men participated in in-depth interviews at two time points. Comparative analysis compared girls who reported reducing risk behaviours over time to girls who did not and identified factors that respondents described as influential to behaviour change. Among the twenty girls self-reporting sexual risk at the first time point, half had reduced these behaviours one year later. Changes in girls' behaviours were contingent upon household- and interpersonal-level factors, particularly households' economic stability and family members' financial support. Future interventions with adolescents in similar settings should evaluate and leverage household and family support to achieve sexual risk reduction.

Adolescent and covert family planning users' experiences self-injecting contraception in Uganda and Malawi: implications for waste disposal of subcutaneous depot medroxyprogesterone acetate.

BACKGROUND: Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is poised to increase access to contraception; however, governments are concerned about the waste management of used units. Self-injectors in Malawi and Uganda are currently instructed to store used units in containers and return them to health workers for disposal. However, this may not be feasible in low-resource settings, especially for younger or covert self-injectors. We describe adolescent (15-19 years) and adult (20-49 years) self-injectors' disposal experiences in Uganda and Malawi. When possible, we compare covert and overt users' experiences. METHODS: We conducted cross-sectional qualitative studies in 2019 with 50 self-injectors in Uganda and 60 in Malawi. We purposively selected approximately half adolescents and included those trained by clinic-based providers and community health workers. We conducted semi-structured interviews and thematic data analysis and compared the findings across settings. RESULTS: Just under half of both samples were adolescents, substantially more of whom were covert users in Uganda (68%) than Malawi (~ 10%). Most participants reported being told to store used units in a container and return them to health workers. About two-thirds of Uganda participants had disposed of at least one unit by the interview, most commonly returning them to health workers. Over one-third of Malawi participants had disposed of at least one unit by the interview, slightly more disposed into latrines compared to returning to health workers. Participants in both settings reported compliance with health workers' disposal instructions as a primary reason for their disposal method. One-fifth of Uganda participants, mostly adolescent covert users, and one-quarter in Malawi said they were told they could dispose into latrines, and often did so. The majority in both settings said they would prefer to dispose units in latrines because they worried about needlestick injuries to others and because it was convenient. Some Uganda adolescent covert users felt returning units to health workers was challenging due to privacy concerns. CONCLUSIONS: While most self-injectors disposed of used units as instructed, findings from both studies suggest that returning units to health workers is not preferred and may not be feasible for some adolescent covert users. More convenient disposal solutions should be identified.

A Social Media-Based Support Group for Youth Living With HIV in Nigeria (SMART Connections): Randomized Controlled Trial.

BACKGROUND: Youth living with HIV (YLHIV) enrolled in HIV treatment experience higher loss to follow-up, suboptimal treatment adherence, and greater HIV-related mortality compared with younger children or adults. Despite poorer health outcomes, few interventions target youth specifically. Expanding access to mobile phone technology, in low- and middle-income countries (LMICs) in particular, has increased interest in using this technology to improve health outcomes. mHealth interventions may present innovative opportunities to improve adherence and retention among YLHIV in LMICs. OBJECTIVE: This study aimed to test the effectiveness of a structured support group intervention, Social Media to promote Adherence and Retention in Treatment (SMART) Connections, delivered through a social media platform, on HIV treatment retention among YLHIV aged 15 to 24 years and on secondary outcomes of antiretroviral therapy (ART) adherence, HIV knowledge, and social support. METHODS: We conducted a parallel, unblinded randomized controlled trial. YLHIV enrolled in HIV treatment for less than 12 months were randomized in a 1:1 ratio to receive SMART Connections (intervention) or standard of care alone (control). We collected data at baseline and endline through structured interviews and medical record extraction. We also conducted in-depth interviews with subsets of intervention group participants. The primary outcome was retention in HIV treatment. We conducted a time-to-event analysis examining time retained in treatment from study enrollment to the date the participant was no longer classified as active-on-treatment. RESULTS: A total of 349 YLHIV enrolled in the study and were randomly allocated to the intervention group (n=177) or control group (n=172). Our primary analysis included data from 324 participants at endline. The probability of being retained in treatment did not differ significantly between the 2 study arms during the study. Retention was high at endline, with 75.7% (112/163) of intervention group participants and 83.4% (126/161) of control group participants active on treatment. HIV-related knowledge was significantly better in the intervention group at endline, but no statistically significant differences were found for ART adherence or social support. Intervention group participants overwhelmingly reported that the intervention was useful, that they enjoyed taking part, and that they would recommend it to other YLHIV. CONCLUSIONS: Our findings of improved HIV knowledge and high acceptability are encouraging, despite a lack of measurable effect on retention. Retention was greater than anticipated in both groups, likely a result of external efforts that began partway through the study. Qualitative data indicate that the SMART Connections intervention may have contributed to retention, adherence, and social support in ways that were not captured quantitatively. Web-based delivery of support group interventions can permit people to access information and other group members privately, when convenient, and without travel. Such digital health interventions may help fill critical gaps in services available for YLHIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT03516318; https://clinicaltrials.gov/ct2/show/NCT03516318.

Factors associated with reported modern contraceptive use among married men in Afghanistan.

BACKGROUND: Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples. METHODS: Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis. RESULTS: Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not. CONCLUSIONS: Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.

Young Women's Experiences With Subcutaneous Depot Medroxyprogesterone Acetate: A Secondary Analysis of a One-Year Randomized Trial in Malawi.

PURPOSE: The purpose of this study was to compare the effectiveness, safety, and experiences with side effects of self-injected and provider-administered injectable contraception between young (18-24 years) versus older (≥25 years) women. METHODS: We conducted secondary analysis of data from a 12-month randomized controlled trial in Malawi, where a total of 731 women were randomized to receive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) administered by a provider or be trained to self-inject subcutaneous depot medroxyprogesterone acetate. Data collectors contacted women after the reinjection window at 3, 6, and 9 months to collect data on discontinuation and women's experiences, including adverse events. Twelve months after enrollment or at early discontinuation, women had their final interview, including pregnancy testing. We compared continuation, pregnancy, safety, and side effects among young women versus older women. RESULTS: Among self-injectors, there were no significant differences found in continuation by age (p = .345) with continuation rates at 12 months of 79% for young women and 69% for older women. Continuation rates were lower for both age groups with provider-administered injections. In the provider-administered group, continuation rates among young women (39%) were lower than among older women (49%) (p = .047). The distribution of reasons for discontinuation did not differ significantly by age for those receiving provider injections (p = .698). However, younger self-injectors were less likely to miss the reinjection window than older self-injectors (p = .011). Age did not significantly influence pregnancy or safety. CONCLUSIONS: With evidence of potential higher impact on continuation and no safety concerns, we recommend self-injection be added to the contraception options available to young women in low-resource settings.

Voluntary Contraceptive Uptake Among Postabortion Care Clients Treated With Misoprostol in Rwanda.

INTRODUCTION: Unsafe abortion remains a problem in Rwanda, where abortion is highly restricted by law. To reduce mortality and morbidity from unsafe abortion, Rwanda implemented a national postabortion care (PAC) program in 2012, which included using misoprostol to treat incomplete abortion. Key components of PAC are offering and providing voluntary contraceptive methods and counseling on their use, but little is known about contraceptive uptake among PAC clients treated with misoprostol. The objectives of the current study were (1) to assess the contraceptive uptake of PAC clients treated with misoprostol, including whether extended bleeding hinders uptake; and (2) to assess providers' knowledge of contraception and their willingness to counsel PAC clients on contraception, provide methods, or refer for contraceptive services. METHODS: We surveyed 68 PAC clients treated with misoprostol and 43 providers (84% nurses) in 17 health facilities across 3 districts in Rwanda where misoprostol for PAC had been introduced recently. PAC clients were recruited into the study prior to facility discharge and surveyed between 10 days and 1 month after discharge. We asked PAC clients and providers about demographic characteristics and attitudes toward contraception. We also asked PAC clients about contraceptive counseling received and postabortion contraceptive uptake or reasons for nonuse, and providers about their knowledge about return to fertility, pregnancy and contraceptive counseling, practices related to contraceptive method provision, and their knowledge and potential biases about PAC clients using contraception. We used descriptive statistics for analysis. RESULTS: PAC clients were 19-46 years old, and most (69%) had at least 1 child. Almost all PAC clients (94%) reported being counseled on contraception, but only 47% reported choosing and receiving a method before being discharged from the facility. Nevertheless, by the time of the survey, 71% reported using a method. PAC clients' main reason for not using contraception was wanting to become pregnant. Only 1 woman reported nonuse because of bleeding. Among providers, more than half (56%) reported there are contraceptive methods PAC clients should never use and about a quarter (26%) reported incorrect information on when PAC clients' fertility could return. CONCLUSION: We found no evidence that bleeding associated with misoprostol for PAC influenced women's contraceptive uptake. However, as PAC programs expand to include misoprostol as a treatment option, accurate and high-quality postabortion contraception counseling and method provision at both treatment and follow-up visits must be strengthened.

A longitudinal qualitative evaluation of an economic and social empowerment intervention to reduce girls' vulnerability to HIV in rural Mozambique.

PURPOSE: An intervention including business training and health education was implemented in Mozambique, where girls are at elevated risk for acquiring HIV. As part of a mixed-methods evaluation, we describe perceived effects of the intervention on girls' sexual behavior and school attendance. METHODS: We conducted 49 in-depth interviews (IDIs) with girl intervention participants (ages 13-19), 24 IDIs with heads of girls' households, 36 IDIs with influential males identified by girls, and 12 focus group discussions with community members after the intervention ended and one year later. RESULTS: Informants said the primary intervention benefit was realized when girls had money to stay in or return to school and/or to buy necessities for themselves and their households-reducing their need for transactional or intergenerational sex. However, some girls did not make a profit and some businesses were not sustainable. Sometimes the intervention appeared to be implemented in a way to reinforce inequitable gender norms resulting in some girls feeling shame when they reengaged in risky sex after their businesses failed. CONCLUSIONS: Earning money enabled girls to potentially reduce their vulnerability to HIV. We offer recommendations for future multi-sector interventions, including the need to address potential harms in programs serving vulnerable girls.

Opportunity, satisfaction, and regret: Trying long-acting reversible contraception in a unique scientific circumstance.

Increased use of long-acting reversible contraception (LARC) can reduce unintended pregnancies. However, significant barriers exist to LARC uptake, particularly high up-front costs. In North Carolina in 2014, we interviewed thirty-four purposively selected participants (aged 20-30 years) enrolled in a partially randomized patient preference trial to learn about their experiences with and attitudes toward contraception in this unique trial context. Cost of LARC was important in participants' decision-making. Experiencing an unintended pregnancy motivated women to switch to LARC. No participants who tried LARC, even those who experienced side effects, regretted it. Several participants regretted discontinuing their LARC. Concerns about insertion and removal did not influence future willingness to try LARC. Participants discussed the importance of affordability and feeling in control when choosing a contraceptive method. Cost, combined with uncertainty over whether LARC is the right method for them, may deter young women from trying LARC. Intrauterine devices (IUDs) and implants should be made affordable so that women can try them without significant financial commitment. Affordability will likely increase uptake, which will reduce unintended pregnancies. Regret from discontinuing LARC was more frequently reported than regret from trying LARC. Providers should offer young women LARC and counsel to support continuation.

Exploring intersections of localised gender norms and unanticipated effects of a sexual and reproductive health intervention: implications of respect and being a "good girl" in Zambézia Province, Mozambique.

Women First was a combined economic and social empowerment intervention implemented between 2010 and 2015 in Zambézia Province, Mozambique. The intervention was designed to reduce adolescent girls' risk of HIV and gender-based violence, improve school attendance and empower girls. However, perceptions of girls' improved respectfulness also emerged as an unanticipated effect during the programme evaluation. In this paper, we explore emic definitions of respect and girls' good behaviour and perceptions of how the intervention caused improvements in behaviour from the perspective of intervention participants, their heads of household, influential men in their lives, and community members. In depth interviews and focus group discussions were conducted at two time points in 12 rural communities where the intervention was implemented. Respondents described "good girls" as deferential and obedient; productive and willing to serve their families and communities; and sexually chaste and modestly dressed. Respondents believed the intervention had reinforced or taught these behaviours, although they were generally aligned with gender norms that were not part of the formal intervention content and sometimes contrary to the intervention's primary goals. Implications for future sexual and reproductive health programmes are discussed.

An Online Support Group Intervention for Adolescents Living with HIV in Nigeria: A Pre-Post Test Study.

BACKGROUND: Adolescents living with HIV (ALHIVs) enrolled in HIV treatment services experience greater loss to follow-up and suboptimal adherence than other age groups. HIV-related stigma, disclosure-related issues, lack of social support, and limited HIV knowledge impede adherence to antiretroviral therapy (ART) and retention in HIV services. The 90-90-90 goals for ALHIVs will only be met through strategies targeted to meet their specific needs. OBJECTIVES: We aimed to evaluate the feasibility of implementing a social media-based intervention to improve HIV knowledge, social support, ART adherence, and retention among ALHIV aged 15-19 years on ART in Nigeria. METHODS: We conducted a single-group pre-post test study from June 2017 to January 2018. We adapted an existing support group curriculum and delivered it through trained facilitators in 5 support groups by using Facebook groups. This pilot intervention included five 1-week sessions. We conducted structured interviews with participants before and after the intervention, extracted clinical data, and documented intervention implementation and participation. In-depth interviews were conducted with a subset of participants at study completion. Quantitative data from structured interviews and group participation data were summarized descriptively, and qualitative data were coded and summarized. RESULTS: A total of 41 ALHIV enrolled in the study. At baseline, 93% of participants reported existing phone access; 65% used the internet, and 64% were Facebook users. In addition, 37 participants completed the 5-session intervention, 32 actively posted comments in at least one session online, and at least half commented in each of the 5 sessions. Facilitators delivered most sessions as intended and on-time. Participants were enthusiastic about the intervention. Aspects of the intervention liked most by participants included interacting with other ALHIVs; learning about HIV; and sharing questions, experiences, and fears. The key recommendations were to include larger support groups and encourage more group interaction. Specific recommendations on various intervention components were made to improve the intervention. CONCLUSIONS: This novel intervention was feasible to implement in a predominantly suburban and rural Nigerian setting. Social media may be leveraged to provide much-needed information and social support on platforms accessible and familiar to many people, even in resource-constrained communities. Our findings have been incorporated into the intervention, and an outcome study is underway. TRIAL REGISTRATION: ClinicalTrials.gov NCT03076996; https://clinicaltrials.gov/ct2/show/NCT03076996 (Archived by WebCite at http://www.webcitation.org/73oCCEBBC).

Adolescents living with HIV in the Copperbelt Province of Zambia: Their reproductive health needs and experiences.

BACKGROUND: Understanding and meeting the reproductive health needs of adolescents living with HIV (ALHIV) is a growing concern since advances in antiretroviral therapy mean that many ALHIV are now living into adulthood and starting to have sex. METHODS: We conducted a mixed-methods study in the Copperbelt Province of Zambia to advance our understanding of the reproductive health needs of ALHIV and to assess the extent to which these needs are being met. We conducted in-depth interviews (IDIs) with 32 ALHIV from two HIV clinics, 23 with their caregivers, and 10 with clinic staff. ALHIV were interviewed twice. We used the data from the qualitative interviews to create a cross-sectional survey that we conducted with 312 ALHIV in three HIV clinics. FINDINGS: The vast majority of ALHIV reported they wanted to have children in the future but lacked knowledge about preventing mother-to-child transmission. Some sexually active adolescents used condoms, although they wanted more information about and access to non-condom methods. Many ALHIV reported that their first sexual encounters were forced. Religious beliefs prevented some caregivers from discussing premarital sex and contraception with ALHIV. Clinic staff and caregivers had mixed views about integrating contraceptive counseling and method provision into HIV care and treatment services. Few sexually active ALHIV reported that they disclosed their HIV status to their sexual partners and few reported that they knew their sexual partner's status. CONCLUSIONS: ALHIV are in dire need of comprehensive sexual and reproductive health services and information including a range of contraceptive methods to prevent pregnancy, knowledge about preventing mother-to-child transmission and having a healthy pregnancy, skills related to HIV disclosure and condom negotiation to prevent horizontal transmission, and screening for sexual violence for both males and females if services are available.

Client and provider experiences with self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in Malawi.

OBJECTIVE: As low- and middle-income countries (LMICs) consider adding self-administration of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to their contraceptive method mix, learning about family planning clients' and providers' experiences with self-injectable DMPA-SC during trials will inform introduction and scale-up efforts. STUDY DESIGN: We conducted semistructured interviews with 30 randomly selected adult women enrolled in the self-administration group of a 12-month randomized controlled trial studying DMPA-SC continuation rates in rural Malawi. We asked about their experiences learning to self-inject, self-injecting, remembering when to reinject, and storing and disposing of DMPA-SC. We also interviewed 12 providers - clinic-based providers (CBPs) and community-based health surveillance assistants (HSAs) - who trained clients to self-inject DMPA-SC during the trial. We asked about their experiences training and supporting women to self-inject DMPA-SC during the trial and their recommendations for scale-up of self-administered DMPA-SC. RESULTS: Clients and providers reported positive experiences with DMPA-SC self-injection. Clients felt that DMPA-SC self-injection saved them time and money, and providers felt that it reduced their workload and saved them time. We found that both CBPs and HSAs successfully trained clients to self-inject DMPA-SC and that clients safely and appropriately stored and disposed of DMPA-SC. CONCLUSIONS: Our findings contribute to the growing body of evidence of the feasibility of DMPA-SC self-injection in LMIC settings. We recommend that providers plan to train clients for at least 30min, emphasize the activating and injecting steps during training, use up to four practice injections per client trained and give self-injectors calendars to help them remember when to reinject. IMPLICATIONS: DMPA-SC self-administration should be made available in LMIC settings, but because it is a new practice, implementation guidance is needed. We offer practical recommendations for introducing and scaling up DMPA-SC self-administration based on clients' and providers' experiences during a trial investigating this practice in Malawi.

Factors Related to Incomplete Adherence to Antiretroviral Therapy among Adolescents Attending Three HIV Clinics in the Copperbelt, Zambia.

Little is known about adherence to antiretroviral therapy (ART) among adolescents in sub-Saharan Africa, where the majority of the world's HIV-positive adolescents reside. We assessed individual, household, and HIV self-management characteristics associated with a 48-hour treatment gap in the preceding 3 months, and a pharmacy medication possession ratio (MPR) that assessed the number of ART pills dispensed divided by the number of ART pills required in the past 6 months, among 285 Zambians, ages 15-19 years. Factors significantly associated with a 48-hour treatment gap were being male, not everyone at home being aware of the adolescent's HIV status, and alcohol use in the past month. Factors associated with an MPR < 90% included attending the clinic alone, alcohol use in the past month, and currently not being in school. Findings support programs to strengthen adolescents' HIV management skills with attention to alcohol use, family engagement, and the challenges adolescents face transitioning into adulthood, especially when they are no longer in school.

Transitioning to Second-line Antiretroviral Therapy Among Adolescents in Copperbelt Province, Zambia: Predictors of Treatment Switching and Adherence to Second-line Regimens.

BACKGROUND: Adolescents living with HIV (ALHIV) experience less favorable antiretroviral therapy (ART) outcomes than other age groups. First-line treatment failure complicates ART management as second-line regimens can be costlier and have greater pill burdens. Understanding predictors of switching ART regimens and adherence among adolescents on second-line ART may help to prevent poor treatment outcomes. METHODS: A quantitative survey was administered to 309 ALHIV attending 3 ART clinics in the Copperbelt Province, Zambia. Medical chart data, including pharmacy refill data, were abstracted. Associations between being on second-line ART and sociodemographic, psychosocial and ART adherence characteristics were tested. Cox proportional hazards models were used to estimate the effect of baseline ART variables on time to switching. RESULTS: Ten percent of participants were on second-line regimens. Compared with ALHIV on first-line ART, adolescents on second-line regimens were older (P = 0.02), out of school due to completion of secondary studies (P = 0.04) and on ART longer (P = 0.03). Adolescents on second-line regimens were more likely to report missing ≥48 consecutive hours of drugs in the last 3 months (P = 0.01). Multivariable analysis showed that adolescents who initiated ART with efavirenz-based regimens were more likely to switch to second-line than those put on nevirapine-based regimens (hazard ratio = 2.6; 95% confidence interval: 1.1-6.4). CONCLUSIONS: Greater support is needed for ALHIV who are on second-line regimens. Interventions for older adolescents that bridge the gap between school years and young adulthood would be helpful. More research is needed on why ALHIV who start on efavirenz-based regimens are more likely to switch within this population.

A Review of 10 Years of Vasectomy Programming and Research in Low-Resource Settings.

Vasectomy is a highly effective and safe contraceptive method for couples who want to stop childbearing, but only 2.4% of men around the world use this method. We conducted an extensive review of the vasectomy research literature and programmatic reports, published between April 2005 and April 2015, to synthesize barriers and facilitators to vasectomy adoption. Of the more than 230 documents initially retrieved in our search, we ultimately included 75 documents in our review and synthesized the findings according to the Supply-Enabling Environment-Demand (SEED) Programming Model. Regarding promoting demand for vasectomy services, we found there was a general lack of awareness about the method among both men and women, which often fueled erroneous assumptions about how vasectomy affects men. Several types of programmatic activities directly addressed knowledge gaps and negative misperceptions, including community-based and mass media communications, employer-based promotion, and group counseling. For supply of services, the lack of or inaccurate knowledge about vasectomy was also prevalent among providers, particularly among community-based health workers. Programmatic activities to improve service delivery included the use of evidence-based vasectomy techniques such as no-scalpel vasectomy, whole-site trainings, task shifting, cascade training, and mobile outreach. Finally, programmatic approaches to building a more enabling environment included engagement of governments and other community and religious leaders as well as campaigns with gender transformative messaging that countered common myths and encouraged men's positive engagement in family planning and reproductive health. In summary, a successful vasectomy program is comprised of the mutually reinforcing components of continual demand for services and access to and supply of well-trained providers. In addition, there is an underlying need for enabling policies within the cultural and gender environments that extend beyond vasectomy and include men not just as default partners of female family planning clients but as equal beneficiaries of family planning and reproductive health programs in their own right. Accelerating progress toward meaningful integration of vasectomy into a comprehensive contraceptive method mix is only possible when political and financial will are aligned and support the logistical and promotional activities of a male reproductive health agenda.

Contraceptive service delivery in Kenya: A qualitative study to identify barriers and preferences among female sex workers and health care providers.

OBJECTIVE: Female sex workers (FSWs) need access to contraceptive services, yet programs often focus on HIV prevention and less on the broader sexual and reproductive health needs of FSWs. We aimed to identify barriers to accessing contraceptive services among FSWs and preferences for contraceptive service delivery options among FSWs and health care providers (HCPs) in order to inform a service delivery intervention to enhance access to and use of contraceptives for FSWs in Kenya. STUDY DESIGN: Twenty focus group discussions were conducted with FSWs and HCPs in central Kenya. RESULTS: Three barriers were identified that limited the ability of FSWs to access contraceptive services: (1) an unsupportive clinic infrastructure, which consisted of obstructive factors such as long wait times, fees, inconvenient operating hours and perceived compulsory HIV testing; (2) discriminatory provider-client interactions, where participants believed negative and differential treatment from female and male staff members impacted FSWs' willingness to seek medical services; and (3) negative partner influences, including both nonpaying and paying partners. Drop-in centers followed by peer educators and health care facilities were identified as preferred service delivery options. CONCLUSIONS: FSWs may not be able to regularly access contraceptive services until interpersonal (male partners) and structural (facilities and providers) barriers are addressed. Alternative delivery options, such as drop-in centers coupled with peer educators, may be an approach worth evaluating. IMPLICATIONS STATEMENT: An unsupportive clinic infrastructure, discriminatory provider-client interactions and negative partner influences are barriers to FSWs accessing the contraception services they need. Alternative service delivery options, such integrating contraceptive service delivery at drop-in centers designed for FSWs and information delivery through peer educators, might provide improved access and better service quality to FSWs seeking contraception.