Can payment by results ensure equitable access to contraceptive services? a qualitative case study.

BACKGROUND: The Leave No One Behind (LNOB) agenda compels sexual and reproductive health and rights (SRHR) implementers to focus on the multiple and intersecting forms of discrimination and inequalities. One strategy to address these is Payment by Results (PbR). Using the Women's Integrated Sexual Health (WISH) programme as a case study, this paper examines if and how PbR can ensure equitable reach and impact. METHODS: Given the complexity of PbR mechanisms, a theory-based approach was used in the design and analysis of this evaluation, drawing on four case studies. These were conducted by reviewing global and national programme data and by interviewing 50 WISH partner staff at national level and WISH programme staff at global and regional levels. RESULTS: The case studies found that inclusion of equity-based indicators in the PbR mechanism had demonstrable effects on people's incentives, on how systems work, and on modes of working. The WISH programme was successful in achieving its desired programme indicators. The use of Key Performance Indicators (KPIs) clearly incentivised several strategies for service providers to innovate and reach adolescents and people living in poverty. However, there were trade-offs between performance indicators that increased coverage and others that increased equitable access, as well as several systemic challenges that limited the possible incentive effects. CONCLUSIONS: The use of PbR KPIs incentivised several strategies to reach adolescents and people living in poverty. However, the use of global indicators was too simplistic, resulting in several methodological issues.

Prevalence and determinants of contraception utilization over time in Migori County, Kenya: Repeated cross-sectional household surveys.

Contraception use and family planning have been shown to save lives and benefit women, their families, and their communities. We conducted a cross-sectional study analyzing data from a 2021 survey that was conducted across eight different regions in Migori County, Kenya to examine the potential role that different factors play in meeting family planning targets. Comparisons are made to data collected in 2018/2019 in order to estimate the change over time of contraception uptake. Descriptive statistics were calculated, the Cochran-Mantel-Haenszel test was used to compare contraception use over time, and multivariable logistic regression was used to model determinants of contraceptive use. Sixty-four percent of respondents in 2021 reported that they currently use some form of contraception, and implants are the most popular contraceptive method. Factors associated with higher contraception usage were region, ages 25-34 years, and marital status. Contraception uptake increased significantly in East Kamagambo following a community-driven sexual and reproductive health intervention by the Lwala Community Alliance, suggesting that increased investment in family planning may be influential. We recommend targeted outreach to population groups with low uptake of contraception and investment in both demand- and supply-side interventions to increase contraceptive uptake. Additional research, especially for populations under 18, is needed to further inform effective investment and policy.

Impact of the Safe Childbirth Checklist on health worker childbirth practices in Luapula province of Zambia: a pre-post study.

BACKGROUND: A strong evidence base exists regarding routine and emergency services that can effectively prevent or reduce maternal and new-born mortality. However, even when skilled providers care for women in labour, many of the recommended services are not provided, despite being available. Barriers to the provision of appropriate childbirth services may include lack of availability of supplies, limited health worker knowledge and confidence, or inadequate time. The WHO Safe Childbirth Checklist (SCC) includes reminders for evidenced-based practices at specific points in the childbirth process. Zambia is currently considering nation-wide adoption of the SCC, but there is a need for context-specific evidence. Beginning in September 2017, a program is being implemented in Nchelenge District to pilot use of the SCC, along with coaching that focuses on strengthening the systems that allow the essential practices in childbirth to be performed. METHODS: This study will use a pre-post study design to measure health worker adherence to the essential practices for delivery care outlined in the SCC. Data will be collected through observations of health workers as they care for mothers during childbirth at four facilities. Data collection will take place before the start of the intervention, at 3 months, and at 6 months post-intervention. The primary outcome interest is the change in the average proportion of essential childbirth practices completed. A health worker questionnaire will be administered at the time that the SCC is introduced and 6 months later to gather their perspectives on incorporating the SCC into clinical practice in Zambia. DISCUSSION: Findings are expected to inform plans for introducing the SCC in Zambia. This evaluation will aim to understand uptake and impact of the SCC and associated coaching in the context of a basic level of mentorship that the government could feasibly provide at a national scale. TRIAL REGISTRATION: Clinical Trials.gov ( NCT03263182 ) Registered August 28, 2017.

Impact of passenger engagement through road safety bus stickers in public service vehicles on road traffic crashes in Zambia: a randomized controlled trial.

BACKGROUND: Road Traffic Crashes (RTCs) are the third highest cause of death in Zambia, claiming about 2000 lives annually, with pedestrians and cyclists being the most vulnerable. Human error accounts for 87.3% of RTCs. Minibus and big bus public service vehicles (PSVs) are among the common vehicle types involved in these crashes. Given the alarmingly high rate of road traffic crashes involving PSV minibuses and big buses within Zambia, there is a need to mitigate this through innovative solutions. In other settings, it has been shown that stickers in PSVs encouraging passengers to speak out against reckless driving can reduce RTCs, but it is unclear whether such an intervention could work in Zambia. Based on this evidence, the Zambia Road Transport and Safety Agency (RTSA) has developed a road safety bus sticker campaign for PSVs and before national scale-up, RTSA is interested in evidence of the impact of these stickers. METHODS: This evaluation will be a stratified two-arm randomized controlled trial with a one-to-one ratio. The sample will be stratified by vehicle type, thus creating a two-arm trial for minibuses and a separate two-arm trial for big buses. The sample will include 2110 minibuses and 300 big buses from four towns in Zambia. The primary outcome of interest will be the difference in the rate of RTCs over a 14-month period (7-months before the intervention and 7 months after) between buses with and without the new RTSA road safety bus stickers. DISCUSSION: This study will provide evidence on the impact of the Zambian sticker program on road traffic crashes as implemented through minibuses and big buses, that can help inform the scale up of a national 'Zambia road safety bus sticker campaign'. TRIAL REGISTRATION: PACT-R, PACTR201711002758216 . Registered 13 November 2017-Retrospectively registered.

Interpersonal violence against women and maternity care in Migori County, Kenya: evidence from a cross-sectional survey.

Background: Interpersonal violence (IPV) is an issue of major public health concern, with 24% of Kenyan women reporting physical violence perpetrated by a current husband or partner. IPV has profound impacts on physical and mental health outcomes, particularly for pregnant women; it has been found to increase the risk of perinatal mortality, low birth weight, and preterm birth. This study aims to identify variables associated with IPV and assess the effects of IPV experience on prenatal and peripartum maternal healthcare in Migori County, Kenya. Findings build on a previous study that investigated a smaller region of Migori County. Methods: Responses to cross-sectional household surveys conducted in six wards of Migori County, Kenya in 2021 from female respondents aged 18 and older were analyzed. The survey contained validated screening tools for interpersonal violence. Group-wise comparisons, and bivariate and multivariate logistic regression analyses were performed to describe community prevalence, factors associated with IPV against women, and the effect of IPV exposure on prenatal and peripartum health care. Results: This study finds that 2,306 (36.7%) of the 6,290 respondents had experienced lifetime IPV. IPV experience was associated with the age group 25-49 (adjusted odds ratio (aOR) 1.208; 95%CI: [1.045-1.397]; p = 0.011), monogamous marriage [aOR 2.152; 95%CI: (1.426-3.248); p < 0.001], polygamous marriage [aOR 2.924; 95%CI: (1.826-4.683); p < 0.001], being widowed/divorced/separated [aOR 1.745; 95%CI: (1.094-2.786); p < 0.001], feeling an attitude of "sometimes okay" toward wife beating [aOR 2.002 95%CI: (1.651, 2.428); p < 0.001], having been exposed to IPV in girlhood [aOR 2.525; 95%CI: (2.202-2.896); p < 0.001] and feeling safe in the current relationship [aOR 0.722; 95%CI: (0.609, 0.855); p < 0.001]. A depression score of mild [aOR 1.482; 95%CI: (1.269, 1.73); p < 0.001] and severe [aOR 2.403; 95%CI: (1.429, 4.039); p = 0.001] was also associated with IPV experience, and women who experienced emotional abuse were much more likely to have experienced IPV [aOR 10.462; 95% CI: (9.037, 12.112); p < 0.001]. Adjusted analyses showed that having experienced IPV was negatively associated with attending at least four antenatal care visits during the most recent pregnancy (OR 0.849, p = 0.044) and with having a skilled birth attendant (OR 0.638, p = 0.007). Conclusions: IPV is prevalent in Migori County, Kenya, with increased prevalence among women aged 25-49, those residing in West Kanyamkago, those in a monogamous or polygamous marriage, those who have been widowed/divorced/separated, and those with severe depressive symptoms. Further, IPV exposure is associated with lower use of maternal care services and may lead to worse maternal health outcomes. There is need for enhanced effort in addressing social and gender norms that perpetuate IPV, and this study can contribute to guiding policy interventions and community responses towards IPV.

Adapting to a global pandemic: a qualitative assessment of programmatic responses to COVID-19 in the multi-country Women's Integrated Sexual Health (WISH) programme.

The COVID-19 pandemic caused significant disruption to sexual and reproductive health and rights (SRHR) globally but there is little published evidence on the COVID-19 response of SRHR programmes, or lessons learned through their adaptations. To document the COVID-19 response of a global SRHR programme (the Women's Integrated Sexual Health programme), in-depth interviews were conducted between April and July 2021 with 22 key informants from implementing partners in Sierra Leone, Ethiopia and central or regional offices, the UK Foreign, Commonwealth and Development Office and the third-party monitoring partner. Framework analysis methods were used. Several rapid COVID-19 adaptations were identified: the development of crisis management and communication teams; increased partnership and engagement with government; reduced contact and risk in service delivery; reformulated community mobilisation; flexible performance management and remote methods of quality assurance; and sharing of learnings alongside the development of new guidance and tools. Throughout the pandemic, the programme was able to continue high-quality service delivery, though equity goals proved more difficult to reach. Challenges included the continually changing environment, competing pressures on governments, burdensome reporting, and staff burnout. The pandemic response was facilitated by prior experience of health emergencies, strong government relationships, a supportive workforce and some pre-existing approaches, tools, and systems. This study has identified important lessons that can inform programming in future crises, including the need for immediate recognition of SRHR as essential, sustained support for staff, use of multiple mechanisms to reach marginalised groups, adequate funding for equity goals, and a better balance between the burden of reporting and accountability needs.

Training and experience outperform literacy and formal education as predictors of community health worker knowledge and performance, results from Rongo sub-county, Kenya.

Introduction: There is a growing recognition that Community Health Workers are effective at improving health outcomes and expanding health access. However, the design elements that lead to high-quality Community Health Worker programing are relatively understudied. We looked at the predictors of Community Health Worker knowledge of obstetric and early infant danger signs as well as performance in achieving antenatal care and immunization uptake among their clients. Methods: The study takes place in the context of an intervention implemented jointly by Lwala Community Alliance and the Kenya Ministry of Health which sought to professionalize Community Health Worker cadres through enhanced training, payment, and supervision. There were four cohorts included in the study. Two cohorts started receiving the intervention prior to the baseline, one cohort received the intervention between the baseline and endline, and a final cohort did not receive the intervention. Data on Community Health Worker demographics, knowledge tests, and key performance indicators were collected for 234 Community Health Workers. Regression analyses were used to explore education, literacy, experience, training, and gender as potential predictors of CHW performance. Results: We found that clients of Community Health Workers trained through the intervention were 15% more likely to be fully immunized and 14% more likely to have completed four or more antenatal care visits. Additionally, recency of training and experience caring for pregnant women were associated with increased Community Health Worker knowledge. Finally, we found no association between gender and CHW competency and tenuous associations between education/literacy and Community Health Worker competency. Discussion: We conclude that the intervention was predictive of increased Community Health Worker performance and that recency of training and experience were predictive of increased knowledge. Though education and literacy are often used in the selection processes of Community Health Workers globally, the link between these characteristics and Community Health Worker knowledge and performance are mixed. Thus, we encourage further research into the predictive value of common Community Health Worker screening and selection tools. Further, we encourage policymakers and practitioners to reconsider the use of education and literacy as means of Community Health Worker selection.

Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey.

OBJECTIVES: The under-five mortality (U5M) rate in Kenya (41 per 1000 live births) remains significantly above international goals (25 per 1000 live births). This is further exacerbated by regional inequalities in mortality. We aimed to describe U5M in Migori County, Kenya, and identify associated factors that can serve as programming targets. DESIGN: Cross-sectional observational survey. SETTING: Areas served by the Lwala Community Alliance and control areas in Migori County, Kenya. PARTICIPANTS: This study included 15 199 children born to respondents during the 18 years preceding the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was mortality in the first 5 years of life. The survey was powered to detect a 10% change in various health metrics over time with 80% power. RESULTS: A total of 15 199 children were included in the primary analyses, and 230 (1.5%) were deceased before the fifth birthday. The U5M rate from 2016 to 2021 was 32.2 per 1000 live births. Factors associated with U5M included year of birth (HR 0.926, p<0.001), female sex (HR 0.702, p=0.01), parental marriage (HR 0.642, p=0.036), multiple gestation pregnancy (HR 2.776, p<0.001), birth spacing less than 18 months (HR 1.894, p=0.005), indoor smoke exposure (HR 1.916, p=0.027) and previous familial contribution to the National Hospital Insurance Fund (HR 0.553, p=0.009). The most common cause of death was malaria. CONCLUSIONS: We describe factors associated with childhood mortality in a Kenyan community using survival analyses of complete birth histories. Mortality rates will serve as the baseline for future programme evaluation as a part of a 10-year study design. This provides both the hyperlocal information needed to improve programming and generalisable conclusions for other organisations working in similar environments.

The clinical burden of malaria in Nairobi: a historical review and contemporary audit.

BACKGROUND: Widespread urbanization over the next 20 years has the potential to drastically change the risk of malaria within Africa. The burden of the disease, its management, risk factors and appropriateness of targeted intervention across varied urban environments in Africa remain largely undefined. This paper presents a combined historical and contemporary review of the clinical burden of malaria within one of Africa's largest urban settlements, Nairobi, Kenya. METHODS: A review of historical reported malaria case burdens since 1911 within Nairobi was undertaken using archived government and city council reports. Contemporary information on out-patient case burdens due to malaria were assembled from the National Health Management and Information System (HMIS). Finally, an audit of 22 randomly selected health facilities within Nairobi was undertaken covering 12 months 2009-2010. The audit included interviews with health workers, and a checklist of commodities and guidelines necessary to diagnose, treat and record malaria. RESULTS: From the 1930's through to the mid-1960's malaria incidence declined coincidental with rapid population growth. During this period malaria notification and prevention were a priority for the city council. From 2001-2008 reporting systems for malaria were inadequate to define the extent or distribution of malaria risk within Nairobi. A more detailed facility review suggests, however that malaria remains a common diagnosis (11% of all paediatric diagnoses made) and where laboratories (n = 15) exist slide positivity rates are on average 15%. Information on the quality of diagnosis, slide reading and whether those reported as positive were imported infections was not established. The facilities and health workers included in this study were not universally prepared to treat malaria according to national guidelines or identify foci of risks due to shortages of national first-line drugs, inadequate record keeping and a view among some health workers (17%) that slide negative patients could still have malaria. CONCLUSION: Combined with historical evidence there is a strong suggestion that very low risks of locally acquired malaria exist today within Nairobi's city limits and this requires further investigation. To be prepared for effective prevention and case-management of malaria among a diverse, mobile population in Nairobi requires a major paradigm shift and investment in improved quality of malaria diagnosis and case management, health system strengthening and case reporting.

Attracting and retaining health workers in rural areas: investigating nurses' views on rural posts and policy interventions.

BACKGROUND: Kenya has bold plans for scaling up priority interventions nationwide, but faces major human resource challenges, with a lack of skilled workers especially in the most disadvantaged rural areas. METHODS: We investigated reasons for poor recruitment and retention in rural areas and potential policy interventions through quantitative and qualitative data collection with nursing trainees. We interviewed 345 trainees from four purposively selected Medical Training Colleges (MTCs) (166 pre-service and 179 upgrading trainees with prior work experience). Each interviewee completed a self-administered questionnaire including likert scale responses to statements about rural areas and interventions, and focus group discussions (FGDs) were conducted at each MTC. RESULTS: Likert scale responses indicated mixed perceptions of both living and working in rural areas, with a range of positive, negative and indifferent views expressed on average across different statements. The analysis showed that attitudes to working in rural areas were significantly positively affected by being older, but negatively affected by being an upgrading student. Attitudes to living in rural areas were significantly positively affected by being a student at the MTC furthest from Nairobi. During FGDs trainees raised both positive and negative aspects of rural life. Positive aspects included lower costs of living and more autonomy at work. Negative issues included poor infrastructure, inadequate education facilities and opportunities, higher workloads, and inadequate supplies and supervision. Particular concern was expressed about working in communities dominated by other tribes, reflecting Kenya's recent election-related violence. Quantitative and qualitative data indicated that students believed several strategies could improve rural recruitment and retention, with particular emphasis on substantial rural allowances and the ability to choose their rural location. Other interventions highlighted included provision of decent housing, and more rapid career advancement. However, recently introduced short term contracts in named locations were not favoured due to their lack of pension plans and job security. CONCLUSIONS: This study identified a range of potential interventions to increase rural recruitment and retention, with those most favored by nursing students being additional rural allowances, and allowing choice of rural location. Greater investment is needed in information systems to evaluate the impact of such policies.

Improving the quality of childbirth services in Zambia through introduction of the Safe Childbirth Checklist and systems-focused mentorship.

Although strong evidence exists about the effectiveness of basic childbirth services in reducing maternal and newborn mortality, these services are not provided in every childbirth, even those at health facilities. The WHO Safe Childbirth Checklist (SCC) was developed as a job aide to remind health workers of evidenced-based practices to be provided at specific points in the childbirth process. The Zambian government requested context-specific evidence on the feasibility and outcomes associated with introducing the checklist and related mentorship. A study was conducted on use of the SCC in four facilities in Nchelenge District of Zambia. Observations of childbirth services were conducted just before and six months after the introduction of the intervention. Observers used a structured tool to record adherence to essential services indicated on the checklist. The primary outcome of interest was the change in the average proportion of essential childbirth practices completed. Feedback questionnaires were administered to health workers before and six months after the intervention. At baseline and endline, 108 and 148 pause points were observed, respectively. There was an increase from 57% to 76% of tasks performed (p = 0.04). Considering only these cases where necessary supplies were available, health workers completed 60% of associated tasks at baseline compared to 84% at endline (p<0.01). Some tasks, such as taking an infant's temperature and hand washing, were never or rarely performed at baseline. Feedback from the health workers indicated that nearly all health workers agreed or strongly agreed with positive statements about the intervention. The performance of health workers in Zambia in completing essential practices in childbirth was low at baseline but improvements were observed with the introduction of the SCC and mentorship. Our results suggest that such interventions could improve quality of care for facility-based childbirth. However, national-level commitment to ensuring availability of trained staff and supplies is essential for success. Trial registration Clinical Trials.gov (NCT03263182) Registered August 28, 2017 This study adheres to CONSORT guidelines.

Report on invasive disease and meningitis due to Haemophilus influenzae and Streptococcus pneumonia from the Network for Surveillance of Pneumococcal Disease in the East African Region.

Pneumococcal disease in young children has not been as well characterized in East Africa as it has been in industrialized countries. Although pneumococci are likely to cause substantial mortality and morbidity, universal diagnostic challenges plus the rudimentary nature of public health surveillance make the true epidemiological characteristics of these diseases difficult to ascertain with these methods alone. However, local data are critical to inform the debate on vaccine deployment and assess vaccine impact. The Network for Surveillance of Pneumococcal Disease in the East African Region has worked to expand the World Health Organization Paediatric Bacterial Meningitis Surveillance Network-initiated surveillance process aimed at Haemophilus influenza type b to perform surveillance on pneumococcal diseases. A total of 119 H. influenzae isolates from children aged >2 years but <5 years of age have been confirmed. Eighty-three isolates (69.75%) were serotype b, 19 belonged to other capsular antigen groups, and 17 were nontypable. For Streptococcus pneumoniae, a total of 442 isolates were confirmed to be pneumococci; 302 isolates were from blood cultures, and 140 were from cultures of cerebrospinal fluid. Most of the isolates were obtained from patients in the 6-29-month age group; in this age group, overall coverage by the heptavalent vaccine was 56% (increasing to 67% with the addition of cross-protection due to serotype 6A). S. pneumoniae isolates are susceptible to most commonly used antibiotics, with the exception of trimethoprim-sulfamethoxazole, and have exhibited no resistance to penicillin. A surveillance network is in place to provide local data on the importance of S. pneumoniae as a cause of both meningitis and bacteremia. Serotypes in the currently available heptavalent conjugate pneumococcal vaccine and related serotypes account for two-thirds of invasive pneumococcal disease among children aged 6-29 months.

Behind the data: establishing the Network for Surveillance of Pneumococcal Disease in the East African Region.

In a region with high rates of mortality among children aged <5 years, the underfunded health care systems of sub-Saharan Africa have few resources available to perform surveillance activities that can help determine the causes of morbidity and mortality in the region. At present, there are few examples of attempts to promote public health care surveillance that might inform current debates about how to expand and improve surveillance, particularly for bacterial diseases. Driven by this gap in knowledge, we attempted to explore the successes and failures of the Network for Surveillance of Pneumococcal Disease in the East African Region and to share the experiences of what are essentially nonresearch public-sector hospitals in East Africa, with the hopes that surveillance systems for other diseases, especially those that require complex diagnostic support, may be informed by these experiences. The state of services essential for surveillance and the measures taken to overcome any shortcomings are described, as is the progress made in improving clinical diagnosis, laboratory processing, and data management. For surveillance to play a role in public health care, ministries of health and associated institutions must own and push forward the surveillance agenda, with support from global partners, and take advantage of the developments that have been achieved within the institutions.

Impact of the Umoyo mother-infant pair model on HIV-positive mothers' social support, perceived stigma and 12-month retention of their HIV-exposed infants in PMTCT care: evidence from a cluster randomized controlled trial in Zambia.

BACKGROUND: Public health systems in resource-constrained settings have a critical role to play in the elimination of HIV transmission but are often financially constrained. This study is an evaluation of a mother-infant-pair model called "Umoyo," which was designed to be low cost and scalable in a public health system. Facilities with the Umoyo model dedicate a clinic day to provide services to only HIV-exposed infants (HEIs) and their mothers. Such models are in operation with reported success in Zambia but have not been rigorously tested. This work establishes whether the Umoyo model would improve 12-month retention of HEIs. METHODS: A cluster randomized trial including 28 facilities was conducted across two provinces of Zambia to investigate the impact on 12-month retention of HEIs in care. These facilities were offering Prevention of Mother-to-Child-Transmission (PMTCT) services and supported by the same implementing partner. Randomization was achieved by use of the covariate-constrained optimization technique. Secondary outcomes included the impact of Umoyo clinics on social support and perceived HIV stigma among mothers. For each of the outcomes, a difference-in-difference analysis was conducted at the facility level using the unweighted t test. RESULTS: From 13 control (12-month retention at endline: 45%) and 11 intervention facilities (12-month retention at endline: 33%), it was found that Umoyo clinics had no impact on 12-month retention of HEIs in the t test (- 11%; 99% CI - 40.1%, 17.2%). Regarding social support and stigma, the un-weighted t test showed no impact though sensitivity tests showed that Umoyo had an impact on increasing social support (0.31; 99% CI 0.08, 0.54) and reducing perceived stigma from health care workers (- 0.27; 99% CI - 0.46, - 0.08). CONCLUSION: The Umoyo approach of having a dedicated clinic day for HEIs and their mothers did not improve retention of HEIs though there are indications that it can increase social support among mothers and reduce stigma. Without further support to the underlying health system, based on the evidence generated through this evaluation, the Umoyo clinic day approach on its own is not considered an effective intervention to increase retention of HIV-exposed infants. TRIAL REGISTRATION: Pan African Clinical Trial Registry, ID: PACTR201702001970148 . Prospectively registered on 13 January 2017.

Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania.

AIM: To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa. DESIGN: Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression. RESULTS: Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use. CONCLUSIONS: There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.