Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic.

OBJECTIVES: To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use. METHODS: Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically. RESULTS: 64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears. CONCLUSIONS: Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.

Exploring risk of experiencing intimate partner violence after HIV infection: a qualitative study among women with HIV attending postnatal services in Swaziland.

OBJECTIVE: To explore risks of experiencing intimate partner violence (IPV) after HIV infection among women with HIV in a postnatal care setting in Swaziland. DESIGN: A qualitative semistructured in-depth interview study, using thematic analysis with deductive and inductive coding, of IPV experiences after HIV infection extracted from service-integration interview transcripts. SETTING: Swaziland. PARTICIPANTS: 19 women with HIV, aged 18-44, were purposively sampled for an in-depth interview about their experiences of services, HIV and IPV from a quantitative postnatal cohort participating in an evaluation of HIV and reproductive health services integration in Swaziland. RESULTS: Results indicated that women were at risk of experiencing IPV after HIV infection, with 9 of 19 disclosing experiences of physical violence and/or coercive control post-HIV. IPV was initiated through two key pathways: (1) acute interpersonal triggers (eg, status disclosure, mother-to-child transmission of HIV) and (2) chronic normative tensions (eg, fertility intentions, initiating contraceptives). CONCLUSIONS: The results highlight a need to mitigate the risk of IPV for women with HIV in shorter and longer terms in Swaziland. While broader changes are needed to resolve gender disparities, practical steps can be institutionalised within health facilities to reduce, or avoid increasing, IPV pathways for women with HIV. These might include mutual disclosure between partners, greater engagement of Swazi males with HIV services, and promoting positive masculinities that support and protect women. TRIAL REGISTRATION NUMBER: NCT01694862.

Integration of HIV and maternal healthcare in a high HIV-prevalence setting: analysis of client flow data over time in Swaziland.

OBJECTIVE: Maternal and child health (MCH) care may provide an entry point for HIV services in high HIV-prevalence settings. Our objective was to assess integration of HIV with MCH services in public sector facilities in Swaziland. DESIGN: In 2009, 2010 and 2012, client flow assessments (CFAs) were conducted over 5 days in the MCH units of eight government facilities, purposively selected as intervention or comparison sites. PARTICIPANTS: 8263 MCH visits with female clients were tracked: 3261 in 2009, 2086 in 2010 and 2916 in 2012. INTERVENTION: Activities and resources to strengthen integration of HIV services into postnatal care (PNC), 2009-2010. MAIN OUTCOME MEASURES: The proportion of all visits in which an HIV/sexually transmitted infection (STI) testing, counselling or treatment was received together with an MCH service; the proportion of all visits in which a client receives HIV counselling. RESULTS: Across facilities, the proportion of visits in which HIV/STI and MCH services were received varied considerably, for example, from 9% to 49% in 2009. HIV/STI services were integrated most frequently with child health (CH), antenatal care (ANC) and family planning (FP)-the most common reasons for women's attendance-and least often with PNC and cervical screening (CS). There was no meaningful difference in integration over time by design group and considerable heterogeneity across facilities. Receipt of integrated services increased in one intervention and two comparison facilities, where HIV counselling also rose, and fell in one intervention and two comparison facilities. CONCLUSIONS: Provision of HIV/STI services with MCH care occurred at all facilities, yet relatively few women receive integrated services. Increases in integration were driven by increases in HIV counselling, while sharp declines in some facilities indicate that integration is difficult to sustain. Opportunities for intensifying HIV integration lie with ANC, CH and FP, while HIV-PNC integration will remain limited until more women attend PNC. TRIAL REGISTRATION NUMBER: Current Controlled Trials NCT01694862.

Are integrated HIV services less stigmatizing than stand-alone models of care? A comparative case study from Swaziland.

INTRODUCTION: Integrating HIV with primary health services has the potential to reduce HIV-related stigma through delivering care in settings disassociated with HIV. This study investigated the relationship between integrated care and felt stigma. The study design was a comparative case study of four models of HIV care in Swaziland, ranging from fully integrated to fully stand-alone HIV care. METHODS: An exit survey (N=602) measured differences in felt stigma across model of care; the primary outcome "perception of HIV status exposure through clinic attendance" was analyzed using multivariable logistic regression. In-depth interviews (N=22) explored whether and how measured differences in stigma experiences were related to service integration. RESULTS: There were significant differences in perceived status exposure across models of care. After adjustment for potential confounding between sites, those at a partially integrated site and a partially stand-alone site had greater odds of perceived status exposure than those at the fully stand-alone site (aOR 3.33, 95% CI 1.98-5.60; and aOR 11.84, 95% CI 6.89-20.36, respectively). There was no difference between the fully stand-alone and the fully integrated clinic. Qualitative data suggested that many clients at HIV-only sites felt greater confidentiality knowing that those around them were positive, and support was gained from other HIV care clients. Confidentiality was maintained in various ways, even in stand-alone sites, through separate waiting areas for HIV testing and HIV treatment, and careful clinic and room labelling. CONCLUSIONS: The relationship between model of care and stigma was complex, and the hypothesis that stigma is higher at stand-alone sites did not hold true in this high prevalence setting. Policy-makers should ensure that service integration does not increase stigma, in particular within partially integrated models of care.

Need, demand and missed opportunities for integrated reproductive health-HIV care in Kenya and Swaziland: evidence from household surveys.

OBJECTIVE: Little is known about the need and demand for integrated reproductive health and HIV services at the population level. DESIGN: Descriptive data analysis of household surveys collected by the Integra Initiative. METHODS: Household surveys were conducted among 18-49-year-olds in Kenya (N = 1752) and Swaziland (N = 779) in 2009. Data on fertility intentions, contraceptive use, sexual behaviours and HIV testing were used to determine unmet needs. Demand for integrated services was defined as wanting reproductive health services with HIV/sexually transmitted infection (STI) services within one visit. RESULTS: At the population level, family planning needs (90%) were higher than HIV/STI prevention needs: 53% (women) and 75% (men). Fewer had unmet family planning needs through non-use of contraceptives: 17% (women) and 27% (men); versus unmet HIV/STI prevention needs through inconsistent condom use: 48 and 26% of women; 51 and 32% of men in Kenya and Swaziland, respectively. Dual need was higher for men: 64% (Kenya) and 73% (Swaziland) versus women (48%) with more unmet in Kenya (43%) compared to Swaziland (25%). Missed opportunities for integrated service provision were high among women: 49 and 57% with unmet family planning needs; and 55 and 32% with unmet HIV/STI prevention needs in Kenya and Swaziland, respectively, used services, but did not receive the needed service. Most men with unmet needs were non-service users. Approximately a quarter of women wanted and received integrated reproductive health-HIV/STI services in both countries. CONCLUSIONS: Demand creation at the community level and provider-initiated integrated service provision are needed, using different strategies for men and women, to address substantial family planning and HIV/STI prevention needs.

The relationship between service integration and client satisfaction: a mixed methods case study within HIV services in a high prevalence setting in Africa.

Integration of HIV with other primary health services, including sexual and reproductive health (SRH) care, is being widely promoted in sub-Saharan Africa. However, evidence on its benefits is equivocal, and some studies indicate client preferences for stand-alone HIV services. A comparative case study investigated the relationship between integration and client satisfaction across different models of care in Swaziland: two clinics integrated with SRH services, and two stand-alone HIV clinics. An exit survey (n=602) measured satisfaction across model using logistic regression. In-depth interviews (n=22), repeated three times, explored satisfaction and how it was influenced by integration or not. Satisfaction was highest at the fully stand-alone clinic; in multivariable models, clients there were more satisfied than partially integrated and partially stand-alone sites (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.25-0.81; and aOR 0.53, 95% CI 0.31-0.90, respectively); there was no difference between the fully integrated and fully stand-alone sites. Qualitative analysis suggested that satisfaction was constituted by eleven dimensions of care, including access to HIV medication, interpersonal care, efficiency, and confidentiality. Some dimensions were positively influenced by integration, while others were positively influenced by stand-alone care; some were not influenced by integration at all. Assumptions on the inherent value of integrated care were challenged in this high HIV prevalence setting, where stand-alone HIV care could be equally if not more satisfying to many clients. Those aiming to scale-up access to HIV care in this region may need to consider providing a variety of treatment models for clients with different health care needs.