Browsing by Author "Brown, Anna"

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    Perspectives on contraceptive implant use in women living with HIV in Cape Town, South Africa: a qualitative study among primary healthcare providers and stakeholders
    (2019-07-26) Brown, Anna; Harries, Jane; Cooper, Diane; Morroni, Chelsea
    Abstract Background This study explored primary healthcare provider and HIV/contraception expert stakeholder perspectives on South Africa’s public sector provision of contraceptive implants to women living with HIV. We investigated the contraceptive service-impact of official advice against provision of implants to women using the HIV antiretroviral drug, efavirenz, issued by the South African National Department of Health (NDoH) in 2014. Methods Qualitative data was collected in Cape Town in 2017 from primary healthcare contraceptive providers in four clinics that provide implants, as well as from other expert stakeholders selected for expertise in HIV and/or contraception. In-depth interviews and a group discussion explored South Africa’s implant introduction and implant provision to women living with HIV. Data was analysed using an inductive thematic analysis approach. Results Interviews were conducted with 10 providers and 10 stakeholders. None of the four clinics where the providers worked currently offered the implant to women living with HIV. Stakeholders confirmed that this was consistent with patterns of implant provision at primary healthcare facilities across Cape Town. Factors contributing to providers’ decisions to suspend provision of the implant to women living with HIV included: inadequate initial and ongoing provider training; interpretation of NDoH communications about implant use with efavirenz; provider unwillingness to risk harming clients and concerns about professional liability; and other pressures related to provider capacity. Conclusions All South African women, including those living with HIV, should have access to the full range of contraceptive options for which they are medically eligible. Changing guidance should be initiated and communicated in consultation with primary-level providers and service beneficiaries. Guidance issued to providers needs to be clear and fully evidence-informed, and its correct interpretation and implementation facilitated and monitored. Guidance should be accompanied by provider training, as well as counselling messages and tools to support providers. Generalized retraining of providers in rights-based, client-centred family planning, and in particular implant provision for women with HIV, is needed. These recommendations accord with the right of women living with HIV to access the highest possible standard of sexual and reproductive healthcare, including informed contraceptive choice and access to the contraceptive implant.
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    Perspectives on etonogestrel implant use in HIV-infected women in Cape Town, South Africa: a qualitative study among providers and stakeholders
    (2018) Brown, Anna; Morroni, Chelsea; Harries, Jane
    Access to a range of safe and effective modern contraceptive methods enables women to make free and informed choices about their reproductive lives and broadly improves maternal and child health outcomes. Successful avoidance of unintended pregnancy and the corresponding ability to plan for pregnancy are especially valuable in the context of Human Immunodeficiency Virus (HIV) infection. Revised South African national guidelines seeking to expand overall contraceptive access were released in 2012 and, in response to the severity of the domestic HIV epidemic, specifically detailed the sexual and reproductive health rights and needs of HIV-positive women. Six years later, evaluation of the implementation and impact of these guidelines, as well as of more recent policy responses in this area, is necessary. This need for evaluation is outlined in Part A of this mini-dissertation in the form of a research proposal. A literature review (Part B) assesses what is currently known about considerations surrounding contraceptive decision-making in the context of HIV and antiretroviral therapy (ART). The use of the subdermal Long Acting Reversible Contraceptive (LARC) implant in HIV-positive women is explored in depth, given that the 2012 guidelines introduced the method as an entirely new option for South African women, as well as in light of recent controversy surrounding the implant’s provision to women taking the first-line ART drug, efavirenz (EFV). A journal-style article structured for submission to BMC Public Health (Part C) then uses thematic qualitative methodology to explore primary family planning provider and other relevant stakeholder perspectives on the provision of implants to HIV-positive women clients attending Cape Town primary care facilities. The study adds to existing literature regarding implant provision in the context of HIV and ART, and offers new insight into the impact of a 2014 South African Department of Health decision to recommend against the then-newly introduced implant as an option for women taking EFV-based ART. This research finds that several converging factors may have lead primary providers to view the implant as broadly contraindicated in all HIV-positive clients regardless of their iii exposure to EFV, namely: insufficient provider training; provider and community unfamiliarity with and scepticism about the new method; structural pressures on providers to keep up to date with and provide wide-ranging integrated services in busy clinical environments; and inadequate stakeholder consultation surrounding the wording and overall appropriateness of the implant/EFV guidance itself. Recommendations are provided in the article, including the need for: the retraining of primary healthcare providers in rights and choice-based family planning (particularly in implant provision and counselling); simplified counselling messages and user-friendly decision-making tools to help providers facilitate informed contraceptive choice for HIV-positive women; generalized beneficiary and community sensitization/education about implants including in the context of HIV and ART; and more comprehensive stakeholder/beneficiary consultation in future contraceptive policy-related endeavors.