Strengthening implant provision and acceptance in South Africa with the ‘Any woman, any place, any time’ approach: An essential step towards reducing unintended pregnancies

Progress in reducing unintended pregnancies in South Africa is slow. The implant, introduced in 2014, expanded the range of available longacting reversible contraceptives (LARCs) and held much promise. Uptake, however, has declined precipitously, in spite of its ‘unmatched effectiveness’ and high levels of satisfaction for most users. We propose policy and provider interventions to raise implant use, underscored by a ‘LARC-first’ approach. Contraceptive counselling should focus on the particular benefits of LARCs and methods be presented in order of effectiveness. Moreover, implants hold particular advantages for certain groups, especially adolescents and young women, in whom it is considered first-line contraception. Provision of immediate postpartum and post-abortion implants is safe and highly acceptable, yet remains under-utilised. Implant services at HIV and tuberculosis clinics are a key priority, as is inclusion of LARC provision within school health services. Implants could also be delivered by existing mobile outreach services, for example in sex worker programmes. Services could be built around nurses dedicated solely to providing implants, with other health workers receiving brief refresher training. Women who experience side-effects, especially abnormal bleeding, require timely interventions, following a standardised protocol, including use of medications. Encouraging return for side-effects, follow-up phone calls and home visits would raise continuation rates. Removal services require doctor support or designated nurses at specific centres. Limited access to removal services, health workers’ resistance or botched procedures will further undermine implant provision. Rapid implant demonstration projects in postpartum wards, schools, outreach services and by dedicated providers may rapidly advance the field. Together, the actions outlined here will ensure that the implant fulfils its potential and reinvigorates family planning services

Lessons learnt from the introduction of the contraceptive implant in South Africa

In 2014, South Africa (SA) introduced the subdermal contraceptive implant with the aim of expanding the contraceptive method mix and availability of long-acting reversible methods in the public sector. Three years on, concerns have been raised about the decline in uptake, early implant removals and challenges in service delivery. This article explores the lessons learnt from the introduction of contraceptive technologieselsewhere and applies these to the SA context. Drawing on the World Health Organization’s conceptual framework for the introduction of new contraceptive methods, and subsequent literature on the topic, lessons are classified into six cross-cutting themes. Recommendations highlight the need for SA to review and explore strategies to strengthen current implant services, including the provision of improved provider training aimed at sensitive, client-centred approaches; increased community engagement; and improved systems for programmatic monitoring and evaluation. With implementation of these recommendations, worrying trends in the provision of implants could be reversed

Morbidity in the first year postpartum among HIV-infected women in Kenya

Objective: To assess the effects of HIV infection on morbidity and the needs of infected women for services in the first year postpartum. Methods: A cross-sectional study with 500 women attending a child-health clinic in Mombasa, Kenya. Results: Postpartum duration was a median of 3.3 months (interquartile range, 1.9–6.1 months). The 54 HIV-infected women had a lower income and less financial support than the uninfected women, and they were more likely to experience fever, dyspnea, and dysuria, and to have genital warts (odds ratio [OR], 9.6; 95% confidence interval [CI], 2.6–35.6; P \u3c 0.001), candidiasis (OR, 2.9; 95% CI, 1.2–6.8; P = 0.012), and bacterial vaginosis (OR, 1.8; 95% CI, 0.95–3.3; P = 0.066). Six (nearly 15%) of the HIV-infected women had low- or high-grade squamous intraepithelial lesions, and 21 (42%) had an unmet need for contraception. More than half of all women were anemic, and normocytic anemia was predominant among the HIV infected. Conclusion: Compared with uninfected women, morbidity was increased for HIV-infected women during the year following delivery. This period could be used to offer these, and all-women, family planning services, cervical cancer screening, and treatment for anemia and reproductive tract infections

Implementation of a PMTCT programme in a high HIV prevalence setting in Johannesburg, South Africa: 2002-2015

Background: Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country's prevention of mother-to-child transmission (PMTCT) guidelines.Objectives: In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa.Methods: We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002-2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated.Results: In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001.Conclusion: The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women

Intravaginal Practices, Bacterial Vaginosis, and HIV Infection in Women: Individual Participant Data Meta-analysis

Background: Identifying modifiable factors that increase women's vulnerability to HIV is a critical step in developing effective female-initiated prevention interventions. The primary objective of this study was to pool individual participant data from prospective longitudinal studies to investigate the association between intravaginal practices and acquisition of HIV infection among women in sub-Saharan Africa. Secondary objectives were to investigate associations between intravaginal practices and disrupted vaginal flora; and between disrupted vaginal flora and HIV acquisition. Methods and Findings: We conducted a meta-analysis of individual participant data from 13 prospective cohort studies involving 14,874 women, of whom 791 acquired HIV infection during 21,218 woman years of follow-up. Data were pooled using random-effects meta-analysis. The level of between-study heterogeneity was low in all analyses (I-2 values 0.0%-16.1%). Intravaginal use of cloth or paper (pooled adjusted hazard ratio [aHR] 1.47, 95% confidence interval [CI] 1.18-1.83), insertion of products to dry or tighten the vagina (aHR 1.31, 95% CI 1.00-1.71), and intravaginal cleaning with soap (aHR 1.24, 95% CI 1.01-1.53) remained associated with HIV acquisition after controlling for age, marital status, and number of sex partners in the past 3 months. Intravaginal cleaning with soap was also associated with the development of intermediate vaginal flora and bacterial vaginosis in women with normal vaginal flora at baseline (pooled adjusted odds ratio [OR] 1.24, 95% CI 1.04-1.47). Use of cloth or paper was not associated with the development of disrupted vaginal flora. Intermediate vaginal flora and bacterial vaginosis were each associated with HIV acquisition in multivariable models when measured at baseline (aHR 1.54 and 1.69, p&lt;0.001) or at the visit before the estimated date of HIV infection (aHR 1.41 and 1.53, p&lt;0.001), respectively. Conclusions: This study provides evidence to suggest that some intravaginal practices increase the risk of HIV acquisition but a direct causal pathway linking intravaginal cleaning with soap, disruption of vaginal flora, and HIV acquisition has not yet been demonstrated. More consistency in the definition and measurement of specific intravaginal practices is warranted so that the effects of specific intravaginal practices and products can be further elucidate

The Pap smear for detection of bacterial vaginosis

Objective To assess validity of Pap smears in diagnosing bacterial vaginosis. Method A prospective diagnostic accuracy study with 533 women in Mombasa, Kenya. Diagnosis of bacterial vaginosis using clinical observations scored with simplified Amsel\u27s criteria and Bethesda system for Pap smears was compared with a reference standard (Nugent criteria for gram stains). Both laboratory tests were interpreted blindly. Result Bacterial vaginosis prevalence was 36.7% (191/521) with Nugent criteria. Pap smear sensitivity and specificity were 59.4% (111/187) and 83.3% (270/324), with corresponding figures for simplified Amsel\u27s criteria of 44.8% (81/181) and 84.8% (263/310). For Pap smear and simplified Amsel\u27s criteria, positive predictive values were 67.3 and 63.3%, and negative predictive values 78.0% and 72.5%. Conclusion In diagnosing bacterial vaginosis, Pap smears have moderate sensitivity (though higher than simplified Amsel\u27s criteria). Specificity of Pap smears is adequate. Including bacterial vaginosis assessment as a standard component of Pap smears warrants consideratio