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 the Feasibility of Service Integration in a Low-Income Setting: A Mixed Methods Investigation into Different Models of Reproductive Health and HIV Care in Swaziland.

Integrating reproductive health (RH) with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602) measured integrated care received and unmet family planning (FP) needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05), despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice) less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of care inhibited provision of fully integrated RH-HIV services in these clinics. Programmes should move beyond simplistic training and equipment provision if integrated care interventions are to be sustained

Swaziland (2013): Qualitative Study Exploring Factors Related to the Timely and Regular Uptake of ANC and PMTCT Services by Women in Swaziland.

A recent literature review of research conducted in Swaziland and in the region by Lusweti Institute for Health Development Communication, a partner of PSI/Swaziland, reveals that several factors contribute to failure to take up early and frequent ANC and PMTCT services including: multiple and persistent forms of stigma and discrimination surrounding HIV and AIDS; gender roles and relations; socioeconomic status of both women and men; social norms and beliefs, lack of community involvement, particularly for men; absence of accurate and adequate knowledge on PMTCT; and supply side issues such as lack of qualified personnel, inhospitable attitudes of service providers towards men accompanying women to ANC and PMTCT sites, and lack of trust and confidentiality. As a follow up to the literature review, Lusweti Institute for Health Development Communication will implement this study in order to inform on gaps in knowledge related to ANC/PMTCT service uptake, and explore how timely and regular utilization of ANC/PMTCT services can be encouraged among women, especially with respect to the active involvement of men. This study was conducted as part of the formative audience research on factors relat ed to regular and timely uptake of ANC and PMTCT services and the role of men in a bid to produce mass media edutainment activities not for only Lusweti or PSI but partners working with HIV in the country. The study used a qualitative method to collect data from the general public (men and women), health care workers as well as females above 50 years old considered to be aunts/mother in-laws. The robustness of the thematic analysis combined with the researcher triangulation lends credibility to the research reported here

Eliminating malaria from the margins of transmission in Southern Africa through the Elimination 8 Initiative

Four southern Africa countries, namely, Botswana, Eswatini, Namibia and South Africa, were identified by the World Health Organization as having the potential to eliminate malaria in the near future. However, the extreme interconnectedness of southern African countries facilitates the constant movement of malaria parasites across country-borders, predominately from higher-burden “source” countries to lower-burden “sink” countries, reinforcing the notion that malaria elimination in any southern African country would not be possible without regional cooperation and collaboration. The Elimination 8 initiative (E8) was therefore, created by Health Ministers from eight countries (Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia and Zimbabwe) to coordinate the implementation of a regional malaria elimination strategy. The E8 supported the implementation of five cross-border malaria control initiatives and the deployment of malaria health units at strategic points along shared borders. These units have contributed to a 30% and 46% reduction in malaria incidence and mortality, respectively, in the E8 border regions. The Situation Room, a novel data sharing platform developed and supported by the E8, has allowed for the early detection of and prompt response to malaria outbreaks. This platform played a vital role in identifying resources gaps due to the COVID-19 pandemic. Despite advancing the elimination agenda, the E8 region faces challenges which include, significant increases in malaria in certain member states, limited domestic funding and health system bottlenecks. These must be urgently addressed if the gains made through the E8 are to be sustained and malaria elimination is to be achieved across southern Africa.https://www.tandfonline.com/loi/ttrs202022-05-05hj2022School of Health Systems and Public Health (SHSPH

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

Providers and services accessed on day of survey and since testing HIV positive, by clinic.

<p>Providers and services accessed on day of survey and since testing HIV positive, by clinic.</p

Desired additional services on day of survey, by clinic.

<p>*Anova F Statistic (p value)</p><p>Desired additional services on day of survey, by clinic.</p

Contextual influences on structure, process and outcomes of integrated RH-HIV care.

<p>Contextual influences on structure, process and outcomes of integrated RH-HIV care.</p

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