Experiences of Accessing and Providing Contraceptive Implant Removal Services in Gaborone, Botswana: A Qualitative Study Among Implant Users and Healthcare Providers

Introduction: This study explored implant user and healthcare provider experiences of accessing and providing contraceptive implant removal services in Gaborone, Botswana, following introduction of the implant in the public sector in 2016. We sought to understand reasons for satisfaction and dissatisfaction with services and their potential impact on wider perceptions of the implant, including influence on future uptake. Methods: Qualitative data were collected through in-depth interviews. Participants comprised ten women who had previously undergone implant removal, and ten providers whose work included provision of implant insertion and removal. Data were analyzed using thematic content analysis. Results: Seven of the ten users in this study had experienced a delay between initial request and undergoing implant removal. This interval ranged from <1 week to 3 months. Users identified the principal barriers to accessing implant removal services as lack of access to trained removal providers, inconvenient appointment times, and provider resistance to performing removal. Nine of the ten providers in this study had experienced barriers to providing implant removal, including insufficient training, lack of equipment, lack of time, and lack of a referral pathway for difficult removals. Despite experiencing barriers in accessing removal, users' perceptions of the implant remained generally positive. Providers were concerned that ongoing negative user experiences of removal services would damage wider perceptions of the implant. Conclusion: Introduction of the contraceptive implant in Botswana has been an important strategy in increasing contraceptive choice. Following an initial focus on provision of insertion services, the development of comparable, accessible removal services is critical to ensuring that the implant remains a desirable contraceptive option and is vital to upholding women's reproductive health rights. The experiences of users and providers in this study can inform the ongoing development of services for implant insertion and removal in Botswana and other lower-resource settings

Case Report: Traumatic Incomplete Fracture of an Implanon NXT® Contraceptive Implant

The etonogestrel (ENG) subdermal contraceptive implant (Implanon NXT®) is a safe and highly effective method of contraception which is increasing in popularity globally. This case report describes a 26-year-old woman who  requested removal of the Implanon NXT® contraceptive implant. She  reported that her implant had bent following direct trauma. The implant was removed in accordance with her request and without complication, but was noted to be incompletely fractured. We compare this case with a summary of the existing literature on fractured or damaged contraceptive implants. Structural damage detected whilst the implant is in situ is one potential complication of  contraceptive implant use. The incidence of this  complication and the implications for contraceptive efficacy are unknown. Damaged implants may present healthcare providers with more technically challenging ―difficult  removals‖. With the scale-up of services for implant provision, consideration should be given to this issue in order to inform counselling and removal services.Keywords: Contraception, contraceptive implant, implant removal, fractured implant, Implanon NXT®L'implant contraceptif sous-cutané étonogestrel (ENG) (Implanon NXT®) est une méthode de contraception sûre et très efficace qui gagne en popularité dans le monde entier. Ce rapport de cas décrit une femme de 26 ans qui a demandé le retrait de l'implant contraceptif du type Implanon NXT®. Elle a signalé que son implant s'était plié à la suite d'un traumatisme direct. L'implant a été retiré conformément à sa demande et sans complication, mais il a été noté qu'il était incomplètement fracturé. Nous comparons ce cas avec un résumé de la documentation existante sur les implants contraceptifs fracturés ou endommagés. Les dommages structuraux détectés lorsque l'implant est in situ sont une complication potentielle de l'utilisation d'implants contraceptifs. L'incidence de cette complication et les implications pour l'efficacité contraceptive sont inconnues. Les implants endommagés peuvent présenter aux prestataires de soins de santé des «déménagements difficiles» plus difficiles sur le plan technique. Avec   l'intensification des services de fourniture d'implants, il convient de tenir compte de cette question afin d'informer les services de conseil et de retrait.Mots-clés: Contraception, implant contraceptif, retrait d'implant, implant fracturé, Implanon NXT

Difficult etonogestrel implant removals in South Africa: a review of 74 referred cases

Objectives: To assess etonogestrel contraceptive implant location and outcomes among women referred for “difficult” removal to a specialist clinic in South Africa. Study Design: We performed a retrospective review of cases referred to our clinic for removal of nonpalpable, deep, migrated, or damaged implants, or failed removals from March-August 2017. Results: Most (n=68, 92%) of the 74 referrals were nonpalpable in our clinic. We used ultrasound for localization and successfully removed 72 implants (97%) in the outpatient clinic. Conclusion: With proper protocols and equipment, localization and removal of nonpalpable implants can be safely and effectively achieved in an outpatient African setting

Comparison of plasma etonogestrel concentrations sampled from the contralateral-to-implant and ipsilateral-to-implant arms of contraceptive implant users

Objective To compare plasma etonogestrel concentrations sampled from the contralateral- versus ipsilateral-to-implant arm. Study design Sub-analysis of a cross-sectional study in Botswana in 33 participants who provided contralateral and ipsilateral blood samples. Results Plasma etonogestrel concentrations in contralateral and ipsilateral specimens were highly correlated (correlation coefficient = 0.99; p < 0.0001). Bland–Altman analysis of agreement showed that etonogestrel levels were on average 5.9 pg/mL higher (2.1%) in ipsilateral compared to contralateral specimens (95% confidence interval: −4.1, 15.9 pg/mL). Conclusions We found no meaningful differences in plasma etonogestrel concentrations between samples taken from the contralateral- versus ipsilateral-to-implant arm. Implications Our data suggest that etonogestrel plasma concentrations are unlikely to be meaningfully different between samples drawn from the ipsilateral- versus the contralateral-to-implant arms in etonogestrel contraceptive implant users

Closing the Gap: Ensuring Access to and Quality of Contraceptive Implant Removal Services is Essential to Rights-based Contraceptive Care

The use of the subdermal contraceptive implant is increasing globally, and particularly so in lower- and middle-income countries in sub-Saharan Africa. For initiation or discontinuation of the implant, users need to have access to services for insertion and removal by healthcare providers. Providing access to safe and effective contraceptive implant removal services presents both clinical and programmatic challenges. The most challenging implant removal cases, termed ―difficult removals‖, place additional demands upon removal services. In this commentary, we outline challenges for the provision of removal services. Based on our experience in this field, we make  recommendations on how healthcare providers and health services can plan for these challenges. Through  maximising the provision of comprehensive and accessible implant removal services, including those for difficult  removals, implant users can be empowered to discontinue their use of this method of contraception if they choose, thus upholding the principles of rights-based contraceptive care.Keywords: Contraception, contraceptive implant, implant removal, difficult implant remova

Demographic and travel characteristics and self‐reported predeparture SARS‐CoV‐2 testing behavior in air passengers entering the United States from foreign destinations from July to September 2021

Abstract Introduction From January 2021 to June 2022, the United States Centers for Disease Control and Prevention required predeparture SARS‐CoV‐2 testing for all air passengers arriving into the United States from a foreign country. Methods Using data collected during a surveillance project, we described predeparture testing behavior among a convenience sample of international air passengers entering the United States from July to September 2021 at six US ports of entry. We analyzed pairwise relationships between self‐reported test type, test timing, demographic and travel characteristics, and COVID‐19 vaccination status using chi‐square and Fisher's exact tests. Results Participants were more likely to get a NAAT versus antigen test if they identified as non‐Hispanic Asian or Pacific Islander (68.2%, n = 173), non‐Hispanic Black (62.6%, n = 147), or if they preferred not to report race and ethnicity (60.8%, n = 209) when compared to those who identified as non‐Hispanic White (47.1%, n = 1086, all p < 0.05). Those who identified as Hispanic or Latino (n = 671) were less likely to get a NAAT than the non‐Hispanic White group (39.5% vs. 47.1%, p < 0.05). Participants arriving in the US from the Americas were less likely to get a NAAT (38.5%, n = 871) compared to those arriving from Europe (45.5%, n = 1165, p < 0.05). Participants who reported receiving their predeparture test 2 days or 3 or more days before departure were more likely to report receiving a NAAT (52.2%, n = 879, and 60.2%, n = 410, respectively) than those who reported testing within 1 day (41.4%, n = 1040, all p < 0.001) of departure. Discussion Test type was significantly associated with race and ethnicity, departure region, and test timing. Differences likely reflected regional disparities in the availability of tests at the time of the activity. Discrepancies in predeparture test timing and type worldwide may have consequences for the effectiveness and equity of travel requirements in future pandemics

Integration of family planning services into health care for HIV‐positive women in Botswana

Objective: To create and assess a clinic model to address the unmet need for effective contraception among women living with HIV in Botswana, where half of all pregnancies are unintended and 30% of women of reproductive age are living with HIV. Methods: We introduced family planning services into an HIV clinic in Gaborone, Botswana. Our intervention gave HIV providers brief training on contraceptive counseling plus the option of immediate referral of interested patients to an on-site contraception provider. We administered a survey to patients and providers before and after intervention. Patients were female, aged 18–45 years and using antiretrovirals. Results: At baseline, 6% of 141 patients discussed contraception with their HIV-care provider, compared with 61% of 107 post intervention (P < 0.001). At baseline, 6% of patients reported wanting to use long-acting reversible contraception (LARC). Post intervention, 45% of patients chose to meet with the contraception provider, and 29% wanted to use LARC (P < 0.001 versus baseline). All providers strongly agreed that they were better informed about contraception post intervention and were satisfied with their ability to counsel and refer women for contraception. Conclusions: Provision of on-site contraceptive services in this HIV clinic encouraged family planning discussions and increased interest in LARC. K E YWORDS Botswana, contraception, family planning, HIV, service integratio

Etonogestrel concentrations among contraceptive implant users in Botswana using and not using dolutegravir-based antiretroviral therapy

Objectives: To evaluate whether etonogestrel concentrations are reduced to a level that could potentially reduce contraceptive efficacy when the etonogestrel contraceptive implant is used concomitantly with dolutegravir-based antiretroviral therapy (ART). Study Design: We conducted a non-randomized, open-label, cross-sectional pharmacokinetic study among women using single-rod etonogestrel contraceptive implants in Botswana. We compared plasma etonogestrel concentrations, sampled at a single time-point between 3 and 12 months from implant insertion, among implant users living with HIV and receiving dolutegravir-based ART with HIV-negative implant users. We also assessed concentrations among implant users living with HIV and receiving efavirenz-based ART. We compared geometric mean etonogestrel concentrations analyzing data from 142 participants: 97 HIV-negative, 30 using dolutegravir, and 15 using efavirenz. Results: The groups were similar. Duration of implant use was between 3 and 12 months (median=5). Geometric mean etonogestrel plasma concentrations and 90% confidence intervals of the mean were 227.5(212.4-243.8), 289.6(251.8-333.0) and 76.4(63.9-91.4) pg/mL among the HIV-negative, dolutegravir- and efavirenz-based ART groups, respectively. All women in the HIV-negative and dolutegravir-based ART groups had etonogestrel concentrations above 90pg/mL; 9/15 women (60%) using efavirenz-based ART had concentrations below 90 pg/mL. On average, etonogestrel levels were lower among individuals who had implants inserted for longer durations. Conclusions: Implant users receiving dolutegravir-based ART had a higher mean etonogestrel concentration compared to HIV-negative women, and none had etonogestrel concentrations below the posited threshold for ovulation suppression. In contrast, women in the efavirenz-group had much lower etonogestrel concentrations. Overall, these data provide evidence that the etonogestrel implant may be effectively combined with dolutegravir-based ART regimens