Family Planning and HIV Interventions among Women in Low-income Settings

This dissertation examines the effectiveness of interventions related to family planning and the uptake of HIV-related preventive services among women in low-income settings. Women in low-income settings and living with HIV face many barriers to care, including limited access to services for family planning and HIV-related preventive care. At the same time, national, regional, and global efforts are looking for interventions to help control rapid population growth, create an HIV-free generation, and provide adequate preventive care for those living with HIV. This dissertation cuts across these issues and can help to inform debate and policies to address these issues. This dissertation comprises three discrete papers. Paper 1 (chapter 1) examines the effectiveness of a national scale-up of community-based distribution of family planning services on contraceptive use in Malawi’s rural areas during the period 2005-2016. The national-scale up of the intervention followed the success of a pilot of a similar intervention implemented in the period 1999-2004. As in the pilot, the scaled-up program distributed condoms and oral contraceptives and provided family planning education. Further, because education and income are important determinants of individual contraceptive use, the paper also examines whether the effectiveness of the national scale CBDs varies over these dimensions. The paper uses the Malawi Demographic and Health Surveys. The study finds that the intervention increased contraceptive use by 6.8 percentage points and the effects were greater among uneducated and low-income women. Paper 2 (chapter 2) conducts a cost-effectiveness analysis of a trial of cash incentives aimed at increasing the uptake of services for the prevention of mother-to-child transmission (PMTCT) of HIV. The trial was conducted in the Democratic of the Congo (DRC) as part of an effort to find ways of increasing uptake of PMTCT services in sub-Saharan Africa where uptake of these services remains low. The study is conducted from the societal perspective, relies on multiple sources within and outside of the DRC for cost data, and reports economic costs in 2016 International Dollars (I$). At a threshold of 3*GDP per capita for the DRC (I$2409), the study finds that the intervention is cost-effective. Paper 3 (chapter 3) examines the guideline concordance of the time to follow-up anal cancer screening in women living with HIV at high risk for anal cancer. In the US, the incidence of anal cancer in women living with HIV has increased significantly in the past 2-3 decades. However, early detection of anal cancer, through regular screening, can lead to effective secondary prevention of the disease. While guidelines for anal cancer screening exist, very little is known about the guideline concordance of the time to follow-up anal cancer screening in women at high risk of acquiring anal cancer. Hence this study. The study uses Medicaid Analytic eXtract files which compile claims of individuals enrolled in Medicaid—a public health insurance program largely for eligible low-income adults and the largest single payer for HIV/AIDS in the US. The study finds that time to follow-up screening is not guideline-concordant for most women living with HIV, particularly those with one of the two risk factors for anal cancer: a history of abnormal cervical test results or a history of genital warts

Suboptimal geographic accessibility to comprehensive HIV care in the US: regional and urban–rural differences

Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county-level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban–rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co-located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillance data (2014), we used geographic analysis to estimate the fastest one-way drive time between the population-weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county-level drive time, population-weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was \u3e30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significance were not performed, since the analysis is population-based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county-level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county-level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban–rural differences in the West. Nationally, population-weighted drive time, an approximation of individual-level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority

Suboptimal geographic accessibility to comprehensive HIV care in the US: regional and urban–rural differences

Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county-level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban–rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co-located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillance data (2014), we used geographic analysis to estimate the fastest one-way drive time between the population-weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county-level drive time, population-weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was \u3e30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significance were not performed, since the analysis is population-based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county-level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county-level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban–rural differences in the West. Nationally, population-weighted drive time, an approximation of individual-level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority