South Africa became the first country in Africa to introduce oral PrEP in June 2016. The National Department of Health has used a phased approach to rollout, allowing for a dynamic learn-and-adapt ...process which will lead ultimately to scale-up. Phased rollout began with provision of oral PrEP at facilities providing services to sex workers in 2016 and was expanded in 2017, first to facilities providing services to MSM and then to students at selected university campus clinics, followed by provision at primary health care facilities. Programmatic data shows variability in initiation and continuation between these populations. This study examines factors related to PrEP initiation, continuation, and discontinuation at facilities providing services to sex workers and MSM during the national PrEP rollout.
A cross-sectional survey was administered September 2017-January 2018 among clients (ages 18-62 and providers at 9 facilities implementing oral PrEP in South Africa, followed by in-depth interviews. The client survey captured PrEP initiation, continuation and discontinuation. Analysis was performed in STATA 13 for survey data and thematic analysis was performed in NViVO 11 for in-depth interview data.
299 clients (203 from sex worker facilities, 96 from MSM facilities) participated in the survey and additionally, in-depth interviews were conducted with 29 clients. Participants self-identified as either current users (n = 94; 36.2%), past users (n = 80; 30.8%) and never users of PrEP (n = 86; 33.1%). Participants who had never used PrEP either cited not being offered PrEP by a provider (57%, n = 49) or declining PrEP (43%, n = 37) as reasons for lack of uptake. The primary reason for declining to use oral PrEP was fear of side effects (41.7%, n = 15). The primary reasons for initiating and continuing on oral PrEP were all related to perceived risk associated with sexual activity. The majority of participants (87.9%, n = 153) also noted that printed IEC materials influenced their decision to initiate PrEP. Qualitative data suggested that several clients initiated on PrEP because they wanted additional protection beyond using condoms due to challenges such as partners refusing to use condoms, having partners with unknown HIV status, having multiple partners, involvement in sex work, or having a partner living with HIV. The majority (73.8%, n = 59) of participants who discontinued oral PrEP cited side effects as the primary reason for discontinuation, followed by feeling stigmatized (18.8%, n = 15).
This study provides valuable insights on early rollout of PrEP of how clients perceive oral PrEP and where to target efforts to improve the uptake of this highly effective HIV prevention product. By identifying strengths and areas for improvement, the ACCESS study has generated evidence that can be used to guide high quality scale-up in South Africa and may be instructive for other countries' efforts to expand quality access to oral PrEP.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ARV-based pre-exposure prophylaxis (PrEP) has the potential to avert many new HIV infections, yet little is known about how to reach women at high risk for HIV infection and motivate them to initiate ...PrEP. Clinical trials have succeeded in recruiting at-risk participants, evidenced by control arm HIV incidence ≥3% (defined by the World Health Organization as "substantial risk"). We examined experiences from HIV prevention trials to document recruitment strategies and identify practical, potentially effective strategies for reaching women in real-world PrEP delivery.
We conducted semi-structured qualitative phone interviews with 31 staff from five countries who had worked on one or more of seven ARV-based HIV prevention clinical trials. Questions explored recruitment strategies used to reach women at risk of HIV and to successfully communicate about PrEP (inclusive of oral and vaginal formulations). We structurally coded data in NVivo and analyzed codes to derive themes. We conducted results interpretation webinars with research and programmatic stakeholders to validate findings and develop recommendations.
Clinical trial researchers employed a range of recruitment strategies to recruit at-risk women. They recommended engaging the local community and potential PrEP users via community events, meetings with gatekeepers, and use of community advisory boards; and they encouraged interpersonal communication like presentations in waiting rooms and door-to-door recruitment to address personal concerns and prevent misinformation. Participants also stressed the importance of addressing the challenges that already exist within the health system to create a more enabling environment and delivering positive messages through a variety of communication channels to normalize PrEP.
Findings from this study provide important insights into potentially effective ways for countries currently rolling out oral PrEP to reach at-risk women with information about PrEP and promote uptake.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The global health community should urgently: (1) fill the evidence gap around plastic exposure and impact for human health to strengthen the current indirect and disjointed evidence; (2) join forces ...with environmentalists and animal health specialists to advocate for policies to influence plastic production, consumption and waste management; (3) advocate for the adoption of a circular economy model in healthcare to reduce plastic medical waste and (4) contribute to combatting plastic pollution through the use of their technical skills, the ‘public health toolbox’. The annual rate of mismanaged end-of-life plastic entering terrestrial and aquatic ecosystems will respectively reach 11 million tons and 18 million tons per year in 2040, more than double those of 2016.4 These threats are being recognised and challenged through global agreements spearheaded by the United Nations (UN) and other international bodies to prevent, reduce and control plastic pollution.5 Individual nations are also taking action, with bans in over 120 countries on selected single-use plastics.6 Despite concrete and coordinated preventive and mitigation measures, growing plastic production, over-reliance on single-use plastics, ineffective waste management, and slow decomposition are leading to a significant worsening of pollution and associated impacts.2 7 Pollution—‘unwanted waste released to air, water and land by human activity’8—is increasingly recognised as a threat to human health,9 yet the growing burden of plastic pollution specifically does not appear to be a priority on the agenda of the global public health community Global health is defined as ‘an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. In marine environments, for example, plastic wastes interfere with the absorption of carbon dioxide by marine micro-organisms, with possible implications on climate warming.16 Small plastic particles also interfere with the production of algae in oceans and could create an imbalance in the marine food chain.17 In terrestrial environments, plastic pollution affects water infiltration, the microbiome and the structure of soils, with possible implications for agricultural productivity.17 18 Burning plastics, a common means of managing waste around the world, emits toxic smokes and ashes. Effects of plastics on humans The evidence base suggesting that exposure to plastics could lead to adverse health effects in humans is growing but still disjointed.13 27 28 Due to ethical and methodological challenges of conducting studies on plastics in humans, this evidence is overwhelmingly dominated by results from in-vitro experiments and animal models using parameters that may or not represent real-life conditions for humans.27 29 This gap indicates the need for more studies to elucidate the human health impact of plastics.30 As described in the section that follows, the current evidence on exposure routes and the scientific plausibility of potential pathogenic effects from plastics raise concerns and warrant a precautionary approach for dealing with this crisis while more robust evidence is generated.28 Humans are exposed to plastics from several sources, including food, water and consumer products through three main routes: ingestion, inhalation and dermal contact.27 31 32 Recent evidence indicates that humans consume on average 0.1–5 g (or 0.004–0.18 ounces) of micro- and nano-plastics (smaller than 100 nm) weekly32 33 34 but the exposure–outcome relationship is yet to be characterised and fully understood.
The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern ...contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa.
A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined.
The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods.
Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Introduction Injectable contraceptives are now the most popular contraceptive methods in sub-Saharan Africa. Injectables have not been an option for African women lacking convenient access to health ...facilities, however, since very few family planning programmes permit community-based distribution (CBD) of injectables by non-medically trained workers. Committed to reducing unmet contraceptive need among remote, rural populations, the Ministry of Health and Family Planning (MOHFP) of Madagascar sought evidence regarding the safety, effectiveness and acceptability of CBD of injectables. Methods The MOHFP joined implementing partners in training 61 experienced CBD agents from 13 communities in provision of injectables. Management mechanisms for injectables were added to the CBD programme's pre-existing systems for record keeping, commodity management and supervision. After 7 months of service provision, an evaluation team reviewed service records and interviewed CBD workers and their supervisors and clients. Results CBD workers demonstrated competence in injection technique, counselling and management of clients' re-injection schedule. CBD of injectables appeared to increase contraceptive use, with 1662 women accepting injectables from a CBD worker. Of these, 41% were new family planning users. All CBD agents wished to continue providing this service, and most supervisors indicated the programme should continue. Nearly all clients interviewed said they intended to return to the CBD worker for re-injection and would recommend this service to a friend. Conclusions This experience from Madagascar is among the first evidence from sub-Saharan Africa documenting the feasibility, effectiveness and acceptability of CBD services for injectable contraceptives. This evidence influenced national and global policy makers to recommend expansion of the practice. CBD of injectables is an example of effective task shifting of a clinical practice as a means of extending services to underserved populations without further burdening clinicians.
Voluntary use of family planning is instrumental to the health and social well-being of women, families and communities.Although contraceptive use in Sub-Saharan Africa is increasing, unmet need for ...family planning remains high. Even within countries that have achieved increases in contraceptive prevalence, use remains low among some population subgroups. Contraceptive prevalence is generally lower in rural areas than in cities, and is consistently lower among women in the lowest wealth quintile than among those in the highest. Achieving progress in health and social indicators, such as those captured by the Millennium Development Goals, depends on expanding family planning services to poor, remote rural areas in Africa.
Abstract Background Little is known about pregnancy rates among sex workers (SWs) or the factors that predispose SWs to this risk. We aimed to estimate the pregnancy incidence rate among Madagascar ...SWs participating in an intervention trial promoting use of male and female condoms and assess the influence of various predictive factors on pregnancy risk. Methods SWs from two study clinics in Madagascar participated in a randomized trial to assess the effect of peer education and clinic-based counseling on use of male and female condoms and prevalence of sexually transmitted infections (STIs). Women were seen every 2 months for up to 18 months; they received structured interviews at every visit, and physical exams at baseline and every 6 months thereafter. Site staff recorded information on pregnancies during interviews; pregnancy data were then merged with trial data for this analysis. Results Of 935 SWs in the analysis population, 250 became pregnant during follow-up. The cumulative probability of pregnancy was 0.149 at 6 months and 0.227 at 12 months. Comparable proportions of nonpregnant and pregnant SWs reported using highly effective contraception at baseline (∼16%); these users were younger and were more consistent condom users. Method switching and discontinuation were frequent. In multivariate analysis, nonuse of effective contraceptives and any self-reported unprotected sex were associated with higher incidence of pregnancy. Approximately 51% of women delivered, 13% reported a spontaneous abortion, 13% reported an induced abortion and 23% had missing pregnancy outcomes. Conclusions Women traditionally targeted for STI/HIV preventive interventions need more comprehensive reproductive health services. In particular, SWs could benefit from targeted family planning counseling and services.
Bacterial vaginosis (BV) is a condition characterized by a disturbed vaginal ecosystem which fluctuates in response to extrinsic and intrinsic factors. BV recurrence is common. To explore whether ...consistent condom use was associated with BV occurrence or recurrence, we compared the effect of condom use on BV prevalence after 6 months, among women with and without BV at baseline. We used data from a randomized controlled trial, conducted among female sex workers in Madagascar during 2000-2001, that assessed the impact of adding clinic-based counselling to peer education on sexual risk behaviour and sexually transmitted infection incidence. BV was diagnosed at two time points (baseline and 6 months) according to modified Amsel criteria. Consistent condom users were women reporting no unprotected sex acts with clients in the past month or non-paying partners in the past year. Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated using multivariable regression models. At baseline, 563 (56%) women had BV. Of those, 360 (72%) had BV at 6 months, compared to 158 (39%) without BV at baseline. The adjusted 6-month PR for BV comparing consistent to inconsistent condom users was 0.99 (95% CI: 0.85-1.13) among women with BV at baseline and 0.57 (95% CI: 0.30-0.94) among women without BV at baseline. Consistent condom use was associated with reduced BV prevalence at 6 months for women who were BV-negative at baseline, but had no effect among women who were BV-positive at baseline. Male condoms appeared to protect against BV occurrence, but not BV recurrence.
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