Day 5 Introduction and Digest (May 5, 2006)
We will start with a response from Betty Farrell to Abebe Shibru about gender inequalities.
In today’s digest, Dina Hovakmian, a TV producer and health educator, asks forum participants to share their experiences doing health education about dual protection. Dr. D.A.A. Verkuyl from The Netherlands talks about the difficulties of preventing unintentional pregnancies, especially among HIV positive people, the difficulty of using the pill properly. Feruza Fazilova from Usbekistan comments on how it is important to involve men in counseling. And Maria Ofelia Alcantara raises two more questions for discussion.
Next week we will begin to focus on provider perspectives on family planning in HIV/AIDS counseling. Thanks to everyone for your thoughtful comments and questions.
Louise Manning
for INFO and Health Communication Partnership
Response to Abebe Shibru - Betty Farrell
Q: From your experience, how could health providers overcome the gender inequalities while they are providing services to the client? What kind of skills do the providers need to possess to challenge the
prevailing gender inequalities? This is central to the do the discussion of dual protection in FP and HIV integrated counseling.
A: What is our desired performance for FP-HIV integrated counseling that would include helping clients successfully practice dual protection? I would propose:
-Comfort with sexuality and discussion of sexual matters;
-Ability to provide updated, complete, and accurate FP and HIV information;
-Ability to tailor information to help clients weigh how this information fits with her/his circumstances; and
-Ability to support women and men to sustain new behaviors/practices, e.g. dual protection. This last performance may mean defining our relationship with clients, working in partnership with them over longer
periods of time.
FP service providers and counselors are trained with a focus on knowledge (facts, data) and skills (e.g., interpersonal communication, counseling; method provision, decision-making for client management)
with some attitudinal learning experiences primarily through values clarification exercises. What we may need to consider is exploring how counselors and providers manage issues of power dynamics in their own
lives since very often they come from similar cultural backgrounds with similar social norms as the clients they serve. In helping them, they will be in a stronger position to assist clients. This is an area where
we might learn more from the HIV community in the work they are doing to strengthen HIV counseling skills (Uganda).
What the ACQUIRE project has done in the Ghana FP-ART pilot is devote more time to address counselor/provider attitudes related to stigma, discrimination, gender dynamics, and sexuality. Upon this foundation we are building the FP- HIV integrated content to prepare counselors/providers to more effectively counsel for informed decision-making and FP method provision, including dual protection, condom and safer sex negotiation. Evaluation of this pilot scheduled for August 2006 will give us information on whether or not this approach has made a difference in the (a) quality of counseling and (b) increase of access to information for informed decision-making, (c) increased client comfort with FP method selection, and (d) whether the clients experienced a difference in counseling--whether it was an improvement over what they used to receive. Within this area, more focus in skills development for engaging and counseling men and couple is crucial.
Facility-based service providers have varying degrees of meaningful interaction with community-based health workers. Two short-/medium term ways that service providers and counselors may "overcome gender
inequalities while providing client services" is to (i) form coalitions with community-based organizations or networks that are working for changes in social norms. Forming these alliances helps extend the influence and efforts of the facility-based providers*and community health workers. However, coalition-building is a skill that counselors and services providers do not usually receive in their in-service training; (ii) develop community collaboration, e.g., awareness, dialogue, and strategizing for behavior change at the community level; and (iii) develop male peer educators within communities who can influence behavior change for safer sex behavior, including dual protection.
Lastly, a more long-term way that "gender inequalities can be overcome" is in the area of parenting, education, and socialization of children. But this is an extremely complex area fraught with concerns
related to identify, preservation of cultures, and deeply entrenched social values.
I hope this answers your questions and addresses the issues you raised.
Thank you for your question, Abebe Shibru.
Regards,
Betty
Betty L. Farrell, CNM, MPH
Medical Associate
Integration of Reproductive Health Services
Engenderhealth, Inc.
FP and HIV - Dina Hovakmain
Thank you for this forum from which I am assuming that I will acquire a better understanding about family planning and HIV/AIDS integration.
Dual protection is a very important matter from every angle related to family planning and I learned a lot from it. Being TV producer (health educator) it helps me a lot to hear others experiences. I would like to
ask if anyone knows anybody that has done any TV work or at least any form of theater including scenarios or similar thing for training people for public awareness. I found that directly teaching about condoms, for example, has got reverse effect on training. Would anyone in the group please send me some scenarios and some successful teaching methods for TV? Kindest regards
Dina
HIV and Contraception - Dr. D.A.A. Verkuyl, The Netherlands
How to prevent unintentional pregnancies.
This is difficult, mistakes are made and most methods have some failure rate and sometimes contraceptives are out of stock or too expensive.
If one is HIV positive and wants to prevent pregnancies it is even more important that one succeeds but it is also more difficult
It is more difficult because of mood swings, depression, fatalism, optimism, even the AIDS dementia syndrome. Furthermore vomiting and having diarrhoea effects the adsorption of especially oral contraceptives. On top of that oral contraceptives are broken down faster in the liver with some ARV medication and certainly if Rifampicine for TB is used. (Organon, a pill manufacturer, advises taking two tablets of the pill daily if Rifampicine is used). I have seen more than 3 thousand pregnancies on the Pill in my career. Even now in the Netherlands where the women are famous best pill takers I see on average one woman a week who became pregnant on the pill. This in a hospital with only 500 deliveries annually. Most of those who get pregnant on the pill here I do not see. They go to abortion clinics for a legal, free of charge, safe abortion. When I worked in Harare in gynae casualty (before the HIV epidemic) we saw every day the victims of unsafe abortions who got pregnant on the pill (and especially but certainly not limited to POP*
The POP, is progesterone only pill, should not be used at all I think in HIV positive women because it needs very strict adherence to taking the pill every day at the same time. Even then the failure rate is higher than of the combined pill which is already high.
The above leads to the following conclusion.
It is better to use a method which "forces" the woman/couple to do something extra to get pregnant (e.g. have the Norplant removed or the IUD) instead of becoming pregnant by default (forget to collect, take the pill or injection). This because starting a pregnancy is a serious decision at all times but even more so if others (including a grandmother who already has 10 grandchildren to look after) might need to raise the child.
Best are implants, IUDs (studies from Kenya show that that is not an extra risk for infection in HIV + women, some infections like Bartholins'' abscess or infected fingers or teeth are not obviously increased in HIV + people)
Tubal ligation is also an option but it takes very motivated health workers to organise such an operation on say a Friday afternoon after a known HIV positive woman has just delivered her 4th child after an unintentional pregnancy on the pill.
Women with a few kids, especially if HIV positive, should be offered a tubal ligation if they are going to have a caesarean section.
Best is to discuss this early in pregnancy: e.g. suppose you need a CS at the end of your pregnancy could you discuss with your partner if you would want a TL then also (if the baby came out kicking)
After TL, implant, or IUD Depo-Provera is best. Other drug use is not important, one only has to think about it 4 times a year and vomiting etc does not affect its use.
Condoms have not much use in a stable relationship unless it is known that only one partner is positive. That will motivate.
In general people who could not be motivated to use a condom to prevent HIV infection will not be motivated to use a condom in a relationship where there is a theoretical risk that different sub-strains of the virus are exchanged. The only advantage of having HIV is, I would say, that you do not need to use a condom anymore to prevent getting infected by HIV.**
Condoms and Gender - Feruza Fazilova, Uzbekistan
Thank you to all of you for your valuable comments. Actually, in Uzbekistan, in country of post Soviet period there is enough number of service providers, and particularly at PHC level of service provision. During last
years big efforts put towards establishment of counseling services within the FP. Taking into account situation on HIV/AIDS which is extremely critical now, we are trying to integrate the HIV/AIDS counseling services into ongoing training programs on FP/STIs. I agree with my colleagues mentioned about gender perspective of this issue because while condoms are distributing through FP services which clients are mostly women it makes impossible to achieve good results and real protection. Probably we should also think about male involvement mechanisms to FP/HIV counseling.
Two Questions from Maria Ofelia Alcantara
This is great integrating public health programs. May I ask your opinion on how these public health programs can be sustained especially in financing. How health insurance can come in?
Also, how about implementation on the grounds, often times its the national that provides directions and policies but most critical is the implementation at the local level, how does this fit to the integrated local health zones or local health systems.
ADDITIONAL RESOURCES
Dr. Verkuyl raises many interesting questions. We look forward to hearing your opinions about some of them.
Dr. Verkuyl states that the advantage of having HIV is that you do not need to use a condom any more to prevent getting infected by HIV. Others working in HIV treatment would disagree strongly with this assertion.
For a different viewpoint, see this fact sheet by University of California San Francisco Center for AIDS Prevention Studies factsheet called “What do we know about HIV superinfection?” at http://www.caps.ucsf.edu/publications/superinfection.html (HTML) or http://www.caps.ucsf.edu/capsweb/pdfs/superinfectionFS.pdf (PDF). UCSF argues that to prevent superinfection, the general consensus is that HIV+ persons should continue to use a condom every time they have sex.”
For information on which contraceptive methods are best for HIV+ women, please review these resources:
Dr. Jim Shelton’s Pearls
http://www.infoforhealth.org/pearls/parchive.shtml
Take a look at the Pearls for:
March 26, 2004 – ARVs and OC Effectiveness
April 8, 2004 – ARVs and Depo Provera
November 28, 2003 – IUDs for HIV+ Women
Contraception for Women and Couples with HIV
http://www.fhi.org/en/RH/Training/trainmat/ARVmodule.htm
This set of materials (presentations and fact sheets) contains guidance for providers who offer contraception to clients with HIV, including those on ARV therapy. The information can be used in a variety of settings by providers who regularly offer family planning services and by those who want to begin integrating contraceptive services with HIV treatment and care services. Specific information about contraceptive options for clients with HIV, possible interactions between hormonal contraceptives and ARVs, decisions clients with HIV may have to make, and advice about how to counsel them is included. These materials can be used for independent, self-paced study or for group presentations. Guidelines for using the materials in both situations are included. Electronic files are provided to facilitate adaptation of the materials for selected audiences.
Hormonal Contraception and HIV: Science and Policy
http://www.fpandhiv.org/iue_documents/4/docs/statementfromwhohcandhivmeetingsept05final1.pdf
For information on problems that many women (not only HIV+) have with taking oral contraceptives every day at the same time and information on how to take the pill properly, see:
Population Reports: Helping Women Use the Pill by Vera Zlidar (2000)
http://www.infoforhealth.org/pr/a10/a10.pdf
This issue also has an excellent sidebar called “Missed Pills and Pregnancy: When are Women Most at Risk?” which summarizes guidance for missed pills. http://www.infoforhealth.org/pr/a10/a10boxes