Online Discussion Forum
March 9, 2007
Daily Digest #5
Dear FP/HIV Integration Forum Members:
We have had many interesting contributions come in over the last few days. Theresa Hatzell Hoke from FHI, USA talks more about the study presented by Dr. Moodley and asks others about provider misconceptions. Dr. Moodley also has provided answers to Dr. Yoder's questions in the last digest. Dr. Young-Mi Kim from JHU/CCP, currently working in South Africa talks about FP counseling in ART settings and Violeta Ross from Bolivia talks about women living with HIV. Yvonne Morgan from Sierra Leone discusses the case study presented early last week. Jeanne Keller and Arnitra, both from US provide ideas on how to counsel the 15 year old client discussed last week.
Do you want to share your experiences in counseling in FP/HIV service settings? Simply reply to this email.
Best,
Megan O'Brien
For the IBP Initiative
http://www.ibpinitiative.org/
info@ibpinitiative.org
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1. Theresa Hatzell Hoke, from FHI, USA
Dr. Moodley's presentation revealed clients' misconceptions about the safety of different contraceptive methods for HIV-positive women. In this same study, we interviewed 26 providers of family planning (n=7), PMTCT (n=13), and child health (n=6) services. The provider interviews revealed similar misconceptions. For example, only 7 of the 26 providers believed that oral contraceptives were safe for HIV-positive women. Providers were more apt to report that injectable contraceptives were safe for HIV-positive women, but for both Nurestirate and Depo Provera, 8 providers responded that those methods were not safe. Only 6 believed the IUD was safe, and 9 indicated emergency contraception was safe. Just about half of the 26 providers reported that male and female sterilization were safe methods for HIV-infected women.
Although the sample for this formative research was small, we feel there is strong indication of a knowledge gap. It appears providers serving PMTCT clients could benefit from training that updates their knowledge about methods that can be safely promoted to HIV-positive women. This would allow providers to confidently pass on more accurate information to their clients, thereby providing greater choice to those women not currently desiring a pregnancy.
Closing on a more encouraging note, virtually all providers in our sample said that condoms were a safe method for HIV-positive women.
I would be interested to hear from others whether the misconceptions on the part of providers found in our study have been noted in other places. Can anyone comment on recent successful efforts to update providers' knowledge?
I am enjoying participating in this forum and look forward to reading more. Thanks to the organizers!
Theresa Hatzell Hoke
Family Health International
North Carolina, USA
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2. Response to Dr Stan Yoder's questions from Dr. Jennifer Moodley
We used a structured questionnaire to collect data on intended contraceptive use from the clients. I agree that our investigation would benefit from complementary qualitative research in which we really probe into women's intentions and motivations. However funds did not permit us to do such a complementary investigation within this project.
We will be exploring this in another project.
The Women's Health Research Unit, University of Cape Town and the HIV Centre, Columbia University have recently received an NIH grant to develop and evaluate an intervention aimed at integrating Sexual and Reproductive Health Services into pubic sector HIV Care Clinics in Cape Town. As part of this project we will be following up a cohort of HIV positive men and women to better understand how their sexual and reproductive health issues and intentions unfold over time. We will be using a mix of quantitative and qualitative methods to explore the meanings, contexts, dynamics and changes associated with a range of reproductive health issues, including contraceptive use, following entry into HIV care.
Jennifer
Dr Jennifer Moodley
Director Women's Health Research Unit
School of Public Health and Family Medicine Faculty of Health Sciences
University of Cape Town Observatory 7925 South Africa
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3. Dr. Young Mi Kim, JHU/CCP
I appreciate Dr. Amenyah sharing with us his observation on the ART site in Ghana where the providers have little time to deliver FP services due to limited human resources in spite of training and provision of job aids for family planning. I am working in South Africa for a few weeks at the moment. According to what I hear and observe here, it seems to me that it is too much to expect doctors and nurses in ART services to do FP counseling fully because they are very busy. The demand for ART
service is growing and there is a shortage of human resources. However, there are some aspects of family planning counseling which doctors who are initiating patients in ART can incorporate in their consultations without adding too much extra time. For example, a doctor can briefly check whether a female patient is sexually active, currently pregnant, want to have a child in the near future, is using condoms, and is using another family planning method. Doctors can mention that condoms can prevent HIV reinfection and pregnancy if used correctly and consistently, can encourage patients to consider using another family planning method for preventing unwanted pregnancy, and can refer patients to FP services. In South Africa, we noticed that injectables is the method highly recommended to patients who are initiating ART. In that case, doctors should mention that an ART patient using Depo should go for a follow-up visit a couple of weeks later and should inform patients about possible side effects. More detailed counseling on condom use, safer sex, HIV status disclosure, and partner communication are done by lay counselors in ART service in South Africa. These lay counselors can be potentially important for family planning counseling if they are trained properly, supervised and supported with job aides
From Dr. Young-Mi Kim, Senior Advisor for Research and Evaluation,
JHU/CCP/Baltimore
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4 Violeta Ross
Dear friends
On my experience with women living with HIV as I am my own self, and others in Bolivia, family planning is not even an issue. Due to 2 main reasons:
1. We are so still so much in the urgency of helping women with basic opportunistic infections, this is due to late diagnosis of HIV status, there are no VCT campaigns so women are not informed and they learn they are HIV positive once they are ill.
2. If they are HIV positive they think and the service providers think this is not a choice for them, they shouldn't have babies, in the eyes of the health providers and their own as well. However some women did get pregnant, this is the issue of my master thesis study, but they had to face...
3. Stigma and discrimination, virtually the only supporter of pregnancies among women living with HIV is our network, the Bolivian Network of people living with HIV/AIDS, no one else had a voice on this, not even UNFPA.
Violeta Ross
REDBOL
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5. Yovonne Morgan from Sierra Leone
Thank you Dr Richard for your case study.
I would like to contribute the following:
1. Dora is still within the childbearing age, already has 3 children and is faced with other difficult & complex circumstances. Her choice to use condom is being limited, because of her present economic and social status. Providing this vulnerable woman with information and condom alone is not enough.
I think Grace should have done the following:
a) Help Dora to identify her lifestyle and how it places her at risk. Explain the need to act now to change her sexual habits, working with her in each step to help her achieve and sustain behaviour change(this is achieved by helping her work/join social support networks). One example of this in Sierra Leone is HACSA-a non governmental organization that empowers vulnerable HIV+ clients in skills development and nutritional support. With this support, women have more options in
managing their household and negotiating safe sex practices.
b) Family planning method-Dora has never used FP methods before. The counsellor did not take time to help Dora identify which method she prefers. Though condom is the most appropriate in her circumstances, as at present she does not know the source of her infection & does not want another child right now
c) Informing partner-the condoms were left behind because Dora could not face her partners with them. What we usually do here is simultaneous VCT. The woman is encouraged to bring her partner for VCT, without the partner knowing she has been to the site previously. This is especially important for the vulnerable women who stands a chance of being abandoned and loosing her means of survival. In this case, it would be helpful if Dora brings the boyfriend for VCT and later the husband when he comes home from the mines.
d) Other effects-the counselor should have gone further to explain the effect of HIV on Dora's 3 children & her entire household, and therefore the need for her to act responsibly
2. Dora refuses to take the condoms along because she is faced with many fears, such as-how does she ask her partner to use them for the first time, the fear of annoying him, resulting in her loosing the relationship, she has 3 children under the ages of 5yrs, plus herself to feed, how would they survive without the support of her partners?
Dora's responsibility in this situation is, either she act responsibly by using the condoms-preferably the female condom and sees her partner reaction. Or she should have asked the counselor to involve partner in the VCT, to establish the source of her infection.
3. This scenario is very similar to what is happening in Sierra Leone also. Most women because of their social and economic vulnerability do not have a choice in their sexual relationship. Females are perceived as docile and cultural norms often affect a woman's negotiating power in sexual activity. It is for this reason that health and social workers should work closely with this vulnerable group to give them a stronger voice & decision-making power in any given situation.
Thank you.
Yvonne Morgan
Africa Aids Research Network-Sierra Leone
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Jean Keller - Johns Hopkins HIV Women's Health Program , Baltimore, MD, USA
In response to the question on how to counsel the 15 year old girl.
Anal intercourse is more common among woman and young girls then we would think, but rarely discussed by health care providers. Often the belief is that this is an activity that occurs among men who have sex with men when in fact it may be a regular part of sexual activity for women. Additionally, engaging in anal intercourse to preserve virginity and avoid pregnancy is fairly common among young women especially in cultures that hold high regard for the preservation of virginity until marriage. Young women may also believe that because they are "safe" from pregnancy they are also safe from sexually transmitted infections when just the opposite is true. Anal intercourse is the most risky sexual behavior in terms of HIV transmission and HPV can cause dysplasia similar to cervical dysplasia.
Additionally, the client may not consider anal intercourse as being sexually active and providers may phrase questions in a manner that implies vaginal intercourse. If not asked specifically, the clients belief system may not consider anal intercourse in the same light as vaginal intercourse. Because they are preserving virginity and avoiding pregnancy anal intercourse may not be viewed as "sexual activity". In Baltimore, anal intercourse among young women is becoming more common and often believed to be safer in terms of STDs.
STD counseling should include some specific questions, especially when dealing with teens. Although you may begin by asking if the person is sexually active it is usually a good idea to then get more and more specific about their activities including oral and anal intercourse. Once it has been established that the client is sexually active counseling can then be directed to each activity, its risks and prevention techniques. For instance, they are techniques where a women can put a condom on a man using her mouth.
Written materials to accompany counseling is extremely effective. If it is in writing it most be "true". In counseling large groups the use presentation that include pictures of STDs is extremely effective. The images can be quite powerful and motivating for prevention counseling.
Last, with young girls a discussion on how comfortable they are about talking to their mothers may be helpful. If the young girl is adamant or very uncomfortable about not discussing this with her mother I do not usually push the issue. On the other hand, if she is willing to speak with her mother or bring her mother to clinic it may be an opportunity to educate the mother and enlist her support.
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Arnitra - Health Educator - Baltimore, MD, USA
Culturally, I can understand why the women would not want to use a condom.
Maybe someone could suggest to the women the following:
* If a condom or IUD is utilized properly it would help prevent a woman from becoming infertile. Without using some form of protection you run the risk of acquiring a STD (that is what causes the infertility). For example, if Chlamydia isn't treated properly, it can turn into Pelvic Inflammatory Disease (PID) which causes the fallopian tubes to
become infected, which could cause infertility or an ectopic pregnancy.
* Some of the women have concerns about their hygiene status. If a condom is used it will actually protect her vagina. Letting a man ejaculate inside of you (raw) can cause a woman to develop an odor. Some women have developed certain types of bacterial infections from this type of behavior. Women have to understand, some men are not as conscious about their hygiene as we are.
* Women could also look at this from another point of view. If a man asked to use a condom, he actually is saying you are clean and I want to help you stay this way...something to think about.
* Condoms don't create lack of sensation, we do. Most of the time you want to feel wetness and heat (going raw). The way you can obtain the same sensation is by putting some lubricant (water-based) inside of the condom. This will make the man feel like he is in the vagina without a glove. Furthermore, this will give him some extra time to delay ejaculation -which will benefit the woman.
* Another alternative that could be suggested is the female condom. It has extra lubrication, men don't have to wear one, can also be used for anal sex, and if someone is allergic to latex it is beneficial is made out of polyurethane.
* The 15 year old girl having anal sex is very risky. Short term-the blood vessels are being broken at the lining of the anus, which can cause direct transmission for HIV. If this older man is having anal sex with this 15 year old it probably was a task for him to insert himself inside of her. This causes him to bleed, because of the layers
of tissues that have to be broken (this is direct blood to blood contact). Long term-because she is allowing this older man to have anal sex without a condom, it causes him to come in contact with her feces. He could possibly carry this feces inside of his penis which will cause bacteria to form (Hep B). The next time they encounter each other she could get infected. Also, she may not wipe her vagina properly after they have anal sex. If she wipes herself from the back to the front, she could carry feces to her vagina. Some women have stated that after having anal sex for a while it makes you feel like you want to douche your behind. Some people actually douche to keep themselves feeling fresh which in turn can also give her an infection.