Integration of Contraceptive Counseling into HIV Services for Youth:

Transcription

1 Integration of Contraceptive Counseling into HIV Services for Youth: Findings and Future Directions Donna McCarraher, FHI

2 Outline I. Brief overview of integration research in clinical settings II. YouthNet strategy and key findings from first wave of integration studies III. Considerations for future OR studies

3 Where Are We Now Contraception as a key HIV prevention strategy Models demonstrate that preventing unintended pregnancies reduces new HIV infections Policy level support WHO Country support need

4 Where Are We Now In search of effective strategies to meet the contraceptive needs of youth seeking HIV services Several OR studies underway First OR studies show significant challenges: Little change in provider contraceptive counseling Training providers inadequate Operational challenges: manpower shortages; motivating providers; and lack of institutional support

5 First Wave of Youth Integration Studies YouthNet strategy Focused on youth who experienced or may experience negative outcomes (VCT, PMTCT, PAC, or EC clients) Concern that youth seeking these services needed contraception YouthNet clinic-based studies focused on Attracting at risk youth Quality of services with the addition of a new service Whether youth seeking HIV services (VCT and PMTCT) had an unmet need for contraception Provider contraceptive counseling

6 YouthNet VCT Studies Haiti Five NGO sites In four sites, youth only, clients 24 years old Tanzania Four sites Public and NGO clinics Three sites had youth friendly elements, fourth was a stand alone VCT center Female client exit interviews Haiti n=169 Tanzania n=203

7 Characteristics of Female VCT Clients Haiti Tanzania Median age Not married/not in union (%) Still in school (%) Ever been pregnant (%)

8 Female VCT Clients Desire for Pregnancy, Contraceptive Use, and Unmet Need for Contraception 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Haiti Tanzania At risk of unintended pregnancy (in need) Using a modern FP method (no need) Desire pregnancy < 2 yrs (no need)

9 Female VCT Clients Current Contraceptive Use Majority of contraceptive use is condom use 74% Haiti 50% Tanzania Condom use at last sex act 71% Haiti 82% Tanzania

10 Variations in Unmet Need for Contraception Haiti Tanzania Unmet need -standard Unmet -inconsisten condom use

11 Clients Reports of Discussions with Provider on Fertility Desires and Pregnancy Prevention % Fem ale VC T clients reported that providers discussed... w hether client w ants to have c h ild re n so o n how to prevent an unintended pregnancy Haiti Tanzania

12 Kenya YouthNet PMTCT Study Four ANC clinics with PMTCT programs in four regions 637 women with at least one ANC visit 200 ages ages Client exit interviews

13 Demographic Characteristics of PMTCT Clients Children (%) No children 1-2 children 3-4 children Married/living in union (%) Education (%) No school Primary Secondary or above

14 100 Youth Clients RH Needs and FP Experiences Never used FP prior to pregnancy Intend to use FP in the next two years Want to wait 4 or more years for next pregnancy

15 PMTCT Clients Reports of Condom and FP Counseling Condoms prevent H IV How to discuss condoms D em onstrated condom use Condoms prevent pregnancy R ecevied info about FP methods

16 PMTCT Clients Reports of Methods Discussed and Where to Get Them Inj Pill Cond IUD Implants Where to get

17 Results Demonstrated unmet need for contraception among VCT and PMTCT clients Contraceptive counseling opportunities missed Possible provider bias against younger adolescents

18 The Way Forward What does integration entail? What should we use as outcome measures? Within these, what are particular concerns for youth?

19 What Does Integration Entail? What do we want providers to do? Screen for fertility desires and make referrals for contraception Provide contraceptive counseling and methods When should contraceptive counseling occur Special consideration for HIV+ youth Counseling on safe pregnancy and reducing risk of vertical transmission

20 Outcome Measures Unmet need for contraception Used standard DHS measurement of unmet need for family planning How do we adjust for the reliance on condom use, especially when reported use is not consistent? Casting a larger net for Unmet Need Dixon-Mueller & Germain 1992 Women using an ineffective method of FP Women who are using an effective method inconsistently Women using methods that are safe for them

21 Outcome Measures Given the reliance on condom use among youth we must include measures to assess consistency of condom use

22 Variance in unmet Description of in need population Definition 1: No contraceptive use, in a relationship, and Don t want 1 Definition 2: No contraceptive use or inconsistent condom use, in a relationship, and Don t want 1 Percent in need Increase in percent Cumulative number in need

23 Outcome Measures Are questions to determine unmet need meaningful to youth?

24 Outcome Measures What should be our measures of success? Client Indicators Long term outcome- Reduction in unintended pregnancies Shorter term II Continued contraceptive use Short term I Contraceptive uptake, referrals, and contraception intentions Provider Indicators Assess fertility intentions Give information on contraceptive methods Quality or content of contraceptive counseling

25 Issues for HIV+ Youth HIV+ youth need information on pregnancy prevention and healthy pregnancy Newly developed counseling tools with complex messages Need information on providers willingness to deliver messages and youths understanding of these messages

26 Dual Protection vs. Dual Method Use Influence by HIV/STI prevalence and risk of disease and/or pregnancy Providers missing opportunities to assess contraceptive needs YouthNet studies suggest that youth rely on condoms for pregnancy prevention, but use is not consistent To prevent pregnancy, youth need information on methods other than condoms Need to examine if the promotion of other methods undermines condom use Feasibility of adopting 2 methods

27 Further Thoughts Generic Consistent Condom Use vs. a provider assisted self risk assessment Tool provider to follow help ensure they do it Personalizes the condom use message Role AB of HIV services Secondary abstinence? Being faithful and relationship strengthening How reasonable or feasible is your be faithful strategy Few programs if any to refer clients to