Addressing Unmet Need for Contraception among HIV-Positive Women: Endline Survey Results and Comparison with the Baseline

Transcription

1 pathfinder international authors: Elizabeth Oliveras, Caroline Nalwoga, Lucy Shillingi Addressing Unmet Need for Contraception among HIV-Positive Women: Endline Survey Results and Comparison with the Baseline Foreign Affairs, Trade and Development Canada Affaires étrangères, Commerce et Développement Canada

2 A R I S E Enhancing HIV prevention for at-risk populations Addressing Unmet Need for Contraception among HIV-positive Women Endline Survey Results and Comparison with the Baseline Elizabeth Oliveras, Caroline Nalwoga, and Lucy Shillingi Submitted by Pathfinder International 9 Galen Street Watertown, MA Phone: (617) Fax: (617) April 2014 Submitted to PATH *Correspondence to: Margaret Waithaka, mwaithaka@pathfinder.org

3 Pathfinder Research and Evaluation Working Paper Series The purpose of the Working Paper Series is to disseminate work in progress by Pathfinder International staff on critical issues of population, reproductive health, and development. Unless otherwise indicated, working papers may be quoted and cited without permission of the author(s), provided the source is clearly referenced as a working paper. Full responsibility for the content of the paper remains with the author(s). Comments from readers are welcomed and should be sent directly to the corresponding author. Published by Pathfinder International. Copyright by the author(s) Pathfinder International Pathfinder International places reproductive health services at the center of our work around the world, providing women, men, and adolescents access to a range of quality health services from contraception and maternal care to the prevention and care of sexually transmitted infections. Pathfinder strives to halt the spread of HIV and AIDS, strengthen access to family planning, advocate for sound reproductive health policies, and, through all of our work, improve the rights and lives of the people we serve. Pathfinder International/Headquarters 9 Galen Street, Suite 217 Watertown, MA USA Tel: Fax:

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5 Acknowledgements This study was conducted under Arise Enhancing HIV Prevention for At-Risk-Populations. Arise implements innovative HIV prevention initiatives for vulnerable communities with a focus on determining cost-effectiveness through rigorous evaluations. Many thanks to the dedicated team of interviewers and the women who participated in the surveys, NACWOLA Project Officers, and the Pathfinder International Uganda Team, as well as to Frederick Makumbi, Makerere University School of Public Health, for his assistance with the two surveys. Thanks also to Pathfinder Research and Metrics staff, Patricia David and Margaret Waithaka, who provided extensive comments on earlier drafts of this report, and Emma Morse, who finalized the text and formatted the report.

6 Table of Contents Table of Figures... 1 Abbreviations... 3 Executive Summary... 4 Section 1. Background... 6 Integrating Family Planning into HIV Services... 6 Project Background... 6 Survey Methodology... 9 Response Rates Section 2. Results Respondent Characteristics Use of HIV Services Integration of Family Planning with HIV Services Contraceptive Use Dual Method Use HIV Risk Behaviors at Last Sex Unmet Need for Family Planning Effect of Exposures on Outcomes Section 3. Discussion and Conclusions References Appendix A: Endline Survey Questionnaire Appendix B: Survey Team Members Appendix C: IATT Tool for assessing unmet need for family planning among women living with HIV... 62

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8 Table of Figures Table 1. Percent distribution of women by selected background characteristics, baseline and endline surveys Figure 1. Comparison of timing of last sex at baseline and endline Table 2. Comparison of reported timing of last sexual activity, baseline and endline surveys Table 3. Timing of last sex by characteristics of the respondents, endline survey...14 Table 4. Percent distribution of women who ever gave birth at endline, by age and cumulative frequency. 15 Table 5. Percent distribution of women, by number of living children, among women who ever gave birth, at endline Table 6. Percent distribution of currently married women age years by desire for children, according to number of living children, endline survey Table 7. Desire for children among women aged years, baseline and endline surveys Table 8. Months since HIV diagnosis by district of residence, at baseline and endline Figure 2. Time in treatment, comparison of baseline and endline Table 9. Duration of receipt of care or treatment at endline, by characteristic Table 10. HIV services currently recevied among women receiving any treatment, comparison of baseline and endline Table 11. HIV services currently received among women receiving any treatment at endline, by characteristic Table 12. Participation in support groups and receipt of FP information at endline, by characteristic Figure 3. Use of ANC at last pregnancy, among births in the past 2 years, comparison of baseline and endline surveys Table 13. Distribution of ANC utilization at last pregnancy, Among births in the 2 years before endline, by characteristic Table 14. HIV testing during last pregnancy, among women with a birth in the past 2 years, comparison of baseline and endline Figure 4. Percent of women with a birth in the past 2 years receiving recommended information during antenatal care, comparison of baseline and endline Table 15. Information received by women pregnant in the past 2 years, by characteristic, at endline Figure 5. Experience of integrated services among FP users and women recieving care and support, comparison of baseline and endline Table 16. Experience of integrated services, among FP users and women receiving care and support, by characteristic at endline Figure 6. Current contraceptive use among women living with HIV, comparison of baseline and endline Table 17. Percent distribution of current use of contraception among women, endline A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 1

9 Table 18. Source of contraception among contraceptive users, comparison of baseline and endline Table 19. Source of contraception, among current users of modern methods at endline Table 20. Percent of modern contraceptive users experiencing integration, endline Table 21. Percent distribution of contraception decision making, by FP use, at endline Figure 7. Partner knowledge of FP use by marital status, among women using contraception, comparison of baseline and endline Table 22. Percent distribution of partner knowledge and discussion of FP use, by marital status, among current contraceptive users at endline Table 23. Percent distribution of dual method use, by characteristic, among current modern contraceptive users and all women, endline Figure 8. Condom use at last sex among women who reported sex in the past year, comparison of baseline and endline Table 24. Condom use at last sex and having had a non-regular partner in the past year at endline, by characteristic Table 25. Confidence in future condom use at endline, by characteristic Figure 9. Need for family planning calculated using the modified-survey appraoch, comparison of baseline and endline Table 26. Need for family planning calculated using the standard household survey approach, among women who have ever had sex, by background characteristic, endline Table 27. Unmet need calculated using the IATT approach Figure 10. Partner counseling and testing, comparison of baseline and endline Table 28. Partner counseling and testing at endline, by characteristic, among women who are married or living with a partner Table 29. Partner s HIV status at endline, by characteristic, among women who are married or living with a partner Figure 11. Exposure to Arise interventions among women attending ART or pre-art services Table 30. Exposure to Arise project interventions by backround characteristics Table 31. Odds of contraceptive use by key exposures at endline...41 Table 32. Odds of having demand for family planning by key exposures at endline Table 33. Odds of having unmet need for contraception by key exposures at endline P a t h f i n d e r i n t e r n a t i o n a l

10 Abbreviations ANC CI CPR FP HBC HIV IQR NACWOLA OI PEPFAR PLHIV PMTCT SD VCT Antenatal care Confidence interval Contraceptive prevalence rate Family planning Home based care Human immune-deficiency virus Interquartile range National Community of Women Living with HIV/AIDS Opportunistic infections President s Emergency Plan for AIDS Relief Persons living with HIV Prevention of mother to child transmission Standard deviation Voluntary counseling and testing A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 3

11 Executive Summary A facility-based endline survey was conducted as part of a program evaluation to assess the Arise Enhancing HIV Prevention for At-Risk-Populations project in Uganda. Arise is integrating family planning services into HIV services in 11 districts in Northern and Eastern Uganda. The project, funded by the Foreign Affairs, Trade and Development Canada (DFATD) through the Arise project, was designed to address the high unmet need for family planning that had been reported in past studies in Uganda, in order to prevent HIV infections by ensuring that HIV-positive women do not have unintended pregnancies, providing counseling to women who do become pregnant about how to limit transmission to their babies, and by encouraging partner counseling and testing and dual method use to prevent infections in uninfected partners of women infected with HIV. The baseline and endline surveys used the same approach, interviewing women aged years who sought HIV care and treatment at a sample of health facilities covered by Arise. The baseline survey was conducted in October 2011 and included 1,221 respondents; the endline survey was conducted in March 2013 and included 1,231 respondents. For each survey, four districts were randomly selected from among the eight districts covered by the research arm of the project. Three districts were included in both surveys while one of the districts changed. Within those districts, a sample of facilities was selected using probability proportional to client volume. Thirteen facilities were included in the baseline survey and seventeen in the endline survey. Both surveys used the same instrument to collect data on respondent s characteristics, their reproductive history, use of contraceptive methods, marriage and sexual activity, fertility preferences, and experience of integrated FP and HIV/AIDS services. Some minor changes were made between baseline and endline to capture additional information on some key topics. The surveys were conducted by Pathfinder International in collaboration with the National Community of Women Living with HIV/AIDS (NACWOLA), a local partner to Pathfinder for Arise, and were approved by the Institutional review boards at PATH and Makerere University. Overall, the results of the surveys suggest a positive change in terms of services received and in the key outcomes of the project, namely use of family planning by women living with HIV. With regard to services, while the percent of survey respondents who received counseling on FP did not change (81%), the proportion given information on special considerations for women with HIV increased from 93.6% to 99.1% and the proportion that had discussed their desire for children with their provider increased from 75.8% to 80.5%. This suggests that while coverage may not have changed, the quality of the counseling provided did improve. Improvements were also seen in coverage of pregnant women living with HIV. The percent of PMTCT clients who received postpartum follow-up visits that include FP counseling increased from 51.0% to 72.4%. This is substantial improvement, but over one quarter of pregnant women did not receive information in the postpartum period. This finding suggests that this is an area for further improvement. Most importantly, the key project outcomes improved. The modern method contraceptive prevalence rate (CPR) among women living with HIV increased from 38.4% at baseline to 54.2% at endline, a change of 15.8%. At the same time, unmet need for family planning declined significantly from 17.0% at baseline to 14.8% at endline, despite a significant increase in overall demand for family planning (from 56.1% to 67.9%). In addition to use of family planning, dual method use also improved, increasing from 44% to 51.8%. Male involvement, which was also an important focus for Arise has improved in some areas but not others. In particular, the proportion of clients whose partners had been tested for HIV was unchanged but the percentage of women who knew their partners status increased slightly from 76.3% to 81.3%. Thus male involvement is another area where further improvements are possible. In summary, the comparison of the findings from the baseline and endline surveys suggest that the Arise project successfully contributed to increasing demand for and use of family planning by women living with HIV in northern Uganda. The Arise project cannot take full credit for the changes that were seen, given that 4 P a t h f i n d e r i n t e r n a t i o n a l

12 the Government of Uganda and other projects have also been implementing integration of services. However, despite the project s short time frame, when these survey findings are viewed alongside the project monitoring data that show the large number of women who were provided with counselling and/ or family planning services through Arise, it is reasonable to conclude that the project did contribute to these changes. The findings support the importance of integrating family planning into HIV services so that women living with HIV can make informed choices about whether or not to have children and can use appropriate methods to delay or limit births if they do not wish to have more children. Key Messages Women who received information from a community support group were more likely to use contraception than those who had not received information in this way, highlighting the importance of linking facility interventions to community-based ones. At endline, the percentage of women who received information about family planning during antenatal care and postpartum increased, but fewer women reported receiving information during the postpartum period than during pregnancy. This suggests a continuing gap in service provision, despite substantial improvement over the two years of project intervention. Dual method use increased from baseline, but was no more common among women in discordant couples than in concordant positive couples, and partner testing did not significantly increase. HIV positive women still practiced risky sexual behaviors, as evidenced by only half who were sexually active reporting using a condom at last sex. These findings suggest that efforts to increase male involvement need to be more vigorous, in order to increase disclosure and enhance condom use. Concerted efforts to improve access to family planning information and services for women living with HIV by integrating them into other services can increase contraceptive use, and as a result prevent unintended pregnancies and new HIV infections. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 5

13 Section 1. Background Integrating Family Planning into HIV Services Integration of family planning (FP) and HIV services has been widely promoted as an effective approach to ensuring the reproductive rights of persons living with HIV (PLHIV) and to preventing HIV infections by preventing unintended pregnancies (Wilcher and Cates 2009; Guttmacher Institute and UNAIDS 2006). From a rights perspective, integrated services provide a means of ensuring that HIV-positive women are able to safely pursue their reproductive intentions whether they wish to become pregnant or to avoid pregnancy. In the case of HIV-positive women who are pregnant or wish to become pregnant, integrated services can help a woman to reduce risks of transmission to her baby. That HIV-positive women have a range of reproductive intentions is well documented (Chen 2001, Cooper 2007, Homsy 2009, Nakayiwa 2006, Peltzer 2008, Stanwood 2007). For example, studies in Uganda show that around 7% of women wish to become pregnant in the future but among those who do not wish to become pregnant, many are practicing behaviors that put them at risk for pregnancy and use of contraceptives is uncommon (Homsy et al 2009; Nakayiwa 2006). Beyond the immediate benefit to women, integrated services may provide additional benefits in terms of addressing overlapping health needs (e.g., for STI treatment as well as FP) and in reducing stigma for clients seeking services (Ringheim et al 2009). In terms of HIV prevention, integrated FP and HIV services have long been one of the key elements of strategies to prevent mother-to-child HIV transmission (PMTCT) (WHO 2003) and this is reiterated in a new strategy document for (WHO 2010). Particular importance is given to MTCT because it is a leading mode of HIV transmission worldwide, accounting for 430,000 new infections in 2008 (Joint UN Programme 2009). Integration is seen as an important means for preventing HIV infections by enabling HIV-positive women to prevent or delay pregnancies through improved access to and availability of contraception (WHO 2006). The impact of FP/HIV integration has been explored in a number of studies in multiple countries and the results are generally positive (Spaulding 2009). Efforts to model the impact suggest that FP contributes as much or more than ARV-PMTCT in mitigating pediatric HIV (Hladik 2009, Sweat 2004). However, the evidence base is limited. Most of the available studies did not employ rigorous designs and the range of outcomes assessed is limited and no studies have looked at HIV incidence or unintended pregnancy (Spaulding 2009). Rather, studies have looked at uptake of HIV testing, condom use, contraceptive use, quality of services and cost. Of those studies that reported on contraceptive use, the results were not consistent; 2 studies reported positive effects while two reported mixed effects (Spaulding 2009). In addition, because of the various types of integration possible (e.g., family planning integrated into VCT, HIV VCT provided to family planning clients), the evidence on any given approach is based on a handful of studies at most. Thus, while integration is the recommended standard of care, the evidence base for this recommendation could be stronger. Finally, one of the reasons most cited for such integration is the potential cost effectiveness of integrated services although this is largely based on logic rather than evidence. Reynolds et al (2006) estimated the cost per infection averted by FP to be $663 compared to a cost of $857 per infection averted by a singledose nevirapine regimen. More recently, Reynolds et al (2008) estimated the cost savings from adding contraception to HIV services in countries with funding from the Presidents Emergency Plan for AIDS Relief (PEPFAR). They report that preventing unwanted pregnancies among HIV-positive women would lead to annual savings of between $26,000 and $2.2 million, depending on the country. However, both of the above studies provide model-based estimates and costing data from actual interventions would provide stronger evidence for the cost-effectiveness of integrating services. Project Background Pathfinder International, Uganda is working with health facilities and a community group, the National Community of Women Living with HIV/AIDS (NACWOLA) to integrate family planning into HIV services 6 P a t h f i n d e r i n t e r n a t i o n a l

14 in eleven districts in northern Uganda. The project, Arise, began in 2011 and builds on identified bestpractices, providing counseling as well as service provision, bolstering commodity supply, and including a community-based component. Integration of HIV into family planning services is the standard of care per Ugandan government policy, but it has not been fully implemented in all areas, particularly in the project areas. Pathfinder s approach aims to ensure that HIV-positive women are supported in their decision making around childbearing and fertility intentions regardless of whether they would like to stop or delay having children or would like to have a child. The intervention also includes couple counseling, which can support the use of family planning by HIV-positive women. The program is being implemented in Northern Uganda, a post-conflict, underserved area where FP is currently not offered in PMTCT or ART services, and where FP availability is limited to the general population. The intervention is being implemented in 11 districts (technically located in the north and eastern regions): Kaberamaido, Amolatar, Dokolo, Lira, Apac, Katakwi, Amuria, Oyam, Gulu, Pader and Amuru which have a total population of approximately 3.6 million people. According to the national AIDS Indicator Survey, adult HIV prevalence among women in the north central region 1 is 9.0% while it is 3.6% in the north eastern region (MOH and ORC Macro 2006). 85% of the population in the eleven districts covered by this project lives in the higher prevalence north central region and given the proximity of these districts to one another, the degree of variation is likely to be less than the national figures suggest. In terms of CPR for modern methods, it is 23.4 in the northern region where HIV prevalence is higher, and 23.2 in the eastern region (Uganda Bureau of Statistics 2012). HIV and AIDS services are provided through the local government as well as through several partners including the Northern Uganda Malaria, AIDS and TB Project, which supports PMTCT in 5 of the 8 proposed project districts. Other organizations provide PMTCT services in hospitals and level III and IV health centres. These include Protecting Families against AIDS and Canadian Physicians for Aid and Relief; and ART programs such as the TREAT project and The AIDS Support Organization. Additional organizations provide community-level services including NACWOLA, AIDS Information Centre, Network of HIV-positive People, Uganda Young Positives, and district local governments. After over 20 years of conflict, Northern Uganda falls behind the nation as a whole on a range of socioeconomic indicators and continues to suffer the effects of the prolonged conflict. In parts of the region, 90% of the population (a total of close to 2 million people), were displaced, many for long periods of time. A 2007 survey of displaced and returned populations showed limited access to health services, markets, and secondary schools, especially among people who had returned from camps (UNDP 2007). The region as a whole suffers from high levels of poverty, low literacy and high school dropout, and few employment opportunities. A recent report by the Uganda Bureau of Statistics showed that most Ugandans in absolute poverty (31% of the national population) live in the northern and eastern parts of the country. Over 40% of females aged are illiterate and 19% of them have never attended school (Annan 2008). Most employment in the region is subsistence agriculture and small trading although there has been a substantial investment in micro-credit. Women in Northern Uganda are particularly likely to face sexual and reproductive health challenges in the aftermath of two decades of violent conflict and internal displacement. Gender norms limit women s ability to earn independent incomes making them dependent on their spouses and families and leading to prostitution. High levels of sexual and gender-based violence lead to poor health. According the Demographic and Health Survey 2012 (UBOS 2012) in Northern Uganda, only 23.9% of women aged 15 to 49 were using a form of contraception; unmet need is estimated to be 42.5% (UDHS 2012). One of the most common reasons women give for not using contraceptives is fear of disapproval by their husbands. Women in post conflict northern Uganda are further denied services due to distance, inability to pay for services, inability to make individual decisions on when to seek health services, and denial of access to services by their male partners or other decision makers in the family. 1 The AIDS Indicator Survey 2006 used regions that were delineated for the survey; they are not consistent with the 9 districts used in the DHS 2006 or with the four administrative regions. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 7

15 Education levels are low for women in northern Uganda. 22.7% of women have not had any formal education and 48.8% are illiterate (UBOS 2012). Young women aged are not employed, early marriage is common, and polygamy, as in most rural communities in Uganda, is still practiced. Married women in such unions do not make decisions for themselves and consent is usually sought from husbands. In the UDHS 2006, 78% of married women reported that they did not make independent health care decisions. Likewise, while 15% of women in northern Uganda earn more than their husbands or partners, only 36% of women in this region make independent decisions on their earnings. Women with HIV may also face stigma in their homes and communities if their HIV-positive status is known. Unfortunately, the documentation of stigma in Uganda is weak but one study suggests that PLHIV can become socially disenfranchised, with community members unwilling to interact with them. An HIV diagnosis can also have serious financial implications if the person infected with HIV is engaged in business, and can limit participation in politics (Muyinda et al 1997). However, the article was published in 1997 and even then noted some lessening of stigma as people s awareness of HIV increased. In other countries, the availability of ARV has also been linked to a decline in stigma (Wolfe et al 2009). So while there is the potential for stigma to affect women who are HIV-positive, the extent to which this is possible and the potential ramifications are difficult to determine. Discussion with NACWOLA suggests that there is stigma. However this is one of the issues that is addressed seriously with their members because it affects access to services. The Executive Director reported reduced or lack of stigma among NACWOLA members as a result of the work of the community mobilizers during awareness and education activities. Survey Objectives The overall program evaluation aims to answer two key questions about integration of FP into HIV service delivery: Does improved availability of quality FP counseling and services to HIV-positive women reduce unmet need for contraception among this group? Does increased emphasis on couple counseling and testing, and on male involvement among PMTCT and ART clients result in increased use of contraception, particularly dual method use? The research objectives related to the surveys are: 1. Determine whether the contraceptive prevalence rate (CPR) among HIV-positive women changes following integration of FP into HIV service delivery 2. Determine whether levels of dual method use change among HIV-positive women and their partners following integration of FP into HIV service delivery Three key outcomes were assessed in the evaluation and measured through the baseline and endline surveys: The contraceptive prevalence rate (CPR) among HIV-positive women. This will provide a direct measure of the effectiveness of this intervention in increasing use of contraception among HIVpositive women, which should lead to a reduction in fertility among HIV-positive women and a decrease in the number of HIV-positive children. Dual method use. This will provide a measure of the effect of the program in increasing preventive behavior among discordant couples. Unmet need for contraception. This is a more direct measure of the impact of the intervention, which aims to decrease unmet need. Secondary outcomes included: the percent of program participants who have received counseling on FP, the percent of PMTCT clients receiving postpartum follow-up visits that include FP counseling, and the proportion of clients whose partners have had an HIV test. The full report of results from the baseline survey are reported elsewhere (Oliveras and Makumbi 2013). This report focuses on results of the endline survey and compares key findings with the baseline, as stated in the research objectives. 8 P a t h f i n d e r i n t e r n a t i o n a l

16 Survey Methodology Survey Design & Sample Three-stage cluster sampling was used. Four districts were randomly selected: two in the Northern region and two in the north eastern region. This was in order to ensure that the focus of the data collection was in the Northern region where the majority of the population covered by the intervention is located. Then all 67 accredited ART and pre-art service delivery sites in the selected districts were listed. The estimated number of female clients served by each site was documented through a facility needs assessment and through available data from facility registers. A sample of 13 facilities was chosen for the baseline and 17 for the endline using systematic sampling with probability proportional to size, using the volume of female clients served as the measure of size. 2 The total target sample size was allocated to facilities proportionate to client volume (QIQ 2001). All female clients of the participating HIV services (ART or pre-art facility services) aged years were eligible to participate. The number of clients interviewed per site varied with the number of clients served. The number of clients needed per facility was estimated and the number of days required to obtain that number was calculated (# interviews/# interviews per day). The interviewers were asked to conduct as many interviews as possible during the allotted number of days, with the interviewer team starting with the first client who registered for services on a given day and then choosing subsequent women to interview based on when preceding interviews were completed. In other words, once an interviewer completed an interview, she invited the next available woman to participate. They continued in this way over the course of the day. The interviewers were trained and supervised to avoid biased selection of clients. Survey Instrument The survey was conducted using a questionnaire (Annex A) that was developed based on Demographic and Health Survey and AIDS Indicator Survey tools. The questionnaire was translated into the two local languages used in the study areas: Ateso and Langi. Data Collection & Management All survey tools, including instruments and manuals, were pre-tested and validated prior to training for the baseline survey. The research staff (Annex B) were trained on the questionnaire, client selection, informed consent, confidentiality, and interviewing techniques. Training for the baseline included an initial 1-week training and pilot test and a 2-day refresher training that was held just prior to the start of data collection; training for the endline survey was a 3-day refresher training because all of the interviewers and supervisors had participated in the baseline survey. Ethical considerations were stressed and highlighted in materials development, interviewer training, and field work. All interviews were conducted in a private setting by same-sex interviewers. Written informed consent was obtained from all participants. The survey was approved by the Research Ethics Committee at PATH and the Makerere University School of Public Health Higher Degrees and Research and Ethical Committee. The initial training and pilot testing for the baseline took place in May 2011 and the baseline data collection was conducted between 28 September and 11 October 2011; training and data collection for the endline survey were conducted in March Data management differed between baseline and endline. For both surveys, questionnaires and consent forms were collected by the survey supervisors and were transported each day to the Pathfinder office in 2 The number of sites varied because the intervention was never implemented in one district. As a result, that district (which had a large facility) was removed from the list of eligible facilities for the endline survey. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 9

17 Lira for storage. For the baseline, the completed questionnaires were then packaged and sent to Kampala for data entry by the study collaborators at Makerere University School of Public health. Data were entered into EPIDATA capture screens by two well-trained data entry staff. For the endline, the data were entered the following day into EPI-INFO data capture screens by three trained data entry operators. A random sample of 5% of the questionnaires were re-entered and checked for consistency so as to make a decision on 100% double data entry. Inconsistency between the first and second re-entry was below 2%, and so the 100% double entry was not done as earlier determined by the entry guidelines. Inconsistencies were reviewed by the data editor and were corrected after comparison to the questionnaire. The electronic data were then transferred into Stata format for analysis. Both the EPIDATA and Stata data files were backed up and archived. Data Analysis Data analysis was completed in Stata, Release 11, Copyright 2009 StataCorp LP. Frequencies and means were calculated for the sample as a whole and for sub-groups as detailed below. Limitations of the Study These surveys had some limitations that may affect the results. First, the estimates of unmet need excluded pregnant women at baseline and thus differ from the calculation commonly reported in surveys like the DHS and MICS. Second, the findings at baseline may not reflect a true baseline because providers had already been trained at the time that the baseline was conducted. Other project inputs (i.e., the community-based interventions, direct support to facilities to encourage integration) had not begun, so this would likely have had a minimal effect. This potential bias would minimize the differences between baseline and endline findings so the true effects of the project may have been greater than what is shown here. Response Rates The baseline survey was conducted in 13 facilities and the endline survey was conducted in 17 facilities. Eight facilities were common to both surveys and clients from these facilities comprised 69.3% of the endline sample. One large facility, the Lira Regional Referral Hospital comprised 36.2% of respondents in the baseline and 24.8% of respondents in the endline survey. In total, 1,238 women were approached for interview at baseline and 1,259 at endline. Of all the women approached, over 99.7% at baseline and 99.3% at endline completed the interview. At endline, two women were not eligible, two refused to participate and two did not complete the interview. In all, 1,221 women at baseline and 1,231 women at endline provided complete information on key background characteristics (age, marital status and education) and were included in the analysis. 10 P a t h f i n d e r i n t e r n a t i o n a l

18 Section 2. Results Respondent Characteristics Demographic Characteristics Table 1 summarizes the characteristics of the women who participated in the baseline and endline surveys. In general, there were few differences between the respondents in the two surveys. The mean age of respondents at baseline was 33.0 years (95% CI: 32.6, 33.4) while at endline it was 32.7 years (95% CI: 32.3, 33.1). In both the baseline and endline surveys, the majority of the respondents were formally married or living with a partner in informal union (over 60% at baseline and over 70% at endline, p<0.01), although the proportion married was 10% higher at endline. At endline, 4.3% of women had never been married. Notably, 43.6% of women in informal union said that their partner was living elsewhere as did 20.8% of married women (data not shown); this is an increase relative to the baseline survey. These women may be at increased risk for exposure to sexually transmitted infections or HIV reinfection if their partners are having sexual relations outside of their partnership. In both surveys, half of the participants were Catholic, approximately 40% were Protestant, and less than 10% were Pentecostal, Muslim or another religion. Approximately one-quarter of women reported never attending school while most of the rest (over 60%) reported primary schooling only. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 11

19 Table 1. Percent distribution of women by selected background characteristics, baseline and endline surveys Recent Sexual Activity Background characteristics Baseline Endline (%) # (%) # Age * Current marital status Married * Living together Not living with a partner * District Amuria * Dokolo * Lira * Oyam NA NA NA Katakwi NA NA NA Religion Catholic Protestant Pentacostal Muslim * Other/None Missing Education Level No education Lower primary * Upper primary Secondary or higher Total 100% 1, % 1,231 *Two-sample comparison of proportions for baseline vs endline Three quarters of the respondents reported that they had been sexually active in the past year (Figure 1); this is a significantly higher proportion than at the baseline (p<0.01) and significantly fewer women reported last sex more than 1 year before the survey (22.6% at endline vs 29.3% at baseline, p<0.01). Over thirty percent had last had sex within the past week, 20% between 1 week and one month ago, and 19% more than one month ago (Table 2). The proportion of women that reported sex in the past year was inversely related to age. As expected, women who were not married were least likely to have had sex; whereas 90% of women who were married or living in informal union reported sex in the past year, only 33% of women not living with a partner did so (Table 3). 12 P a t h f i n d e r i n t e r n a t i o n a l

20 Percent of clients Figure 1. Comparison of timing of last sex at baseline and endline * * * 0.7 Never Last year > 1 year Baseline Endline *p<0.05 Table 2. Comparison of reported timing of last sexual activity, baseline and endline surveys Baseline Endline p-value* (%) # (%) # Timing of last sex Never had sex Sex in the past week Sex in the past month Sex in the past year Last sex > 1 year ago <0.01 Don t know <0.01 Total 100% 1,221 1,231 *Two-sample comparison of proportions for baseline vs endline A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 13

21 Table 3. Timing of last sex by characteristics of the respondents, endline survey Background Never Timing of last sex Sex in Number characteristic had sex <1 week <1 month <1 year 1 year Don t know past 12 months of women Baseline Survey Age Marital status Married Living together Not living with a partner Education Level No education Lower primary Upper primary Secondary or higher All women ,221 Endline Survey Age Marital status Married Living together Not married Education Level No education Lower primary Upper primary Secondary or higher All women ,231 Reproductive History Understanding the reproductive histories of the respondents is important because it is likely to be related to their demand for and use of contraception. As shown in Table 4, almost all of the women in both samples (95%) had given birth (n=1,155 at baseline, n=1,173 at endline). At least 90% of women in each age group above years had given birth before the survey. In all but one age group (25 29 years), there was no significant difference in the percentage that had given birth at baseline and endline. Although 14 P a t h f i n d e r i n t e r n a t i o n a l

22 a significantly smaller proportion of women age years had given birth at endline, the difference was small 95.5% vs. 98.6%, p=0.03. Table 4. Percent distribution of women who ever gave birth at endline, by age and cumulative frequency Baseline (n=1,221) Ever Given Birth (in Age Group) Endline p-value * (n=1,231) Ever Given Birth (Cumulative by Age Group) Baseline Endline (n=1,221) (n=1,231) Age Total * Two-sample comparison of proportions for baseline vs endline Respondents were asked how many living children they had, in particular about children they had borne. While women may also have foster children or adopted children, children born to them are more likely to affect their fertility desires and decisions regarding contraception. Only women who reported ever giving birth (n=1,155 at baseline and 1,171 at endline) were asked the number of living children. Women who reported ever giving birth had an average (SD) of 3.8 (2.2) living children at baseline and 3.9 (2.1) children at endline; half of these children were boys and half of them were girls (Table 5). Over one-third of women had five or more living children. The proportion of women with three or more living children tended to be higher among women with primary or no education. Thus the average number of living children decreased with increasing level of education, from 4.6 children among women with no education to 2.9 children among women with secondary or higher education at endline. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 15

23 Table 5. Percent distribution of women, by number of living children, among women who ever gave birth, at endline Number of Living Children Mean number of living children Boys Girls Total Baseline Survey Number of women Age Education Level No education Lower primary Upper primary Secondary or higher All women who ever gave birth ,155 Endline Survey Age Education Level No education Lower primary Upper primary Secondary or higher All women who ever gave birth ,171 Fertility Desires Most women (over 63%) in both surveys wanted no more children (Table 6). At endline this increased with number of living children, from 28% among women with one child to 85% among women with 5 or more children. Conversely, 20.9% of women with no children wanted a child soon (within the next 2 years) compared to less than 2% of women with 5 or more children. Overall, 23.3% of women wanted to have another child but wanted to delay the birth of their next child for 2 or more years. Thus, 87% of all women surveyed wished to either limit or space their births. The proportion of women who wanted to have another child did not differ between the two surveys although the proportion that wanted to have another child soon was lower (4.0% vs 7.4%, p<0.01) at endline than at baseline, and the proportion that wanted to have another after 2 or more years was higher (23.6% vs 16.6%, p<0.01) (Table 7). 16 P a t h f i n d e r i n t e r n a t i o n a l

24 Table 6. Percent distribution of currently married women age years by desire for children, according to number of living children, endline survey Number of living children Have another soon* Have another later** Desire for children Have another, Undecided undecided when Want no more At marriage Missing Number of women Total ,231 * Wants next birth within 2 years ** Wants to delay next birth for 2 or more years Table 7. Desire for children among women aged years, baseline and endline surveys Time since Diagnosis Baseline Endline p-value * (%) # (%) # Desire for children Have another soon <0.01 Have another later <0.01 Have another, undecided when <0.01 Undecided Want no more At marriage Missing Total 100% 1, % 1,231 * Two-sample comparison of proportions for baseline vs endline Respondents at endline had been diagnosed anywhere from less than one month before the survey to over 25 years before. Ninety five percent had been diagnosed within 10 years of the survey and 99% within 14 years. The mean number of months since diagnosis was 44.9 (standard deviation, SD=35.9) at baseline and 51.4 (SD=37.7), significantly longer at endline (p<0.01). The median (interquartile range, IQR) was 36 (IQR=24, 60) months at baseline and 48 (IQR=24, 72) months at endline. Although mean time since diagnosis tended to vary by district of residence, these differences were not statistically significant and the mean time since diagnosis varied less by district at endline than it did at baseline. A r i s e : e n d l i n e s u r v e y r e s u l t s a n d b a s e l i n e c o m p a r i s o n 17

25 Percent of clients Table 8. Months since HIV diagnosis by district of residence, at baseline and endline Baseline Endline Months since HIV diagnosis Months since HIV diagnosis p- District Number of women Mean SD Median Inter quartile range Number of women Mean SD Median Inter quartile range value Amuria , , Dokolo , , Lira , , 72 <0.01 Oyam , 60 NA NA NA NA NA NA Katakwi NA NA NA NA NA , 72 NA Total 1,208* , 60 1,221** , 72 <0.01 * 13 women did not provide information on time since diagnosis ** 10 women did not provide information on time since diagnosis Use of HIV Services As expected most of the women interviewed (99%) were receiving care or treatment at the time of the survey. The average duration of treatment at endline was 49 months (versus 39 months at baseline) and 38% of all women had been on treatment for 5 or more years (Table 9). Duration on treatment was positively associated with age. Women not living with a partner had a substantially longer duration of treatment than women who were married or living with a man. Significantly more women had been on treatment for more than 5 years at endline than at baseline (Figure 2). Figure 2. Time in treatment, comparison of baseline and endline * * * <1 year 1 year 2 years 3 years 4 years 5 years Baseline Endline *p< P a t h f i n d e r i n t e r n a t i o n a l