Day 6 Digest
Before we start, we would like to thank everyone who participated our first week of discussion. We are especially grateful to our experts for the first week: Dr. Heidi Reynolds of Family Health International, Dr. Edward Bonku, of EngenderHealth/Quality Health Partners (QHP) Project in Accra, Ghana, Ms. Betty Farrell of EngenderHealth/ACQUIRE, and Dr. Young Mi Kim of the Center for Communication Programs at Johns Hopkins Bloomberg School of Public Health.
This e-mail contains additional comments, questions and resources related to week one of our online forum on “Client and Provider Perspectives on Integration of Family Planning Counseling and HIV/AIDS Services”. You will receive a second e-mail shortly after this one with a new topic of discussion for our 2nd week.
Comments & questions in this e-mail include:
- Dr. Jim Shelton of USAID talks about the problems with relying only on condom promotion to prevent HIV and unwanted pregnancies
- Dr/ Edward Bonku of Ghana responds to some questions from Marian Amoa.
- Josephat Avoce, who runs an NGO in Benin, asks about research methodologies for measuring the impact of condom use for dual protection
- Maria Ofelia Alcantara comments on integration in the Philippines
Finally, we include some links to resources on using entertainment (especially TV and theatre) to promote health and healthy behaviors in response to Dina Hovakmian’s request. If others have suggestions for good resources, please send them in.
Jim Shelton, USAID
Personally I love condoms and I’m happy to see the discussion on condoms that has been going on here. I have spent close to 30 years actively advancing and promoting condoms including supporting research to develop new ones including the female condom, and a large amount of technical support to providing billions. And I believe condom promotion with sex workers (along with largely unprogrammed but still valid reductions in visits to sex workers) has epidemiologically perhaps been the single most important intervention to prevent HIV transmission in the entire pandemic.
Still I believe we need to be much more realistic about the potential for condoms for HIV prevention in the general population, as a method of contraception and specifically in the context of FP/HIV integration. And the specific epidemiology in the location as well as the arena of FP/HIV (C&T, PMTCT, ARV, Care and Support) plays a role as well. In my view it has been far too easy just to endorse condoms as the solution to both problems.
For HIV prevention, the limitations are:
1.They provide about 90% protection.
2. But to achieve that they have to be used correctly and consistently.
3. Many people (especially men) don’t like using condoms and use of condoms tends to be especially low among regular partners.
4. There is the possibility of “risk compensation” in this case that some people may believe they can engage in risky sex with impunity (such as multiple partners) so long as they use (or plan to use) condoms.
5. They require a continuous source of supply.
Unfortunately, correct and consistent use appears to be rather uncommon. Moreover, it is becoming increasingly clear that in generalized epidemics, concurrent sexual partnerships of men and women are quite important. So low use with regular partners is a major problem.
Likewise for contraception, condoms have low acceptability and largely as a consequence of less than perfect use, are all too often not very effective.
Without question, in the context of counseling and testing, for a woman or man who tests positive, there are few options and condoms must be at the forefront of what is recommended. But adding another method of contraception needs to be an option also. And, remember that the large majority of those tested will test negative. So an important opportunity exists with sexually active reproductive age women and men to offer the range of contraceptive methods (along with counseling on behavior change.)
In the context of ARV provision, some may take the view that condoms are a necessity. However, my reading of the literature (notwithstanding the UCSF position) is that the probability of superinfection is quite low once someone is infected and in addition, the ARVs provide substantial protection against acquisition and transmission to a partner. On the other hand, for HIV-infected women who do not want to become pregnant, that desire may be quite strong and they may want a very effective method of contraception.
Dr. Edward Bonku
Thanks for your questions, Marian.
My response is as follows:
1. What would you say were the root causes of provider stigma? (I think that knowing what the causes are would help program managers design interventions to address the issue more effectively).
In our study, stigma among health care providers and clients was not directly assessed. However, two questions in the health provider questionnaire turned up some interesting responses, which although in the minority, provide some insight on the issue. These were:
Question: How do you feel about an HIV positive woman becoming pregnant?
Responses : "Should be counseled against it."
"They will infect mother and baby."
" Man can easily infect the woman"
Question : How do you feel about a HIV positive man having a child?
Responses: "Use condom."
"Not proper to have a child."
It is evident from studies elsewhere, that people are stigmatized and discriminated against by health care systems in a variety of ways, including; withholding treatment, non-attendance of hospital staff to patients, HIV testing without consent, lack of confidentiality and denial of facilities among others. Some of the universal reasons for stigma include the perception of HIV/AIDS as a life threatening disease, the scare of contracting the infection, association of the disease with irresponsible behavior and moral and religious beliefs. I agree entirely with you, that to deal with stigma effectively, some of these factors should specifically be sought in the local context and resolved.
2. Did HIV+ clients prefer to have both FP & HIV services at the same site?
Yes indeed. “The client exit interviews indicate that there is a high demand for FP services by HIV positive women. When asked, 40% of women clients attending the HIV clinic would have liked the nurse or doctor to have talked with them about FP during their consultation."(Source: Integrating FP Counseling and Services into HIV Care and Treatment Services in Ghana: A Performance Needs Assessment. 2005)
3. Could you please shed some more light on how you dealt with issues of confidentiality?
The study evaluated HIV+ women's experience of privacy during consultation at the two hospitals piloting the FP/ART integration. Majority of the clients interviewed (95%), said they thought others outside the consulting room could not see or hear them, and that they were sure that the provider will keep information discussed confidential. (Source: Integrating FP Counseling and Services into HIV Care and Treatment Services in Ghana: A Performance Needs Assessment. 2005).
This finding was made in relation to the HIV clinic areas of the hospitals only. The environment at the FP clinics at the two hospitals is slightly more liberal in this respect, probably due to the fact that they manage less 'sensitive' issues. In part, the other reason is that there had practically been no referrals of HIV+ clients for FP methods before the onset of the integration program. In view of the anticipated referrals of HIV+ women to the FP service area for long-term methods provision, there was the need to ensure that the privacy and confidentiality environment which clients approve of at the HIV clinic areas, also pertain at the FP area in other to assure clients' confidence. This issue was therefore brought to the fore during training and orientation of service providers to the integrated services.
Among the practical suggestions made by the on-site providers themselves in ensuring that confidentiality is assured for the HIV+ women seeking FP methods were:
- Provide and enter client's particulars/details in an FP card that is issued at the HIV clinic, once client demands a method after counseling
- Provide referral information in the card and direct/accompany client to the FP area;
- FP service provider offers method and enters details in the clients' FP card, and at the same time records statistic in a record-book provided for the purpose
- Send client FP card back to the HIV service area for safe-keeping.
Other issues of confidentiality related to provider skills in client-provider interactions was addressed during the training as well.
Josephat Avoce
Mon nom est Josephat AVOCE. Je suis épidémiologiste du VIH, chercheur et spécialiste en éducation pour la santé en matière de reproduction. Je suis consultant indépendant et je gère les activités quotidiennes d'une ONG de promotion de la SR/PF et de lutte contre les IST et le VIH/SIDA au Bénin depuis 1995, ce qui justifie tout mon intérêt pour ce forum.
Mes questions sont relatives aux méthodes et résultats d'évaluation de la double protection notamment avec l'utilsation du condom seul. Avec les autres méthodes contraceptives pures en association avec le condom, on peut se faire une idée. Mais si c'est le condom seul, comment savoir la proportion de personnes parmi celles qui l'ont utilisé comme moyen de double protection, celle qui fut protégée contre les grossesses non désirées d'une part et les IST/VIH/SIDA d'autre part. Par ailleurs, quel aurait été le nombre de cas de grossesse non désirées et d'infection à VIH évités attribuables à la méthode de double protection pour un condom utilisé seul ? Pour les programmes qui en ont fait l'expérience, quelques sont les méthodes de recherchre/évaluation utilisées ? Pour finir, il m'intéresse de savoir quelle est la prévalence du VIH au sein des femmes utilisatrices des méthodes de planification familiale ? S'il est possible de donner des chiffres, il faut préciser pour quelles méthodes (naturelle telle que la méthode des jours fixes, modernes hormonales telles que les injectables et les implants...)
Merci de m'aider pour élucider ces préoccupations.
(English Translation):
My name is Josephat AVOCE. I am an HIV epidemiologist, researcher and specialist in reproductive health education. I am an independant consultant and I have been managing the daily activities of an NGO that promotes family planning, reproductive health and the fight against HIV/AIDS and STIs in Benin since 1995, which explains my interest in this forum.
My questions relate to contraceptive methods and results of evaluation of dual protection in particular related to use of the condom alone. With the other strictly contraceptive methods used in partnership with the condom, one can have an idea.
But if it is the condom alone, how can we know the proportion of people among those who used it as a method of dual protection, that is as protection from unwanted pregnancies on the one hand and the STIs/HIV/AIDS on the other hand.
In addition, what would have been the number of cases of unwanted pregnancies and infections with HIV avoided ascribable to the method of double protection for use of the condom only?
For programs which have done research on the condom as a method of dual protection, what methods of research and evaluation were used? To finish, I am interested in knowing the prevalence of the HIV among female users of the various methods of family planning. If it is possible to give figures, it is necessary to specify which methods (for example natural methods or modern hormonal methods such as injectables and implants…).
Thanks for helping me to elucidate these concerns.
Josephat AVOCE
Maria Ofelia Alcantara
“In the Philippines, its still by FP and HIV in the education campaign although FP can be integrated in HIV curriculum and vice versa. It will be great to learn experiences in other areas.
Resources for using entertainment to educate about health
Theatre-Based Techniques for Youth Peer Education: A Training Manual
This 100-page training manual provides an overview of using theater in health education. It contains four peer theater training workshops, a series of theater games and exercises that can be used in trainings, and information on developing and building a peer theater program. The manual is a result of collaboration between the United Nations Population Fund (UNFPA) and Family Health International. Produced for the Youth Peer Education Network (Y-PEER), a project coordinated by UNFPA.
http://www.fhi.org/NR/rdonlyres/evrew7peejhyciohb7yu2avqygvlyhjfhpq6fr4ghf3byl3q23wuhbe6s7ktluvvdmt5prf2vv2tke/theatrefull.pdf
Participatory Theatre for Development
Links to some excellent resources on using theatre in a participatory way
http://www.hcpartnership.org/Topics/Communication/participatory_theater.php
Entertainment Education
This page on the Center for Communication Programs website has links to many projects that have used entertainment to promote health. Click on “Enter-Educate Projects.”
http://www.jhuccp.org/topics/enter_ed/index.shtml
Tsha Tsha TV Series
Tsha Tsha, an entertainment-educate drama series, forms the centerpiece for the collaboration between Health Communication Partnership (HCP), South African Broadcasting Corporation Limited (SABC) and the Centre for AIDS Development Research and Evaluation (CADRE) in South Africa. The series focuses on young adults living in an HIV-positive world and utilizes identification with key characters and problem-solving approaches as part of its educational methodology.
http://www.hcpartnership.org/Programs/Africa/south_africa/tshatsha.php
Scenarios from the Sahel
A project in West Africa, that develops short dramas about HIV based on scenarios written by students in Senegal, Mali and Burkina Faso. The dramas are filmed and broadcast in French and English. See http://www.jhuccp.org/topics/enter_ed/eeprojects/07-22.shtml for more information.
Edutainment Window – Communication Initiative
This ‘window’ includes links to additional projects in health and development that use entertainment as education.
http://www.comminit.com/edutainment/
Soul City
Soul City is one of the more successful TV series using the Enter-Education / Edutainment approach. It is produced by the Institute for Health and Development Communication (IHDC) in South Africa.
http://www.soulcity.org.za/