Developing and Testing a Chatbot to Integrate HIV Education Into Family Planning Clinic Waiting Areas in Lusaka, Zambia.

BACKGROUND: To maximize protection against both unintended pregnancy and HIV, it is important that family planning (FP) services integrate HIV counseling, both to support method choice and identify potential HIV services of interest, such as pre-exposure prophylaxis (PrEP). However, FP providers often lack sufficient time and knowledge to address HIV vulnerability with clients. To potentially offload some of the initial HIV counseling burden from FP providers, we developed and tested a chatbot that provided information about HIV and dual protection to FP clients in waiting areas of FP clinics in Lusaka, Zambia. CHATBOT DEVELOPMENT: We drafted a scripted conversation and tested it in English in formative workshops with Zambian women between the ages of 15 and 49 years. After translating the content to Bemba and Nyanja, we conducted a second round of workshops to validate the translations, before uploading the content into the chatbot platform. CHATBOT USER TEST: Thirty volunteers tested the chatbot in 3 Lusaka FP clinics, completing an exit survey to provide feedback. A large majority (83%) said they learned new HIV information from the chatbot. Twenty (67%) learned about PrEP for the first time through the chat. Most (96%) reported discussing HIV with the provider, after engaging with the chatbot. In response to an open-ended question, several testers volunteered that they wanted to learn more about PrEP. CONCLUSIONS: Pre-consultation waiting-area time is an underutilized opportunity to impart HIV information to FP clients, thereby preparing them to discuss their dual HIV and pregnancy prevention needs when they see their providers. FP clients expressed particular interest in learning more about PrEP, underscoring the importance of integrating HIV into FP services.

Stigma among key populations living with HIV in the Dominican Republic: experiences of people of Haitian descent, MSM, and female sex workers.

OBJECTIVE(S): To describe stigma among seropositive MSM, female sex workers (FSWs), and Haitian-descent individuals in the Dominican Republic, and to assess whether stigma is associated with HIV treatment outcomes. DESIGN: Cross-sectional survey using Stigma Index 2.0. METHODS: People living with HIV (PLHIV) interviewed seropositive adult MSM, FSWs, Haitian-descent persons, and other PLHIV who did not identify with these communities about experiences of social exclusion, harassment, stigma in healthcare settings, and internalized stigma. Bivariate analyses were conducted to compare experiences between FSWs and other women; MSM and other men; and Haitian-descent participants and non-Haitian PLHIV. Within each community, separate multivariate logistic regression analyses were conducted to examine the association between stigma experiences with viral suppression and with missed antiretroviral doses. RESULTS: The 891 participants consisted of 154 MSM, 216 FSWs, 90 Haitian-descent persons, and 447 who did not identify with any of these three communities. Compared with other women, FSWs reported significantly higher levels of harassment due to their HIV status, and those of Haitian descent reported significantly lower levels of social exclusion compared with non-Haitian PLHIV. In adjusted analyses, MSM who experienced more stigma in HIV-specific services had a significantly lower odds of knowing they had undetectable viral load (adjusted odds ratio 0.37, P < 0.05). Higher internalized stigma scores were significantly associated with missing an antiretroviral treatment dose among FSWs (adjusted odds ratio 1.26, P < 0.05). CONCLUSION: For FSWs and MSM, efforts to mitigate HIV-related stigma are necessary to improve treatment adherence and viral suppression. For Haitian-descent PLHIV, interventions must address not only their HIV-specific needs, but also the broader social and legal barriers to care.

Safer conception for female sex workers living with HIV in Dar es Salaam, Tanzania: Cross-sectional analysis of needs and opportunities in integrated family planning/HIV services.

BACKGROUND: With the advent of effective treatment, women living with HIV can plan for pregnancy while minimizing risk of transmission to infants and seronegative partners. Family planning (FP) services tend to focus solely on addressing contraceptive need, but HIV-positive women-including female sex workers-often plan to have children someday. Various "safer conception" strategies are now available to support women living with HIV achieve fertility intentions, and integrated HIV/FP services may be a promising platform to offer these services. METHODS: At integrated community-based HIV/FP service delivery sites operated by Jhpiego's Sauti project in Dar es Salaam, we conducted exit interviews with 300 HIV-positive female sex workers. Descriptive analyses were conducted to describe their desire for children, use of condoms and other modern contraceptive methods, self-reported viral suppression, and knowledge of and interest in safer conception strategies. We conducted bivariate and multivariate logistic regression analysis to examine correlates of fertility desire among respondents. RESULTS: Median age of participants was 32. Nearly one-third wished to have a child within two years. Seventy-two percent had heard of having the HIV-positive partner taking ART to reduce sexual transmission during pregnancy attempts. Thirty-one percent felt the amount of FP content covered in the consultation was "too little." Factors significantly associated with desire for children were having a nonpaying partner (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI]1.13-4.20) and having fewer children (AOR 0.65, 95% CI 0.48-0.87). Viral suppression was not associated with fertility desire. CONCLUSIONS: Sex workers living with HIV attending integrated HIV/FP services have need for both contraception as well as safer conception counseling. This integrated service delivery modality is a promising platform for providing safer conception services. FP counseling for HIV-positive women should be broadened to broach the topic of safer pregnancy, as well as explicit counseling on strategies to minimize risk of sexual transmission to partners.

Reproductive health and desire for children among young female sex workers in Bangladesh brothels.

Globally, reproductive health research among female sex workers (FSWs) often focuses on pregnancy prevention, but many women who sell sex aspire to have children in the future. In Bangladesh, where early marriage and parenthood is the norm, we examine reproductive histories and childbearing desires of young women who sell sex in brothels. We interviewed 1061 FSWs aged 18 to 24 in eight brothels in three Bangladesh divisions. Interviewers elicited information on sociodemographic characteristics, contraceptive use, pregnancy history, and childbearing desire. Bivariate and multivariate analyses were conducted to examine correlates of wanting to have a child within 24 months.

Pregnancy Experiences of Female Sex Workers in Adama City, Ethiopia: Complexity of Partner Relationships and Pregnancy Intentions.

Research and programs for female sex workers (FSWs) tend to focus exclusively on HIV prevention, with little attention paid to how pregnancy affects their lives. We examine the circumstances surrounding pregnancy and childbirth among women selling sex in Ethiopia. In Adama City, researchers asked 30 FSWs aged 18 and older who had ever been pregnant to participate in in-depth interviews. The women reported on pregnancies experienced both before and after they had begun selling sex. They identified some of the fathers as clients, former partners, and current partners, but they did not know the identities of the other fathers. Missed injections, skipped pills, and inconsistent condom use were causes of unintended pregnancy. Abortion was common, typically with a medication regimen at a facility. Comprehensive sexual and reproductive health services should be provided to women who sell sex, in recognition and support of their need for family planning and their desire to plan whether and when to have children.

Paying for Sex by Young Men Who Live on the Streets in Dhaka City: Compounded Sexual Risk in a Vulnerable Migrant Community.

PURPOSE: Dhaka City is home to thousands of migrants from Bangladesh's rural areas who often live in the streets. Prior studies examine street youth's practice of selling sex as a survival mechanism. We assess their less-studied practice of paying for sex and its association with sexual risk behaviors and outcomes. METHODS: As part of the global Link Up project, trained interviewers recruited 447 young men who live on the streets, ages 15-24, from seven Dhaka City "hotspots" to participate in a survey about sexual health. Among those who ever had sex, we examined frequencies and conducted bivariate analyses of sociodemographic characteristics by paying for sex status. We then conducted bivariate and multivariate logistic regression analyses of paying for sex in the last 12 months and sexual health behaviors and outcomes. RESULTS: Median participant age was 18 years. Among those who ever had sex (N = 321), 80% reported paying for sex in the last 12 months and 15% reported selling sex in the last 12 months. In multivariate analyses, those who paid for sex had significantly increased odds of reporting sexually transmitted infection-related symptoms in the last six months (adjusted odds ratio = 1.76, 95% confidence interval [CI] = 1.17-2.64) and engaging in unprotected last sex with a nonprimary partner (adjusted odds ratio = 2.19, CI = 1.58-3.03). CONCLUSIONS: The adverse factors associated with paying for sex among young men who live on the streets in Dhaka City highlight the need for programs to educate on HIV/sexually transmitted infection prevention and promote condom use, STI screening/treatment, and HIV testing in this population.

Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently?

OBJECTIVES: To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs). STUDY DESIGN: Researchers recruited 579 FSWs using respondent-driven sampling. We conducted multivariate logistic regression to examine the association between consistent condom use and female-controlled nonbarrier modern contraceptive use. RESULTS: A total of 98.8% reported using male condoms in the past month, and 64.6% reported using female-controlled nonbarrier modern contraception. In multivariate analysis, female-controlled nonbarrier modern contraceptive use was not associated with decreased condom use with clients or nonpaying partners. CONCLUSION: Consistency of condom use is not compromised when FSWs use available female-controlled nonbarrier modern contraception. IMPLICATIONS: FSWs should be encouraged to use condoms consistently, whether or not other methods are used simultaneously.

Use of emergency contraceptive pills among female sex workers in Swaziland.

OBJECTIVES: Female sex workers (FSW) often have unprotected sex. Emergency contraceptive pills (ECP) are an important back-up method to prevent unwanted pregnancy among FSW. We examine ECP use among FSW in Swaziland. METHODS: Using data from a 2011 respondent-driven sampling survey of 325 Swazi FSW, we explored the association between individual characteristics and ever having used ECP. RESULTS: In weighted analyses, 27.5% of FSW had ever used ECP. Most (77.8%) had ever been pregnant, among whom 48.7% had had an unwanted pregnancy and 11.7% had had an abortion. Nearly half (47.5%) had experienced condom failure in the past month. Significant independent correlates of ECP use were younger age, higher education, higher income, having two or more children, and never having been married. CONCLUSIONS: FSW who are older or of lower socioeconomic status may not have adequate access to ECP. By better addressing these women's family planning needs, the dual goals of preventing unwanted pregnancy and preventing vertical transmission of HIV can be achieved.

Use of dual protection among female sex workers in Swaziland.

CONTEXT: Female sex workers are at heightened risk of both HIV infection and unwanted pregnancy. Nonbarrier modern contraceptives are highly effective at preventing pregnancy, but offer no HIV protection. A better understanding of sex workers' use of condoms and nonbarrier methods is needed to help them meet their contraceptive and STI protection needs. METHODS: A 2011 respondent-driven sampling survey collected reproductive health and contraceptive use data from 325 female sex workers in Swaziland. Multinomial logistic regression analysis was used to identify associations between selected characteristics and four outcomes of contraceptive use over the past month: consistent condom use alone; nonbarrier modern contraceptive use (either alone or with inconsistent condom use); dual method use; and inconsistent condom use, other method use or nonuse. Adjusted predicted probabilities were also calculated to determine patterns of association. RESULTS: After adjustments were made for background and behavioral factors, 16% of female sex workers were found to be consistent users of condoms alone; 39% used nonbarrier modern methods (without consistent condom use); 8% were dual method users; and 38% were inconsistent condom users or used other methods or none. Women who reported recent condom failure were less likely than others to be consistent condom users (6% vs. 22%). Consistent use of condoms alone was more common among women who had had no noncommercial partners in the past month than among those who reported two or more such partners (39% vs. 3%). In addition, respondents who had children were more likely than their nulliparous counterparts to report use of nonbarrier methods alone (65% vs. 14%). CONCLUSIONS: Inconsistent or no condom use among nonbarrier contraceptive users underscores the need to incorporate HIV prevention into family planning interventions, particularly among female sex workers who have children and noncommercial partners.

Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: a relationship-level analysis of condom and contraceptive use.

OBJECTIVES: Nonbarrier modern contraceptive users often are less likely to use condoms, particularly with more intimate sex partners. We examine whether female sex workers (FSWs) in Swaziland who use nonbarrier contraception use condoms less consistently and whether this inverse association varies by relationship type. METHODS: In 2011, we conducted a survey among 325 Swazi FSWs using respondent-driven sampling. Each woman reported on condom use during sexual activity in the past month with up to 3 partner types (new clients, regular clients, noncommercial partners). We used a generalized estimating equation model to conduct a relationship-level multivariate logistic regression analysis of correlates of consistent condom use in the past month. We tested whether relationship type modified the effect of nonbarrier modern contraception on condom use. RESULTS: Each participant reported up to 3 observations, for a total of 892 measures of condom use in the past month. Compared with sexual activity with new clients, sex with regular clients and noncommercial partners was less likely to be protected by consistent condom use (adjusted odds ratio, 0.30 [95% confidence interval, 0.19-0.47] for regular clients; adjusted odds ratio, 0.15 [95% confidence interval, 0.09-0.24] for noncommercial partners). There was no significant association between condom use and nonbarrier modern contraceptive use. CONCLUSIONS: These data highlight the need to provide condoms and condom-compatible lubricants and targeted education programs for FSWs and their male sex partners to encourage the consistent use of these commodities with all sex partners, irrespective of the use of other contraceptive methods.

Contraception and condom use among Bolivian female sex workers: relationship-specific associations between disease prevention and family planning behaviors.

We examined data from a clinic-based survey of 1,222 Bolivian female sex workers (FSWs) to assess whether use of nonbarrier modern contraception is associated with less consistent condom use with clients and noncommercial partners. Women who were using nonbarrier modern contraception were less likely than nonusers to consistently use condoms with noncommercial partners (AOR 0.393, 95% CI 0.203-0.759, p = .005). With clients, this inverse association did not hold. Public health professionals must consider both disease prevention and pregnancy prevention needs in this vulnerable population, and messages should be tailored to encourage dual method use with all partners.

Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia.

OBJECTIVE: To describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia. METHODS: A clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005. RESULTS: In total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07-9.02) and multiple abortions (OR 4.71; 95% CI, 1.19-18.62). CONCLUSION: The results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.

The role of the Standard Days Method in modern family planning services in developing countries.

BACKGROUND: The mere availability of family planning (FP) services is not sufficient to improve reproductive health; services must also be of adequate quality. The introduction of new contraceptive methods is a means of improving quality of care. The Standard Days Method (SDM) is a new fertility-awareness-based contraceptive method that has been successfully added to reproductive health care services around the world. CONTENT: Framed by the Bruce-Jain quality-of-care paradigm, this paper describes how the introduction of SDM in developing country settings can improve the six elements of quality while contributing to the intrinsic variety of available methods. SDM meets the needs of women and couples who opt not to use other modern methods. SDM providers are sensitised to the potential of fertility-awareness-based contraception as an appropriate choice for these clients. SDM requires the involvement of both partners and thus offers a natural entry point for providers to further explore partner communication, intimate partner violence, condoms, and HIV/STIs. CONCLUSION: SDM introduction broadens the range of FP methods available to couples in developing countries. SDM counselling presents an opportunity for FP providers to discuss important interpersonal and reproductive health issues with potential users.

Women's experiences with legal abortion in Mexico City: a qualitative study.

In April 2007, elective first-trimester abortion was legalized in Mexico City. As of June 2011, more than 60,000 women from Mexico City and other Mexican states have obtained legal abortions in the city's public hospitals and health centers, with private facilities providing additional abortion services. This study examines women's experiences of abortion services in one public and two private clinic settings in 2008. Twenty-five in-depth interviews were conducted: 15 with women who obtained abortions in a public health center and 10 who obtained the procedure at either of two private clinics. Participants were highly satisfied with services at both public and private sites, although some had to go to more than one site before receiving services. None expressed doubts about their decision to have an abortion, and they felt unanimously that they were treated with respect. Furthermore, participants were pleased with the counseling they received and most accepted a contraceptive method after the procedure.

Introducing birth plans in Mexico: an exploratory study in a hospital serving low-income Mexicans.

BACKGROUND: Increased medicalization of childbirth in Mexico has not always translated into more satisfactory childbirth experiences for women. In developed countries, pregnant women often prepare written birth plans, outlining how they would like their childbirth experiences to proceed. The notion of expressing childbirth desires with a birth plan is novel in the developing world. We conducted an exploratory study to assess the feasibility and acceptability of introducing birth plans in a hospital serving low-socioeconomic status Mexicans and to document women's and health practitioners' perspectives on the advantages and barriers in implementing a birth plan program. METHODS: We invited 9 pregnant women to prepare birth plans during their antenatal care visits. The women also participated in interviews before and after childbirth. We also conducted in-depth interviews with 4 women who had given birth in the past year, and with 2 nurses, 2 social workers, and 1 physician to learn about their perspectives on the benefits and challenges of implementing a birth plan program. RESULTS: All 9 women who completed a birth plan found the experience highly satisfying, despite the fact that in some cases, their childbirths did not proceed as they had specified in their plans. Interviewed practitioners believed that birth plans could improve the childbirth experience for women and health care practitioners, but facilities often lacked space and financial incentives for birth plan programs. CONCLUSIONS: Our findings suggest that birth plans are acceptable and feasible in this study population. Facility administrators would need to commit to provide the physical space and financial incentives necessary to ensure successful implementation.

Demonstrating public health at work: a demonstration project of congenital syphilis prevention efforts in Bolivia.

OBJECTIVES: We introduced syphilis immunochromatic strip (ICS) tests into antenatal care (ANC) settings in Bolivia and evaluated feasibility, patient and provider acceptability, and introduction costs. We conducted complementary studies on related topics, strengthened quality of care, and aided the response to sensitive aspects of maternal/congenital syphilis control (e.g., partner notification). GOAL: The goal of this study was to discuss our experience working with Bolivian stakeholders to document potential public health benefits of syphilis ICS test introduction in ANC settings. STUDY DESIGN: We trained public health personnel and offered the Abbott Determine Rapid Syphilis TP test in 4 urban maternity hospitals and 37 rural clinics. RESULTS: Using the ICS test, 11,618 women were tested for syphilis; 5% had positive results and 93.2% received treatment. Women and health personnel found the test acceptable and introduction costs were not prohibitive. CONCLUSIONS: Based on these findings, by mid-2006, the Bolivian Ministry of Health will offer the ICS tests in rural ANC settings.

Jamaican and Barbadian health care providers' knowledge, attitudes and practices regarding emergency contraceptive pills.

CONTEXT: Little is known about health care providers' knowledge of, attitudes toward and provision of emergency contraceptive pills in the English-speaking Caribbean, where sexual violence and unplanned pregnancies are persistent public health problems. METHODS: We conducted interviewer-administered surveys of 200 Barbadian and 228 Jamaican pharmacists, general practitioners, obstetrician-gynecologists and nurses in 2005-2006. For each country, Pearson's chi-square tests were used to assess differences in responses among the four provider groups. RESULTS: Nearly all respondents had heard of emergency contraceptive pills, and large majorities of Barbadian and Jamaican providers had dispensed the method. However, about half had ever refused to dispense it; frequently cited reasons were medical contraindications to use, recent use, method unavailability, safety concerns and being uncomfortable prescribing it. Only one in five providers knew that the method could be safely used as often as needed, and few knew that it was effective if taken within 120 hours of unprotected sexual intercourse. About a quarter of Barbadian and half of Jamaican providers thought the method should be available without a prescription, and half of all providers believed that its use encourages sexual risk-taking and leads to increased STI transmission. Nonetheless, most respondents believed the method was necessary to reduce rates of unintended pregnancy and were willing to dispense it to rape victims, women who had experienced condom failure and women who had not used a contraceptive. CONCLUSIONS: Future educational efforts among Jamaican and Barbadian health care providers should emphasize the safety and proper use of emergency contraceptive pills, as well as the need to increase the availability of the method.

"No party hat, no party": successful condom use in sex work in Mexico and the Dominican Republic.

Sex workers and their clients are particularly vulnerable to HIV/STI transmission. Most research on condom use has focused on barriers preventing use; less is known about attitudes, motivations and strategies employed by those who feel positively about condoms and who use them successfully. For this qualitative study, we conducted focus group discussions with sex workers (14), both female and transvestite, in Ciudad Juarez, Mexico, and female sex workers (17) and male clients (11) in Santo Domingo, Dominican Republic, who identified themselves as successful condom users in a condom use questionnaire. Discussions explored definitions of successful condom use, motivations and strategies for condom use and messages for future condom promotion. Sex workers defined successful condom use as being in agreement with their clients and partners about using condoms, protecting themselves from disease and unwanted pregnancy, and feeling good about using condoms. Condoms were seen to be hygienic, offer protection and provide a sense of security and peace of mind. Specific strategies included always having condoms on hand, stressing the positive aspects of condoms and eroticising condom use. Future educational messages should emphasise condom use to protect loved ones, increase security and pleasure during sex, and demonstrate respect for both sex workers, clients and partners.