abstract background results methods discussion conclusion
Preparing for HIV Prevention Trials: From Training to Service Delivery – Lessons Learned with Long Acting Reversible Contraception (LARC) in Zambia Inambao M1, Munir N1, Wu K1, Dang D1, Ahmed N1, Getachew B1,2, Kilembe W1, Vwalika B1, Allen S1,2 1. Rwanda Zambia HIV Research Group, Lusaka, Zambia and Kigali, Rwanda 2. Emory University School of Medicine, Atlanta, GA, USA
ABSTRACT
RESULTS
Challenge
Solution
The provision of long-acting reversible contraceptive (LARC) methods, specifically intra-uterine devices (IUDs) and Jadelle implants, is critical to prevent unplanned pregnancy and perinatal transmission in HIV+ women and to prevent pregnancy in HIV- prevention trial participants. LARC methods are an innovative and rarely used contraceptive method in Africa. Lack of
Types of family planning staff trained N=1276
and demand of LARC via training clinic nurses throughout Zambia in both insertion and removal of IUDs and Jadelle
discuss their fertility goals and decide on a contraceptive method together, is also increasing in demand. Furthermore, RZHRG has also implemented a successful Training-of-Trainers (ToT) model to teach high performing, fully certified LARC nurses to how to train non-certified nurses in LARC provision services.
Lack of support from highlevel stakeholders
300
both supplies and people trained to insert the methods usually leads to lack of demand. RZHRG has increased both supply
implants. Couples Family Planning Counseling (CFPC), which allows couples to educate themselves about methods,
Gender of nurses trained in LARC (N = 308)
250
Promoters, 353
Low demand for LARC methods resulting in longer time to certification for LARC nurses
200
CFPC, 540
150
Happy clients , 75 LARC, 308
100
248
50
60
0
BACKGROUND
Female
Male
Nurses certified in (N=308)
Zambia has a high burden of mother-to-child transmission of HIV. HIV+ women are challenged with the risk of both unplanned pregnancy and perinatal transmission (1). Recognizing this, the strategy for prevention of mother-to-child
Lack of male involvement and understanding of family planning options resulting in low uptake
• Meeting with representatives at all structural levels of health system • Lobbying to include CVCT/CFPC in country guidelines • Family Planning Technical Working Group (FP TWG) • Demand creation and sensitization of LARC methods: implementing multipronged approach to increase uptake of LARC including use of radio advertisements and interviews (provincial level), District Community Promoters and Influential Network Agents who travel within the community to educate on the benefits of LARC (community level); and training satisfied LARC users to promote LARC methods (clinic level). • Train LARC users to be promoters of the LARC methods (Happy Client Promotions) • Integration of CFPC into the established CVCT model • Provide invites to the couple together, rather than to a single person. This has been shown to increase uptake of CVCT Provide CVCT on weekends and evenings • Provision of LARC methods on weekends during CVCT hours
transmission of HIV (PMTCT) contains two prongs: addressing this risk group with prevention of heterosexual HIV and prevention of unplanned pregnancy in HIV+ women. The total fertility rate (TFR) in Zambia has risen from an average of 5.2 over the last 10 years, to 6.1 in 2010 and 6.0 in 2011 (2,3). Long acting reversible contraceptives (LARC) are currently used by less than 1% of Zambian women (2). The most common modern contraceptives in Zambia are daily oral contraceptive pills (OCP) and quarterly Depo-
PMTCT 4-pronged Strategy Primary Prevention of HIV Infection among Women of Reproductive Age Provision of Care, Treatment, and Support to Mothers Living with HIV, Their Children and Families
Provera injections. These methods are by far the least effective due to supply chain interruptions and adherence failures. LARC methods offer an economical, effective longterm alternative to OCP and injections (4). In this context, ZEHRP’s focus has been on increasing the use of highly effective, user-independent LARC methods.
• •
47%
47%
IUD
Implant
Both
From March 2013 to August 2014, ZEHRP trained 1276 individuals in urban and rural areas: 540 CFPC counselors, 308 LARC nurses, 353 community promoters, and 75 Happy Clients. Certification is
Prevention of HIV Transmission from Women Living with HIV to Their Children
insertion+removal, and 47% are certified in both methods. The main obstacles to completion of
ongoing; currently 47% of nurses are certified in IUD insertion+removal, 74% in implan
practicums were not being assigned to the family planning department when one of the few trainers was available, and coordinating these times with availability of interested LARC clients. A Training-of-
Allows couple to discuss fertility goals (number of children they would like to have and when they want to have them) together and decide on family planning needs together
Trainers was held for the fully certified nurses who were high performers, meetings were held with clinic
When integrated with CVCT, allows couples to make family planning decisions with knowledge of HIV status
in-charges to coordinate trainee schedules, and satisfied clients were recruited to give personal
When integrated with LARC, allows couples to make family planning decisions and receive the method for free the same day
CONCLUSION LARC methods are critical in the prevention of unplanned pregnancy and perinatal transmission amongst HIV+
Prevention of Unintended Pregnancies among Women living with HIV
Couples Family Planning Counseling (CFPC) •
74%
testimonials. In total, 54 LARC ToTs were trained across all sites. LARC ToTs are selected from
women. The ToT model illustrates an effective way to harness successful LARC trainees as trainers and work with clinic administrators and satisfied clients to coordinate practicum training and demand creation. This increase in LARC supply and demand has the potential to reduce mother-to-child transmission of HIV though demand creation will need continued support.
REFERENCES 1. Khu NH, Vwalika B, Karita E, Kilembe W, Bayingana RA, Sitrin D, et al. Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia. Contraception. 2013; 88:74-82. 2. Ministry of Health (MOH) [Rwanda] National Institute of Statistics of Rwanda (NISR) ICF Macro . Rwanda Interim Demographic and Health Survey. MOH, NISR, and ICF Macro; Calverton, Maryland, USA: 2009 3. UN Data. Country profile: Zambia. 2011. www.data.un.org 4. Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception. 2003;68:3–10.
ZEHRP’s pool of high performing GRZ nurses (those who have a minimum of 50 insertions and
METHODS
removals and received full certification in LARC methods).
Through collaboration with District Health Management Teams and Scaling Up Family Planning leaders, RZHRG has
DISCUSSION
CONFLICT OF INTEREST The authors have no financial conflicts of interest.
selected qualified staff from 51 urban and rural government-run clinics to train in LARC certification. In March 2013, RZHRG began conducting trainings with LARC providers, counselors, and promoters. Nurse trainings consisted of a 3-day
Increased provider certification is critical for the expansion of available family planning services in
didactic training followed by supervised IUD and Jadelle insertion and removal practicums. To receive certification, nurses
Zambia. There is a noticeable trend for certification in implant insertion versus IUD or both. Future
must insert 5 IUD and 5 implants and remove 2 IUD and 5 implants under direct supervision. High performing nurses were
studies could evaluate cultural attitudes towards different LARC methods and whether there is provider
selected for ToT based on their experience in LARC service provision and willingness to supervise future LARC training
bias. The training of trainers (ToT) strategy employed by ZEHRP has increased the ratio of trainers to
practicums. Data was collected on gender of trainer, clinic location, and training dates. Promoters and Happy Clients
trainees allowing more one-on-one time during practicums and expedited the certification process for
(individuals currently using a LARC method successfully, who can promote methods and speak to potential clients about
future trainees. ZEHRP has identified challenges to LARC demand creation and is working to provide
their experiences) were also trained on how to effectively promote LARC methods.
solutions (see table).
For more information on our research please visit our other posters at the R4P conference.
ABSTRACT
RESULTS
Challenge
Solution
The provision of long-acting reversible contraceptive (LARC) methods, specifically intra-uterine devices (IUDs) and Jadelle implants, is critical to prevent unplanned pregnancy and perinatal transmission in HIV+ women and to prevent pregnancy in HIV- prevention trial participants. LARC methods are an innovative and rarely used contraceptive method in Africa. Lack of
Types of family planning staff trained N=1276
and demand of LARC via training clinic nurses throughout Zambia in both insertion and removal of IUDs and Jadelle
discuss their fertility goals and decide on a contraceptive method together, is also increasing in demand. Furthermore, RZHRG has also implemented a successful Training-of-Trainers (ToT) model to teach high performing, fully certified LARC nurses to how to train non-certified nurses in LARC provision services.
Lack of support from highlevel stakeholders
300
both supplies and people trained to insert the methods usually leads to lack of demand. RZHRG has increased both supply
implants. Couples Family Planning Counseling (CFPC), which allows couples to educate themselves about methods,
Gender of nurses trained in LARC (N = 308)
250
Promoters, 353
Low demand for LARC methods resulting in longer time to certification for LARC nurses
200
CFPC, 540
150
Happy clients , 75 LARC, 308
100
248
50
60
0
BACKGROUND
Female
Male
Nurses certified in (N=308)
Zambia has a high burden of mother-to-child transmission of HIV. HIV+ women are challenged with the risk of both unplanned pregnancy and perinatal transmission (1). Recognizing this, the strategy for prevention of mother-to-child
Lack of male involvement and understanding of family planning options resulting in low uptake
• Meeting with representatives at all structural levels of health system • Lobbying to include CVCT/CFPC in country guidelines • Family Planning Technical Working Group (FP TWG) • Demand creation and sensitization of LARC methods: implementing multipronged approach to increase uptake of LARC including use of radio advertisements and interviews (provincial level), District Community Promoters and Influential Network Agents who travel within the community to educate on the benefits of LARC (community level); and training satisfied LARC users to promote LARC methods (clinic level). • Train LARC users to be promoters of the LARC methods (Happy Client Promotions) • Integration of CFPC into the established CVCT model • Provide invites to the couple together, rather than to a single person. This has been shown to increase uptake of CVCT Provide CVCT on weekends and evenings • Provision of LARC methods on weekends during CVCT hours
transmission of HIV (PMTCT) contains two prongs: addressing this risk group with prevention of heterosexual HIV and prevention of unplanned pregnancy in HIV+ women. The total fertility rate (TFR) in Zambia has risen from an average of 5.2 over the last 10 years, to 6.1 in 2010 and 6.0 in 2011 (2,3). Long acting reversible contraceptives (LARC) are currently used by less than 1% of Zambian women (2). The most common modern contraceptives in Zambia are daily oral contraceptive pills (OCP) and quarterly Depo-
PMTCT 4-pronged Strategy Primary Prevention of HIV Infection among Women of Reproductive Age Provision of Care, Treatment, and Support to Mothers Living with HIV, Their Children and Families
Provera injections. These methods are by far the least effective due to supply chain interruptions and adherence failures. LARC methods offer an economical, effective longterm alternative to OCP and injections (4). In this context, ZEHRP’s focus has been on increasing the use of highly effective, user-independent LARC methods.
• •
47%
47%
IUD
Implant
Both
From March 2013 to August 2014, ZEHRP trained 1276 individuals in urban and rural areas: 540 CFPC counselors, 308 LARC nurses, 353 community promoters, and 75 Happy Clients. Certification is
Prevention of HIV Transmission from Women Living with HIV to Their Children
insertion+removal, and 47% are certified in both methods. The main obstacles to completion of
ongoing; currently 47% of nurses are certified in IUD insertion+removal, 74% in implan
practicums were not being assigned to the family planning department when one of the few trainers was available, and coordinating these times with availability of interested LARC clients. A Training-of-
Allows couple to discuss fertility goals (number of children they would like to have and when they want to have them) together and decide on family planning needs together
Trainers was held for the fully certified nurses who were high performers, meetings were held with clinic
When integrated with CVCT, allows couples to make family planning decisions with knowledge of HIV status
in-charges to coordinate trainee schedules, and satisfied clients were recruited to give personal
When integrated with LARC, allows couples to make family planning decisions and receive the method for free the same day
CONCLUSION LARC methods are critical in the prevention of unplanned pregnancy and perinatal transmission amongst HIV+
Prevention of Unintended Pregnancies among Women living with HIV
Couples Family Planning Counseling (CFPC) •
74%
testimonials. In total, 54 LARC ToTs were trained across all sites. LARC ToTs are selected from
women. The ToT model illustrates an effective way to harness successful LARC trainees as trainers and work with clinic administrators and satisfied clients to coordinate practicum training and demand creation. This increase in LARC supply and demand has the potential to reduce mother-to-child transmission of HIV though demand creation will need continued support.
REFERENCES 1. Khu NH, Vwalika B, Karita E, Kilembe W, Bayingana RA, Sitrin D, et al. Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia. Contraception. 2013; 88:74-82. 2. Ministry of Health (MOH) [Rwanda] National Institute of Statistics of Rwanda (NISR) ICF Macro . Rwanda Interim Demographic and Health Survey. MOH, NISR, and ICF Macro; Calverton, Maryland, USA: 2009 3. UN Data. Country profile: Zambia. 2011. www.data.un.org 4. Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception. 2003;68:3–10.
ZEHRP’s pool of high performing GRZ nurses (those who have a minimum of 50 insertions and
METHODS
removals and received full certification in LARC methods).
Through collaboration with District Health Management Teams and Scaling Up Family Planning leaders, RZHRG has
DISCUSSION
CONFLICT OF INTEREST The authors have no financial conflicts of interest.
selected qualified staff from 51 urban and rural government-run clinics to train in LARC certification. In March 2013, RZHRG began conducting trainings with LARC providers, counselors, and promoters. Nurse trainings consisted of a 3-day
Increased provider certification is critical for the expansion of available family planning services in
didactic training followed by supervised IUD and Jadelle insertion and removal practicums. To receive certification, nurses
Zambia. There is a noticeable trend for certification in implant insertion versus IUD or both. Future
must insert 5 IUD and 5 implants and remove 2 IUD and 5 implants under direct supervision. High performing nurses were
studies could evaluate cultural attitudes towards different LARC methods and whether there is provider
selected for ToT based on their experience in LARC service provision and willingness to supervise future LARC training
bias. The training of trainers (ToT) strategy employed by ZEHRP has increased the ratio of trainers to
practicums. Data was collected on gender of trainer, clinic location, and training dates. Promoters and Happy Clients
trainees allowing more one-on-one time during practicums and expedited the certification process for
(individuals currently using a LARC method successfully, who can promote methods and speak to potential clients about
future trainees. ZEHRP has identified challenges to LARC demand creation and is working to provide
their experiences) were also trained on how to effectively promote LARC methods.
solutions (see table).
For more information on our research please visit our other posters at the R4P conference.
