Childbearing Dynamics in Setting of High HIV Prevalence and Massive ART Rollout

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DESCRIPTION (provided by applicant): This application is in response to NOT-OD-10-036, "NIH Announces the Availability of HIV/AIDS Funds for Competitive Revision Applications (R01, R03, R15, R21, R21/R33, R37) for HIV/AIDS-related Research through the NIH Basic Behavioral and Social Science Opportunity Network (OppNet)." The competitive revision builds on a parent project examining the relationship between fertility change and the scaling-up of HIV testing and treatment in sub-Saharan Africa. Initial analysis of data from a clinic survey and ethnography in rural Mozambique revealed complex dynamics of use of health facilities for sexual and reproductive care. Clinic staff report that women attend different clinics for different types of care (family planning counseling, prenatal care and delivery, child vaccinations, HIV testing and treatment), with women's choice of clinic depending on both clinic characteristics and their perceived serostatus. Distance and travel time are major barriers to health care access, but impact different types of care differentially. Notably, exploratory spatial data analysis shows different distributions of HIV testing experience and use of clinics for childbirth. These unforeseen results suggest that the integration of HIV treatment and testing into maternal and child health clinics may have varying effects on contraceptive use among women in the study area. Geographic distance between clients and clinics and social distance between clients and providers may moderate the effects of integration on contraceptive use. This revision therefore proposes to expand beyond the parent project by linking information from a survey of married women to the facilities where they receive care and carrying out spatial analyses of the use of health services. The proposed research will combine existing geographic and sociodemographic data from the parent project to (1) describe the geographic distribution of contraceptive use and compare it to the distribution of other health service utilization; and (2) analyze the determinants of contraceptive use, taking into account the mediating effect of characteristics of health care facilities and introduction of HIV services. Spatial data and the spatial aspects of social relationships will be incorporated at all stages of the proposed research. All work will be carried out at Arizona State University by ASU faculty and graduate students; no additional data collection is proposed. PUBLIC HEALTH RELEVANCE: The proposed research will build scientific knowledge of the use of contraception in rural areas experiencing high levels of HIV infection and rapid rollout of HIV testing and treatment services. Analyses measure both geographic access to health care and detailed information on social context. The results will facilitate appropriate placement of health care services as well as increasing understanding of interpersonal interactions within health care systems and their impact on health outcomes. These scientific advances will contribute to efforts to reduce unintended pregnancies.