IUD, implant, and condoms: sexual and perinatal HIV prevention in Rwandan couples

描述（由申请人提供）：卢旺达是非洲人口最稠密的国家，总生育率（TFR）从城市的4.7到农村的5.7不等。现代避孕方法的使用率已从2005年的10%增加到2008年的27%，其中包括15%的注射方法和6%的口服激素方法。只有不到2%的妇女能够获得长效可逆避孕药具（LARC），特别是植入避孕药具和宫内节育器（IUD），而且很少有夫妇知道这些方法。为保障经济发展并将总生育率降至3，增加获得LARC的机会至关重要。我们在卢旺达首都基加利的两家大型诊所进行培训后，计划生育客户选择宫内节育器或植入物的比例从2%上升到65%，证实了提供者和客户的接受程度以及将LARC加入方法组合的可行性。我们以前在卢旺达由NIH资助的工作已经导致将夫妻自愿艾滋病毒咨询和检测（CVCT）作为产前诊所的国家政策，其中85%的丈夫现在接受了检测，每年发现和咨询10,000对不一致的夫妇。在提供全方位避孕选择的研究环境中，81%的生育能力不一致的夫妇希望停止生育，40%的夫妇选择LARC。自我报告和生物标记证实LARC使用者坚持使用避孕套。预防意外怀孕是成本最低的围产期艾滋病毒预防策略，使用避孕药具可延长艾滋病毒阳性妇女的生存时间。夫妻计划生育咨询导致LARC的高吸用率，并将其与CVCT相结合，可以相互促进异性恋和围产期艾滋病毒预防。不幸的是，在政府诊所，CVCT目前仅限于怀孕夫妇，计划生育服务是由没有伴侣的妇女参加的，不提供艾滋病毒检测，并且没有为希望怀孕的不和谐夫妇提供更安全的受孕服务。艾滋病毒预防和生育管理的一体化将需要在几个层面进行调查和干预。与决策者、资助机构、艾滋病毒和计划生育服务提供者以及客户进行形成性研究；从婴儿疫苗接种诊所招募1200对有生育能力的夫妇（每对夫妇携带艾滋病毒M+F+、M+F-、M-F+和M-F-各300对），向他们提供CVCT+FP/LARC/更安全的受孕咨询和适合他们生育愿望的服务，并进行为期三年的定量和定性评估。我们将包括城市和农村、天主教和非天主教诊所，重点是：1)通过向夫妇提供LARC，预防意外怀孕、围产期艾滋病毒和与艾滋病毒有关的孕产妇死亡率；2)通过使用双重方法，使不愿怀孕的不协调夫妇最优化使用避孕套；3)防止试图怀孕的不协调夫妇的性传播。利用我们作为一个已有25年历史的研究项目和CVCT和LARC培训卓越中心的双重角色，我们将确保政策制定者和资助者的承诺，并向他们提供持续的反馈，以确保研究成果在卢旺达全国范围内得到实施，并与非洲其他国家分享。

DESCRIPTION (provided by applicant): Rwanda is the most densely populated country in Africa, and Total Fertility Rates (TFR) range from 4.7 in urban to 5.7 in rural areas. Use of modern contraception has increased from 10% in 2005 to 27% in 2008, including 15% injectable and 6% oral hormonal methods. Less than 2% of women have access to long-acting reversible contraceptives (LARC) - specifically the contraceptive implant and the intra-uterine device (IUD) - and few couples know about these methods. To safeguard economic development and lower TFR to 3, increased access to LARC is essential. Following our training in two large clinics in Kigali, the capital of Rwanda, the proportion of family planning (FP) clients choosing IUD or implant has risen from 2% to 65%, confirming receptivity among providers and clients and feasibility of adding LARC to the method mix. Our previous NIH funded work in Rwanda has led to the adoption of Couples Voluntary HIV Counseling and Testing (CVCT) as national policy in antenatal clinics, where >85% of husbands are now tested and >10,000 discordant couples are identified and counseled each year. In a research setting offering the full range of contraceptive options, 81% of fertile discordant couples wish to cease childbearing and >40% choose LARC. Self-report and biological markers confirm that LARC users maintain consistent condom use. Prevention of unplanned pregnancy is the lowest cost perinatal HIV prevention strategy, and contraceptive use is associated with longer survival in HIV+ women. Couples' family planning counseling results in high uptake of LARC, and combining this with CVCT can mutually leverage heterosexual and perinatal HIV prevention. Unfortunately, in government clinics CVCT is currently limited to pregnant couples, FP services are attended by women without their partners and do not offer HIV testing, and no safer-conception services are in place for discordant couples that wish to conceive. Integration of HIV prevention and fertility management will require investigation and intervention at several levels. Following formative research with policymakers, funding agencies, HIV and family planning service providers, and clients; 1200 fertile couples - 300 each HIV M+F+, M+F-, M-F+, and M-F- - recruited from infant vaccination clinics will be offered CVCT+FP/LARC/safer conception counseling and services tailored to their fertility desires, and followed for three years with quantitative and qualitative assessments. We will include urban and rural, Catholic and non-Catholic clinics with a focus on: 1) Preventing unplanned pregnancy, perinatal HIV, and HIV-related maternal mortality through provision of LARC to couples; 2) Optimizing condom use in discordant couples who do not want to conceive through dual method use, and 3) Preventing sexual transmission in discordant couples attempting to conceive. Leveraging our dual role as a 25-year old research project and a Center of Excellence for CVCT and LARC training, we will secure commitment from, and provide ongoing feedback to, policymakers and funders to ensure that research results are implemented nationwide in Rwanda and shared with other countries in Africa.