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

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到农村地区的5.7不等。现代避孕方法的使用率从2005年的10%上升到2008年的27%，其中包括15%的注射和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（LARC）-特别是避孕植入物和宫内节育器（IUD）-而且很少有夫妇知道这些方法。为了保障经济发展和将总生育率降低到3，必须增加获得LARC的机会。在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（FP）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之间的接受度以及将LARC添加到方法组合中的可行性。 我们以前在卢旺达由国家卫生研究院资助的工作导致在产前诊所采用夫妇自愿艾滋病毒咨询和检测（CVCT）作为国家政策，现在有超过85%的丈夫接受检测，每年有超过10 000对不和谐的夫妇被发现和咨询。在一项提供全方位避孕选择的研究中，81%的生育能力不一致的夫妇希望停止生育，>40%的人选择LARC。自我报告和生物标记证实LARC使用者保持一致的安全套使用。 预防计划外怀孕是成本最低的围产期艾滋病毒预防策略，避孕药具的使用与艾滋病毒阳性妇女的生存期延长有关。夫妇的计划生育咨询导致LARC的高摄取率，将其与CVCT相结合可以相互利用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，计划生育服务由没有伴侣的妇女参加，不提供艾滋病毒检测，也没有为希望怀孕的不和谐夫妇提供更安全的受孕服务。将艾滋病毒预防和生育管理结合起来需要在几个级别进行调查和干预。在与政策制定者、资助机构、艾滋病毒和计划生育服务提供者和客户进行形成性研究后，将向从婴儿疫苗接种诊所招募的1200对育龄夫妇（艾滋病毒M+F+、M+F-、M-F+和M-F各300对）提供CVCT+FP/LARC/更安全的受孕咨询和服务，以满足他们的生育愿望，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预防计划外怀孕，围产期艾滋病毒和艾滋病毒相关的孕产妇死亡; 2）在不想通过双重方法怀孕的不和谐夫妇中优化安全套的使用，以及3）防止试图怀孕的不和谐夫妇的性传播。 利用我们作为一个25岁的研究项目和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，并向其提供持续的反馈，以确保研究成果在卢旺达全国范围内实施，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.