Determinants of Use of Safer Conception Strategies Among HIV Clients in Uganda

描述(由申请人提供)：随着艾滋病毒日益成为一种慢性病，生育的愿望和计划在艾滋病毒/艾滋病患者中日益突出，特别是在撒哈拉以南非洲地区，那里的生育是一种强大的文化价值。在PLHA怀孕既有垂直传播风险，也有水平传播风险，然而，虽然有相当多的资源和支持为患者预防意外怀孕或一旦怀孕(例如防止母婴传播)，但旨在促进更安全受孕的服务很少提供。低成本更安全的受孕策略包括抗逆转录病毒治疗、定时无保护性交和人工授精，但对SSA中PLHA降低受孕风险方法的知识、接受度和使用情况知之甚少。艾滋病毒和计划生育(FP)提供者是为PLHA生殖健康选择提供信息和咨询的重要来源。然而，艾滋病毒提供者经常向PLHA传达这样的信息，即生育是不合适的，他们经常受到限制，觉得没有受到足够的培训，无法提供有效的安全受孕咨询，因此在存在传播给伴侣的风险时，他们很难为患者提供咨询。类似的问题可能适用于计划生育提供者，但这方面的研究更少。因此，患者可能会不舒服地与提供者讨论他们的生育意图和/或怀孕。这种对提供者和患者信任和沟通的破坏，再加上已经压力过大的医疗保健系统和文化信仰，导致许多PLHA寻求传统治疗师的建议，他们更容易接触到，但往往没有准备好充分解决艾滋病毒疾病的背景。到目前为止，研究的重点是生育意愿的流行率及其相关性，对怀孕前和怀孕后风险的使用研究很少 PLHA的复位方法。这项拟议的研究将审查有生育意向的艾滋病毒患者的生殖决策和减少受孕风险方法的使用，卫生服务提供者关于为PLHA提供更安全的受孕咨询的知识、态度和做法，以及提供支持服务的结构性障碍。第一阶段将是对生育规划和决策的形成性评估，通过对最近怀孕或打算怀孕的男性和女性艾滋病毒客户(及其伴侣)的定性深入访谈；我们还将采访艾滋病毒、计划生育和TH提供者，以检查与PLHA生育支持服务有关的知识、态度和做法。第二阶段将对400名有生育意愿的PLHA进行观察性、前瞻性的队列研究，他们将被跟踪24个月，以评估避孕措施的使用(在等待首选怀孕时间和受孕后)、受孕前风险降低方法和预防母婴传播(怀孕时)的决定因素。还将对供应商进行纵向调查，以评估随着时间的推移，在提供更安全的概念支持方面知识、态度、做法和结构性障碍的变化。这项研究的结果将为制定结构性干预措施提供信息，旨在帮助提供者和诊所更好地提供PLHA所需的支持，以获得更安全、健康的怀孕，并限制传播。 公共卫生相关性：项目描述这项研究对公共卫生很重要，因为研究结果将为更好地理解有效的更安全的受孕咨询(从患者和提供者的角度)的个人、伴侣、提供者和结构层面的障碍以及使用受孕前和受孕后降低风险的方法提供关键信息。有了这一认识，我们将能够很好地为诊所和提供者制定结构性干预措施，以改善全面的生殖健康服务，包括孕前咨询，这是防止血清不一致夫妇的水平传播、和谐夫妇的再次感染和母婴传播的关键。

DESCRIPTION (provided by applicant): With HIV becoming more of a chronic disease, desires and plans for childbearing has become increasingly prominent among persons living with HIV/AIDS (PLHA), especially in sub-Saharan Africa (SSA) where fertility is a strong cultural value. Pregnancy in PLHA involves both vertical and horizontal transmission risks, yet while there are considerable resources and support for patients to prevent unwanted pregnancy or once they become pregnant (e.g., PMTCT), services aimed at promoting safer conception are rarely available. Low cost safer conception strategies include antiretroviral therapy, timed unprotected intercourse, and manual insemination, but little known about the knowledge, acceptability and use of conception risk reduction methods among PLHA in SSA. HIV and family planning (FP) providers are a critical source of information and counseling for the reproductive health options for PLHA. Yet HIV providers often convey messages to PLHA that childbearing is inappropriate, are frequently constrained by feeling inadequately trained to offer effective counseling for safe conception, and so struggle with how to counsel patients when a risk of transmission to the partner is present. Similar issues may hold for FP providers, but this is even less studied. Consequently, patients may be uncomfortable discussing their fertility intentions and/or pregnancy with their providers. This breach in provider-patient trust and communication, coupled with an already over stressed health care system and cultural beliefs, lead many PLHA to seek advice from traditional healers (TH) who are more accessible, but often unprepared to fully address the HIV disease context. Research to date has focused on prevalence and correlates of fertility desires, with very little study of the use of pre- and post-conception risk reduction methods by PLHA. The proposed study will examine the reproductive decision making and use of conception risk reduction methods of HIV patients with fertility intentions, the knowledge, attitudes and practices of health providers regarding safer conception counseling for PLHA, and structural barriers to provision of support services. Phase 1 will be a formative evaluation of fertility planning and decision making through qualitative in-depth interviews with male and female HIV clients (and their partners) who have either recently conceived a child or have an intention to conceive; we will also interview HIV, FP and TH providers to examine knowledge, attitudes and practices related to childbearing support services for PLHA. Phase 2 will be an observational, prospective cohort study of 400 PLHA with fertility intentions who will be followed for 24 months to assess determinants of use of contraception (while waiting for the preferred time to conceive, and post-conception), pre-conception risk reduction methods, and PMTCT (when pregnant). Providers will also be surveyed longitudinally to assess changes in knowledge, attitudes, practices and structural barriers regarding provision of safer conception support over time. Findings from this study will inform the development of a structural intervention aimed at helping providers and clinics to better provide support needed by PLHA to have safer, healthy pregnancies, and limit transmission. PUBLIC HEALTH RELEVANCE: Project Narrative This study is important to public health as the findings will provide critical information for better understanding the individual, partner, provider and structural level barriers to effective safer conception counseling (from the perspective of patients and providers) and the use of pre- and post-conception risk reduction methods. With this understanding, we will be well-positioned to develop a structural intervention for clinics and providers to improve comprehensive reproductive health services, including pre-conception counseling, which is the key to preventing horizontal transmission in serodiscordant couples, re-infection in concordant couples, and mother-to-child transmission.