Integrating Counseling to Transform HIV Family Planning Services

为艾滋病毒/艾滋病患者提供的计划生育服务侧重于预防意外怀孕 和母婴传播(PMTCT)，目前没有提供任何服务来支持更安全的受孕， 尽管撒哈拉以南非洲(SSA)约40%的艾滋病毒+妇女在艾滋病毒确诊后怀孕。大约一半 这些怀孕是有计划的，这突显了更安全的受孕咨询(SCC)的必要性，因为超过一半的 乌干达感染艾滋病毒的夫妇血清不一致，而意外怀孕则显示出很高的未满足 需要有效的避孕措施。抗逆转录病毒疗法(ART)大大降低了相关的传播风险 对于生育，但许多PLHA要么不了解艺术，要么没有足够的依从性；因此需要使用 更安全的受孕方法(SCM)，如人工自授精(MSI)和定时无保护性交 (途易)。通过SCC集成来改造FP计划不仅对促进SAFER具有重要意义 怀孕，但也可能是减少意外怀孕以及增加防止母婴传播的关键， 坚持和保留，因为关于生育的公开咨询促进了关于以下方面的明智决定 生育，获得避孕药具，并可能限制客户在以下情况下感到有必要脱离艾滋病毒护理 因害怕怀孕而遭受与生育相关的耻辱。利用信息的生态适应 动机和行为技能(EIMB)模型，我们开发并试行了结构化的SCC干预 血清不一致的夫妇，其中33对(79%)正确使用了TUI或MSI；有7例怀孕 也没有伴侣的血清转换。另有43对夫妇符合条件，但在最初的SCC咨询后， 并讨论了所涉及的风险和好处，决定不再继续生育，并被转介 用于避孕服务。基于这一初步可行性和接受性的证据 干预，并支持全面的计划生育方法，使用开放的生育咨询来 确保患者获得SCC和PMTCT或避孕服务，以实现他们想要的生殖 目标，拟议的集群RCT将比较(1)综合的FP计划，该计划包括结构化的、 多组分SCC干预(SCC1)与(2)针对FP护士的SCC培训研讨会(SCC2；MIMICS 乌干达卫生部用来整合新服务的方法)，和(3)现有的计划生育服务(通常护理)。 由Taso乌干达运营的艾滋病毒诊所。三臂设计，以及计划的成本效益 分析，使我们能够检查将SCC集成到FP服务的两种模式，这两种模式的强度不同， 从而通知MoH策略和资源分配。60名处于血清不一致关系中的客户 招募时的生育意愿将在每个地点登记(n=540)，并跟踪12个月或 怀孕完成(如适用)。主要结果是使用任何一种SCM(对于那些试图 或双重避孕(决定不怀孕的人)。

Family planning (FP) services for people living HIV/AIDS (PLHA) focus on preventing unplanned pregnancies and mother-to-child-transmission (PMTCT), and currently provide no services to support safer conception, despite ~40% of HIV+ women in sub-Saharan Africa (SSA) becoming pregnant post HIV diagnosis. About half of these pregnancies are planned, highlighting the need for safer conception counseling (SCC) as over half of HIV-affected couples in Uganda are serodiscordant, while the unplanned pregnancies reveal a high unmet need for effective contraception. Antiretroviral therapy (ART) greatly reduces the transmission risks associated with childbearing, but many PLHA are either not on ART or not adequately adherent; hence the need for using safer conception methods (SCM) such as manual self-insemination (MSI) and timed unprotected intercourse (TUI). Transforming FP programs through the integration of SCC is not only important for promoting safer conception, but may also be key to reducing unwanted pregnancies, as well as increased PMTCT uptake, adherence and retention, as open consultation about childbearing promotes informed decisions regarding childbearing, access to contraceptives, and can limit clients feeling the need to disengage from HIV care when pregnant due to fear of childbearing-related stigma. Drawing on an ecological adaptation of the Information Motivation and Behavioral skills (eIMB) model, we developed and piloted a structured SCC intervention with 42 serodiscordant couples, 33 (79%) of whom correctly used TUI or MSI as instructed; there were 7 pregnancies and no partner seroconversions. An additional 43 couples were eligible but after the initial SCC consultation, and discussion of the risks and benefits involved, decided not to further pursue childbearing and were referred for contraceptive services. Building on this evidence of preliminary feasibility and acceptance of the intervention, and support for a comprehensive FP approach that uses open childbearing consultations to ensure that clients receive SCC and PMTCT, or contraception services, to achieve their desired reproductive goals, the proposed cluster RCT will compare (1) a comprehensive FP program that incorporates a structured, multi-component SCC intervention (SCC1) versus (2) an SCC training workshop for FP nurses (SCC2; mimics approach used by Ugandan MoH to integrate new services), and (3) existing FP services (usual care) at nine HIV clinics operated by TASO Uganda. The 3-arm design, together with the planned cost-effectiveness analysis, allows us to examine two models for integrating SCC into FP services that differ on level of intensity, thereby informing MoH policy and resource allocation. Sixty clients in serodiscordant relationships who express childbearing desires at recruitment will be enrolled at each site (n=540) and followed for 12 months or completion of pregnancy (if applicable). The primary outcome is use of either SCM (for those trying to conceive) or dual contraception (those who decide against pregnancy).