Publications by authors named "Deborah Mindry"

37 Publications

Provider Perspectives on Navigating Relationship Challenges in Assisting HIV-Affected Couples to Meet Their Reproductive Goals: Lessons Learned from a Safer Conception Counseling Intervention in Uganda.

AIDS Behav 2021 Jul 29. Epub 2021 Jul 29.

Schools of Medicine and Pharmacy, Childrens Mercy Research Institute, University of Missouri, Kansas, MO, USA.

In Uganda, 60% of HIV-affected couples are serodiscordant, many of whom want children. There is a need to assess their reproductive intentions and provide appropriate services that limit transmission risks while meeting reproductive goals. Our Choice intervention engaged male and female HIV-infected clients and their partners in safer conception counseling (SCC) or family planning based on their childbearing decision. We report findings of provider experiences and recommendations for engaging couples in SCC. The intervention was implemented in four clinics offering either SCC1, an intensive training and supervision arm, or SCC2, utilizing the Ministry of Health's standard approach. Qualitative interviews were conducted at 12 (N = 23) and 24 months (N = 25) after initiation of the intervention. Many partners attended at least some SCC sessions, although engaging male partners was more challenging. Providers reported partner involvement improved understanding and facilitated successful implementation of SCM, whereas confusion and challenges were common when the client participated alone. Providers shared successful strategies for engaging male partners.
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http://dx.doi.org/10.1007/s10461-021-03397-4DOI Listing
July 2021

"Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches.

Implement Sci 2021 04 15;16(1):41. Epub 2021 Apr 15.

Children's Mercy Research Institute, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA.

Background: Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.

Methods: In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.

Results: The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.

Conclusions: More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.

Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017.
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http://dx.doi.org/10.1186/s13012-021-01109-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048255PMC
April 2021

Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships.

BMC Public Health 2021 01 19;21(1):156. Epub 2021 Jan 19.

Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, USA.

Context: Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low.

Methods: Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception.

Results: Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression.

Conclusion: Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.

Trial Registration: Clinicaltrials.gov, NCT03167879 ; date registered May 23, 2017.
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http://dx.doi.org/10.1186/s12889-021-10163-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814634PMC
January 2021

Smartphone Self-Monitoring by Young Adolescents and Parents to Assess and Improve Family Functioning: Qualitative Feasibility Study.

JMIR Form Res 2020 Jun 23;4(6):e15777. Epub 2020 Jun 23.

The Methodology Center, Department of Behavioral Health, The Pennsylvania State University, University Park, PA, United States.

Background: The natural integration of mobile phones into the daily routines of families provides novel opportunities to study and support family functioning and the quality of interactions between family members in real time.

Objective: This study aimed to examine user experiences of feasibility, acceptability, and reactivity (ie, changes in awareness and behaviors) of using a smartphone app for self-monitoring of family functioning with 36 participants across 15 family dyads and triads of young adolescents aged 10 to 14 years and their parents.

Methods: Participants were recruited from 2 family wellness centers in a middle-to-upper income shopping area and a low-income school site. Participants were instructed and prompted by alarms to complete ecological momentary assessments (EMAs) by using a smartphone app over 2 weeks 4 times daily (upon waking in the morning, afternoon, early evening, and end of day at bedtime). The domains assessed included parental monitoring and positive parenting, parent involvement and discipline, parent-child conflict and resolution, positive interactions and support, positive and negative affect, sleep, stress, family meals, and general child and family functioning. Qualitative interviews assessed user experiences generally and with prompts for positive and negative feedback.

Results: The participants were primarily white and Latino of mixed-income- and education levels. Children were aged 10 to 14 years, and parents had a mean age of 45 years (range 37-50). EMA response rates were high (95% to over 100%), likely because of cash incentives for EMA completion, engaging content per user feedback, and motivated sample from recruitment sites focused on social-emotional programs for family wellness. Some participants responded for up to 19 days, consistent with some user experience interview feedback of desires to continue participation for up to 3 or 4 weeks. Over 80% (25/31) of participants reported increased awareness of their families' daily routines and functioning of their families. Most also reported positive behavior changes in the following domains: decision making, parental monitoring, quantity and quality of time together, communication, self-regulation of stress and conflict, discipline, and sleep.

Conclusions: The results of this study support the feasibility and acceptability of using smartphone EMA by young adolescents and parents for assessing and self-monitoring family daily routines and interactions. The findings also suggest that smartphone self-monitoring may be a useful tool to support improvement in family functioning through functions of reflection on antecedents and consequences of situations, prompting positive and negative alternatives, seeding goals, and reinforcement by self-tracking for self-correction and self-rewards. Future studies should include larger samples with more diverse and higher-risk populations, longer study durations, the inclusion of passive phone sensors and peripheral biometric devices, and integration with counseling and parenting interventions and programs.
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http://dx.doi.org/10.2196/15777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381003PMC
June 2020

Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy.

Glob Health Action 2020 ;13(1):1728830

Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.

: Test and Treat has been widely adopted throughout sub-Saharan Africa, whereby all HIV-positive individuals initiate antiretroviral therapy (ART) immediately upon diagnosis and continue for life. However, clients who feel healthy may delay ART initiation, despite being eligible under new treatment guidelines.: We examined health care worker (HCW) perceptions and experiences on how feeling healthy positively or negatively influences treatment initiation among HIV-positive clients in Malawi.: We conducted 12 focus group discussions with 101 HCWs across six health facilities in Central Malawi. Data were analyzed through constant comparison methods using Atlas.ti7.5.: Feeling healthy influences perceptions of ART initiation among HIV-positive clients. HCWs described that healthy clients feel that there are few tangible benefits to immediate ART initiation, but numerous risks. Fear of stigma and unwanted disclosure, disruption of daily activities, fear of side effects, and limited knowledge about the benefits of early initiation were perceived by HCWs to deter healthy clients from initiating ART.: Feeling healthy may exacerbate barriers to ART initiation. Strategies to reach healthy clients are needed, such as chronic care models, differentiated models of care that minimize disruptions to daily activities, and community sensitization on the benefits of early initiation.
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http://dx.doi.org/10.1080/16549716.2020.1728830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7054923PMC
November 2020

The Experiences of Young Men, Their Families, and Their Coaches Following a Soccer and Vocational Training Intervention to Prevent HIV and Drug Abuse in South Africa.

AIDS Educ Prev 2019 06;31(3):224-236

Department of Family Medicine, University of California Los Angeles.

Young men in South Africa are at high-risk for HIV, substance abuse, and gender-based violence. This article presents qualitative results from a pilot study testing soccer leagues and vocational training to engage young-adult township men to deliver preventive interventions, including rapid HIV and alcohol/drug testing, shifting attitudes toward gender-based violence, and promoting other prosocial behaviors. Three groups participated in focus groups and in-depth interviews on experiences with the program: (1) a subset of 15 participants, (2) 15 family members, and (3) five intervention coaches. Results suggest that participants first reduced substance use on tournament days and then gradually reduced to practice days and beyond. Families suggested that "keeping young men occupied" and encouragement of prosocial behaviors was critical to risk reduction and led to increased community respect for the men. Coaches noted that behavioral and attitudinal changes were incremental and slow. The use of incentives was problematic and more research is needed to understand how incentives can be used in interventions of this nature.
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http://dx.doi.org/10.1521/aeap.2019.31.3.224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192051PMC
June 2019

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa.

SAHARA J 2018 12;15(1):187-199

b Center of Expertise on Women's Health, Gender and Empowerment , University of California Global Health Institute , San Francisco , CA , USA.

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.
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http://dx.doi.org/10.1080/17290376.2018.1541024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237168PMC
December 2018

High report of miscarriage among women living with HIV who want to conceive in Uganda.

BMC Res Notes 2018 Oct 22;11(1):753. Epub 2018 Oct 22.

RAND Corporation, Santa Monica, USA.

Objective: Data on early miscarriage incidence is limited due to various social and methodological barriers. We report on 24-month pregnancy outcomes of 299 female Ugandan HIV clients in committed relationships with an intention to conceive. Miscarriage data are reported as auxiliary findings to a larger study (5R01HD072633).

Results: 127 (42%) participants reported a pregnancy during the study; among the remaining 172, 82 indicated they stopped trying to conceive, and 16 dropped out prior to month 24. Of the 127 pregnancies, 55 (43%) resulted in live births, 67 (53%) in spontaneous miscarriage, 1 (< 1%) in stillbirth, 1 (< 1%) in abortion, and 3 (2%) in unknown outcomes. Three-quarters (75%) of miscarriages for which time until miscarriage was available were reported to occur in the first trimester (mean = 11.3 weeks gestation). The 67 participants who reported a miscarriage tended to be older (mean 33 vs. 30 years), but the significance of age did not persist after adjusting for multiple tests. We observed relatively low rates of pregnancy and high rates of miscarriage among this cohort of HIV-positive women wanting to conceive. Rigorously designed studies are needed to better understand the observed high rate of early miscarriage among HIV-infected women.
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http://dx.doi.org/10.1186/s13104-018-3857-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198531PMC
October 2018

Study protocol of "Our Choice": a randomized controlled trial of the integration of safer conception counseling to transform HIV family planning services in Uganda.

Implement Sci 2018 08 14;13(1):110. Epub 2018 Aug 14.

RAND Corporation, Santa Monica, CA, USA.

Background: About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services.

Methods: Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined.

Discussion: Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda.

Trial Registration: NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.
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http://dx.doi.org/10.1186/s13012-018-0793-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092849PMC
August 2018

Benefits and Challenges of Safer-Conception Counseling for HIV Serodiscordant Couples in Uganda.

Int Perspect Sex Reprod Health 2018 03 1;44(1):31-39. Epub 2018 Mar 1.

RAND Corporation, Santa Monica, CA, USA.

Context: Safer-conception counseling may help people living with HIV to reduce the risk of transmission to partners and children. However, such counseling is rarely offered or evaluated in low-income countries.

Methods: In 2014-2015, in-depth qualitative interviews were conducted at a Ugandan HIV clinic with 42 HIV-positive clients and 16 uninfected partners who had participated in a safer-conception counseling intervention for serodiscordant couples seeking to have a child. Participants attended up to six monthly counseling sessions in which they received instruction and ongoing support in using the safer-conception method they selected. Content analysis of interview transcripts was used to identify themes related to the benefits and challenges of safer-conception counseling.

Results: Almost two-thirds of participants felt that safer-conception counseling was an empowering experience that enabled them to make informed choices regarding childbearing, learn how to conceive safely and understand how to stay healthy while trying to conceive. Timed unprotected intercourse was the most frequently used safer-conception method. Seven couples had successful pregnancies, and no uninfected partners seroconverted. Participants' primary concerns and challenges regarding counseling and method use were issues with manual self-insemination, difficulty with engaging partners and fear of HIV infection.

Conclusions: Counseling can help HIV-infected individuals make informed choices about childbearing and safer-conception methods; however, a controlled clinical trial is needed to determine whether clients use such methods correctly and to assess rates of pregnancy and transmission. Policymakers need to consider including safer-conception counseling as part of routine HIV care.
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http://dx.doi.org/10.1363/44e5718DOI Listing
March 2018

Utilization of prevention of mother-to-child transmission (PMTCT) services among pregnant women in HIV care in Uganda: a 24-month cohort of women from pre-conception to post-delivery.

BMC Res Notes 2018 Mar 22;11(1):187. Epub 2018 Mar 22.

RAND Corporation, Santa Monica, USA.

Objective: We assessed the uptake of prevention of mother-to-child transmission (PMTCT) services in a cohort of HIV infected women in care at The AIDS Support Organization Jinja and Kampala in Uganda, who were trying to conceive, over a period of 24 months, to inform the strengthening of PMTCT service access for women in care.

Results: Of the 299 women 127 (42.5%) reported at least one pregnancy within 24 months; 61 women (48.0%) delivered a live child. Of the 55 who had a live birth at the first pregnancy, 54 (98.2%) used antenatal care (ANC) starting at 15.5 weeks of gestation on average and 47/49 (95.9%) delivered at a health facility. Excluding miscarriages, 54 (98.2%) received ARVs during pregnancy. Of the 49 live births with post-delivery data, 37 (75.5%) tested the infant for HIV. 79 of the 127 (68.7%) spoke with providers about childbearing. Communication with providers was associated with ANC use (65.8% vs. 41.7%; p = .015). Despite the high rate of miscarriages and late ANC start, this study shows very high uptake of PMTCT services among PLHIV in care and their infants. Improved provider-client communication could enhance ANC attendance and PMTCT outcomes among HIV infected women in care.
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http://dx.doi.org/10.1186/s13104-018-3304-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5863850PMC
March 2018

Changes in Providers' Self-Efficacy and Intentions to Provide Safer Conception Counseling Over 24 Months.

AIDS Behav 2018 Sep;22(9):2895-2905

Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.

High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers' self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers' knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers' intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers' confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.
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http://dx.doi.org/10.1007/s10461-018-2049-xDOI Listing
September 2018

Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda.

PLoS One 2018 20;13(2):e0192902. Epub 2018 Feb 20.

RAND Corporation, Santa Monica, California, United States of America.

Introduction: Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda.

Methods: 400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis.

Results: 75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics.

Conclusions: Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192902PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819785PMC
April 2018

Adherence to self-monitoring healthy lifestyle behaviours through mobile phone-based ecological momentary assessments and photographic food records over 6 months in mostly ethnic minority mothers.

Public Health Nutr 2018 03 4;21(4):679-688. Epub 2017 Dec 4.

6Nexleaf Analytics,Los Angeles,CA,USA.

Objective: Mobile phones can replace traditional self-monitoring tools through cell phone-based ecological momentary assessment (CEMA) of lifestyle behaviours and camera phone-based images of meals, i.e. photographic food records (PFR). Adherence to mobile self-monitoring needs to be evaluated in real-world treatment settings. Towards this goal, we examine CEMA and PFR adherence to the use of a mobile app designed to help mothers self-monitor lifestyle behaviours and stress. Design/Setting In 2012, forty-two mothers recorded CEMA of diet quality, exercise, sleep, stress and mood four times daily and PFR during meals over 6 months in Los Angeles, California, USA.

Subjects: A purposive sample of mothers from mixed ethnicities.

Results: Adherence to recording CEMA at least once daily was higher compared with recording PFR at least once daily over the study period (74 v. 11 %); adherence to both types of reports decreased over time. Participants who recorded PFR for more than a day (n 31) were more likely to be obese v. normal- to overweight and to have higher blood pressure, on average (all P<0·05). Based on random-effects regression, CEMA and PFR adherence was highest during weekdays (both P<0·01). Additionally, PFR adherence was associated with older age (P=0·04). CEMA adherence was highest in the morning (P<0·01). PFR recordings occurred throughout the day.

Conclusions: Variations in population and temporal characteristics should be considered for mobile assessment schedules. Neither CEMA nor PFR alone is ideal over extended periods.
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http://dx.doi.org/10.1017/S1368980017003044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807077PMC
March 2018

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda.

AIDS Behav 2017 Aug;21(8):2488-2496

RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA.

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.
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http://dx.doi.org/10.1007/s10461-017-1816-4DOI Listing
August 2017

Mobile Phone Ecological Momentary Assessment of Daily Stressors Among People Living With HIV: Elucidating Factors Underlying Health-Related Challenges in Daily Routines.

J Assoc Nurses AIDS Care 2017 Sep - Oct;28(5):737-751. Epub 2017 Apr 12.

Stressful life events and daily hassles affect people living with HIV (PLWH). However, capturing stress-related events and cognitive impairment is often plagued with recall biases. Incorporating reliable information technology, such as mobile phones, can be a resourceful method for measuring health behaviors (MHB). We report findings from an MHB pilot study with 32 African American, Latino/Hispanic, and White PLWH from Los Angeles. Participants reported perceived stressors in their daily routines using a smartphone Ecological Momentary Assessment (EMA) application. Participants self-initiated in-the-moment stressful events reports for up to 6 weeks. Stressful event EMAs queried perceived stress levels (1-10 scale) and open-ended text descriptions. Qualitative analysis of participant text responses was completed using grounded thematic coding. Participants reported multiple stressors in their daily routines, impacting activities of daily living or daily functioning. Eliciting input from PLWH via EMA in real time is a novel approach for assessing and identifying sources of stress.
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http://dx.doi.org/10.1016/j.jana.2017.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5572472PMC
December 2017

Barriers and facilitators for men to attend prenatal care and obtain HIV voluntary counseling and testing in Brazil.

PLoS One 2017 17;12(4):e0175505. Epub 2017 Apr 17.

Department of Epidemiology, Fielding School of Public Health at UCLA, Los Angeles, CA United States.

Background: Providing HIV voluntary counseling and testing (VCT) to men who attend their partner's prenatal care is an intervention with potential to reduce HIV transmission to women and infants during the vulnerable period of pregnancy. Little is known about the acceptability of this intervention in global settings outside of Africa.

Methods: We conducted in-depth qualitative interviews to evaluate potential barriers and facilitators to prenatal care attendance for HIV VCT with 20 men who did and 15 men who did not attend prenatal care with their partners at Hospital Conceiçao in Porto Alegre, Brazil. Men were recruited at the labor and delivery unit at Hospital Conceiçao via a scripted invitation while visiting their newborn infant. Interviews lasted from 35-55 minutes and were conducted in Portuguese by a local resident trained extensively in qualitative methods. All interviews were transcribed verbatim, translated, and then analyzed using Atlast.ti software. An analysis of themes was then conducted using direct quotes and statements. We applied and adapted the AIDS Risk Reduction Theoretical Model and HIV Testing Decisions Model to the qualitative data to identify themes in the 35 interviews.

Results: If offered HIV testing during prenatal care, all men in both groups stated they would accept this intervention. Yet, individual, relationship and systemic factors were identified that affect these Brazilian men's decision to attend prenatal care, informing our final conceptual model. The men interviewed had a general understanding of the value of HIV prevention of mother to child transmission. They also described open and communicative relationships with their significant others and displayed a high level of enthusiasm towards optimizing the health of their expanding family. The major barriers to attending prenatal care included perceived stigma against HIV infected individuals, men's lack of involvement in planning of the pregnancy as well as inconvenient scheduling of prenatal care, due to conflicting work schedules.

Conclusions: Brazilian men displayed high levels of HIV-related knowledge as well as open communication about HIV testing; especially when compared to findings from African studies. Future efforts should reorient prenatal care towards providing care to the entire family with a clear focus on protecting the infant from preventable diseases. Formally inviting men to prenatal care and providing them an acceptable medical excuse from work may enhance male involvement.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0175505PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393615PMC
April 2017

Prevalence and Correlates of Use of Safer Conception Methods in a Prospective Cohort of Ugandan HIV-Affected Couples with Fertility Intentions.

AIDS Behav 2017 Aug;21(8):2479-2487

Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda.

We examined the prevalence and correlates of safer conception methods (SCM) use in HIV-affected couples with fertility intentions. A prospective cohort of 400 HIV clients in Uganda who had fertility intentions with their partner was surveyed every 6 months for 24 months. Logistic regression analysis was used to determine individual, relationship and provider level predictors of SCM use. Over one-third (35%) reported any use of timed unprotected intercourse (TUI) during the study; use of other SCM was rare. Baseline predictors of any TUI use included lower social support, greater perceived provider stigma of childbearing, greater SCM awareness, greater control over sexual decision making in the relationship, inconsistent condom use, and the belief that a desire for childbearing impedes condom use. These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV.
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http://dx.doi.org/10.1007/s10461-017-1732-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5536997PMC
August 2017

Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions.

Afr J Reprod Health 2016 Mar 5;20(1):40-51. Epub 2016 Jun 5.

Makerere University School of Public Health, Department of Disease Control and Environmental Health, Kampala, Uganda.

Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297376PMC
http://dx.doi.org/10.29063/ajrh2016/v20i1.4DOI Listing
March 2016

HIV Care Providers' Attitudes regarding Mobile Phone Applications and Web-Based Dashboards to support Patient Self-Management and Care Coordination: Results from a Qualitative Feasibility Study.

J HIV AIDS 2016 Oct 21;2(4). Epub 2016 Jun 21.

Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Science, David Geffen School of Medicine at UCLA, and Department of Epidemiology, UCLA Fielding School of Public Health, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA 90024, USA.

In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217706PMC
http://dx.doi.org/10.16966/2380-5536.127DOI Listing
October 2016

Client and provider knowledge and views on safer conception for people living with HIV (PLHIV).

Sex Reprod Healthc 2016 Dec 31;10:35-40. Epub 2016 Mar 31.

MatCH Research (Maternal, Adolescent and Child Health), Dept. of Obstetrics and Gynecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa; School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa.

Objective(s): The childbearing needs of people living with HIV (PLHIV) and the experiences of healthcare providers serving them are explored. We examine provider and client knowledge and views on safer conception methods.

Methods: The study uses exploratory qualitative research to understand provider and client perspectives on childbearing and safer conception. Interviews were conducted at 3 sites (1 rural, 2 urban) in eThekwini District, KwaZulu-Natal, South Africa between May 2011 and August 2012, including in-depth interviews with 43 PLHIV, 2 focus group discussions and 12 in-depth interviews with providers.

Results: Clients had little knowledge and providers had limited knowledge of safer conception methods. While clients were eager to receive counseling on safer conception, providers had some hesitations but were eager to receive training in delivering safer conception services. Clients and providers noted that biological parentage is a major concern of PLHIV. Clients were willing to use any of the described methods to have biological children but some expressed concerns about potential risks associated with timed unprotected intercourse. Male clients required access to reproductive health information.

Conclusions: Providers need to routinely initiate discussions with clients about childbearing intentions. Providers need to be enabled with approved guidelines and training to support client access to safer conception methods.
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http://dx.doi.org/10.1016/j.srhc.2016.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5155034PMC
December 2016

Attitudes, Knowledge, and Correlates of Self-Efficacy for the Provision of Safer Conception Counseling Among Ugandan HIV Providers.

AIDS Patient Care STDS 2015 Dec 20;29(12):651-60. Epub 2015 Nov 20.

5 RAND Corporation , Santa Monica, California.

High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing.
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http://dx.doi.org/10.1089/apc.2015.0089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4684655PMC
December 2015

Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers.

AIDS Behav 2016 06;20(6):1370-81

RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach's alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60-0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.
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http://dx.doi.org/10.1007/s10461-015-1199-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537001PMC
June 2016

Benefits of PrEP as an Adjunctive Method of HIV Prevention During Attempted Conception Between HIV-uninfected Women and HIV-infected Male Partners.

J Infect Dis 2015 Nov 19;212(10):1534-43. Epub 2015 Jun 19.

Department of Medicine, Division of Infectious Diseases, University of California, David Geffen School of Medicine, Los Angeles.

Background: Data on effectiveness of preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV)-uninfected women attempting conception with HIV-infected male partners are limited to observational studies.

Methods: To explore the benefits of PrEP for conception, we developed a model to estimate the average annual probability of a woman remaining HIV-uninfected and having a child ("successful" outcome) via condomless sex with an HIV-infected male. The outcome likelihood is dependent upon parameters defining HIV-1 infectivity. We simulated 2 scenarios: optimal (condomless sex acts limited to the ovulation window), and suboptimal (acts not limited to ovulation).

Results: In the optimal scenario when the male is on antiretroviral therapy (ART), the average annual probability of the successful outcome is 29.1%, increasing to 29.2% with the addition of PrEP (P = .45). In the suboptimal scenario, the probability is 26.8% with ART alone versus 27.3% with ART/PrEP (P < .0001). Older maternal age reduces the probability of success in both scenarios, particularly after age 30.

Conclusions: In our model, PrEP provides little added benefit when the HIV-infected male partner is on ART, condomless sex is limited to the ovulation window, and other modifiable transmission risks are optimized. Older female age decreases the probability of success by increasing the number of condomless sex acts required for conception.
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http://dx.doi.org/10.1093/infdis/jiv305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621256PMC
November 2015

Men's moralising discourses on gender and HIV risk in rural KwaZulu-Natal, South Africa.

Cult Health Sex 2015 23;17(8):1035-48. Epub 2015 Apr 23.

a Department of Psychiatry and Behavioural Sciences , UCLA Center for Culture and Health, NPI-Semel Institute for Neuroscience , Los Angeles , USA.

Various interventions have resulted in increased rates of HIV testing. However, encouraging men to acknowledge their risk for HIV, to test and link to treatment remains a challenge. In this study, we examine men's perspectives on navigating HIV risk in rural KwaZulu-Natal, South Africa. Qualitative interviews were conducted at four intervals over a three-year time period with a baseline cohort of 126 men and women. We found that men navigated HIV risk in their sexual relationships mainly by monitoring their partner's behaviour. Men expressed concerns about female respectability, invoking discourses on hlonipha rooted in Zulu cultural ideals and Christian ideals about women staying close to home. In the post-apartheid era, these concerns were inflected by anxieties over changing gender norms and the high rates and risks of infection in the region. HIV prevention discourses on behaviour intersected with men's efforts to assert their masculinity through the monitoring and controlling of women's behaviour. The potential negative impacts of this should be addressed. Prevention efforts need to focus on men's vulnerability to infection in terms of their own behaviour as well as the contexts in which they live.
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http://dx.doi.org/10.1080/13691058.2015.1027877DOI Listing
May 2016

Provider attitudes about childbearing and knowledge of safer conception at two HIV clinics in Malawi.

Reprod Health 2015 Mar 7;12:17. Epub 2015 Mar 7.

David Geffen School of Medicine at the University of California, Los Angeles, Division of Infectious Diseases, Los Angeles, California, USA.

Background: There is limited understanding of health care providers' attitudes towards HIV-infected individuals' reproductive choices, as well as knowledge about safer conception. Our study objective was to explore provider-level factors that serve as barriers and/or facilitators to the provision of reproductive and safer conception services for men and women living with HIV.

Methods: Twenty-five providers were interviewed in four focus group discussions about their attitudes regarding childbearing by HIV-infected clients, reproductive health and HIV knowledge, and views and knowledge of safer conception.

Results: Providers reported ambivalence about supporting childbearing among their clients with HIV. They raised concerns about HIV-infected individuals having children, and in certain cases expressed judgment that people with HIV should not have children because of these concerns. Providers lack specific knowledge about safer conception strategies and have low level of knowledge of reproductive health, the efficacy of PMTCT, and the risks of pregnancy for HIV-infected women.

Conclusions: Providers in our setting have complex attitudes about HIV-infected clients having children and lack knowledge to appropriately counsel clients about reproductive health and safer conception. Our findings highlight need for further research in this area as well as the need for provider training in reproductive health and safer conception.
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http://dx.doi.org/10.1186/s12978-015-0004-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4355153PMC
March 2015

Development and Pilot Testing of Daily Interactive Voice Response (IVR) Calls to Support Antiretroviral Adherence in India: A Mixed-Methods Pilot Study.

AIDS Behav 2015 Jun;19 Suppl 2:142-55

Center for HIV Identification, Prevention, and Treatment Services, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), 10920 Wilshire Blvd., Suite. 350, Los Angeles, CA, 90024, USA,

This two-phase pilot study aimed to design, pilot, and refine an automated interactive voice response (IVR) intervention to support antiretroviral adherence for people living with HIV (PLH), in Kolkata, India. Mixed-methods formative research included a community advisory board for IVR message development, 1-month pre-post pilot, post-pilot focus groups, and further message development. Two IVR calls are made daily, timed to patients' dosing schedules, with brief messages (<1-min) on strategies for self-management of three domains: medical (adherence, symptoms, co-infections), mental health (social support, stress, positive cognitions), and nutrition and hygiene (per PLH preferences). Three ART appointment reminders are also sent each month. One-month pilot results (n = 46, 80 % women, 60 % sex workers) found significant increases in self-reported ART adherence, both within past three days (p = 0.05) and time since missed last dose (p = 0.015). Depression was common. Messaging content and assessment domains were expanded for testing in a randomized trial currently underway.
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http://dx.doi.org/10.1007/s10461-014-0983-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498985PMC
June 2015

"Whatever I have, I have made by coming into this profession": the intersection of resources, agency, and achievements in pathways to sex work in Kolkata, India.

Arch Sex Behav 2015 May 13;44(4):1011-23. Epub 2015 Jan 13.

Center for HIV Identification, Prevention & Treatment Services (CHIPTS), Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles, 10920 Wilshire Blvd., Suite 350, Los Angeles, CA, 90024, USA,

This article investigated the complex interplay of choice, socioeconomic structural factors, and empowerment influencing engagement in sex work. The analysis was focused on pathways into and reasons for staying in sex work from in-depth qualitative interviews with participants (n = 37) recruited from the Durbar community-led structural intervention in Kolkata, India. Kabeer's theory of empowerment focused on resources, agency, and achievements was utilized to interpret the results. Results identified that contexts of disempowerment constraining resources and agency set the stage for initiating sex work, typically due to familial poverty, loss of a father or husband as a breadwinner, and lack of economic opportunities for women in India. Labor force participation in informal sectors was common, specifically in domestic, construction, and manufacturing work, but was typically insufficient to provide for families and also often contingent on sexual favors. The availability of an urban market for sex work served as a catalyst or resource, in conjunction with Durbar's programmatic resources, for women to find and exercise agency and achieve financial and personal autonomy not possible in other work or as dependents on male partners. Resources lost in becoming a sex worker due to stigma, discrimination, and rejection by family and communities were compensated for by achievements in gaining financial and social resources, personal autonomy and independence, and the ability to support children and extended family. Durbar's programs and activities (e.g., savings and lending cooperative, community mobilization, advocacy) function as empowering resources that are tightly linked to sex workers' agency, achievements, and sex work pathways.
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http://dx.doi.org/10.1007/s10508-014-0404-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382371PMC
May 2015

Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions.

AIDS Behav 2015 Jun;19(6):1078-88

RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA,

We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care.
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http://dx.doi.org/10.1007/s10461-014-0906-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385507PMC
June 2015

"I may not say we really have a method, it is gambling work": knowledge and acceptability of safer conception methods among providers and HIV clients in Uganda.

Health Care Women Int 2014 8;35(7-9):896-917. Epub 2014 Aug 8.

a Department of Family Medicine , University of Kansas Medical Center , Kansas City , Kansas , USA.

In this qualitative study, researchers assessed knowledge, acceptability, and feasibility of safer conception methods (SCM; timed unprotected intercourse [TUI], manual self-insemination, and sperm washing) among various health care providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM (especially TUI), few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly by men) in safer conception counseling.
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http://dx.doi.org/10.1080/07399332.2014.924520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4150744PMC
January 2015
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