Publications by authors named "Tamaryn L Crankshaw"

18 Publications

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Economic and social dimensions influencing safety of induced abortions amongst young women who sell sex in Zimbabwe.

Sex Reprod Health Matters 2021 Dec;29(1):1881209

Strategic Information & Research Manager, Family AIDS Caring Trust (FACT), Mutare, Zimbabwe.

Globally, women, experience inequities in access to safe abortion services and this is most acutely felt in country contexts where legal abortions are highly restricted. Data around abortion amongst young women who sell sex (YWSS) in sub-Saharan Africa are very limited. We conducted 30 focus group discussions and 42 in-depth interviews (IDIs) amongst YWSS (16-24 years) in urban and peri-urban areas of Zimbabwe, as well as IDIs amongst 16 peer educators, five health care providers and four key informants. Our findings indicate that abortions occur amongst YWSS in Zimbabwe but there remain questions over the extent of safety of abortions. The restrictive legal context around abortion and illegality of sex work in the country are key determinants underlying the clandestine nature of abortions. Socioeconomic concerns are key in decision-making around abortions. Youth, cost and lack of referral networks contribute towards unsafe abortions, even when safe abortion services are available. Many YWSS are not aware of the availability of post abortion care (PAC) services and resort to self-administered PAC. Being young and selling sex combine and interact on the economic and social levels to produce vulnerabilities greater than their sum to experiencing unsafe abortion.
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http://dx.doi.org/10.1080/26410397.2021.1881209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009027PMC
December 2021

Age Matters: Determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16-24 years) in Zimbabwe.

Soc Sci Med 2021 02 13;270:113597. Epub 2020 Dec 13.

Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa.

Introduction: Female sex workers bear a disproportionate burden of HIV and other poor sexual and reproductive health (SRH) outcomes which has led to the tailoring of SRH interventions to mitigate risk. Understanding of the SRH vulnerabilities of young women who sell sex (YWSS) (16-24 years) in Southern Africa is under-represented in research which may result in a mismatch in current SRH interventions and service design.

Objective: This paper is based on a sub-analysis of a qualitative study investigating the SRH of young women who sell sex (16-24 years) in Zimbabwe. We explored the differences in dynamics of SRH vulnerability amongst YWSS within the 16-24 year age band.

Methods: In-depth interviews (IDIs) were conducted amongst key informants (n = 4), health care providers (n = 5), and peer educators (n = 16). Amongst YWSS, we conducted IDIs (n = 42) and focus group discussions (n = 30). Transcripts were inductively coded for emergent themes and categories.

Results: Age and life stage determinants led to key differences in SRH vulnerabilities between younger (16-19 years) and older YWSS (20-24 years). These determinants emerged in the following ways: 1) distancing of younger participants from a "sex worker" identity leading to difficulties in identification and limiting intervention reach, 2) inexperience in dealing with clients and immature cognitive development leading to greater exposure to risk, and 3) the subordinate social position and exploitation of young participants within sex worker hierarchies or networks and lack of protective networks.

Conclusions: We highlight the presence of a diverse group of vulnerable young women who may be missed by sex worker programme responses. In future intervention planning, there is need to consider the age-related needs and vulnerabilities within a spectrum of young women involved in a wide range of transactional relationships to ensure that services reach those most vulnerable to poor SRH outcomes.
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http://dx.doi.org/10.1016/j.socscimed.2020.113597DOI Listing
February 2021

Engaging communities: the key to leaving no one behind in the era of UHC.

Sex Reprod Health Matters 2020 Dec;28(2):1849951

SRHR Programme Lead and Senior Research Fellow, Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa.

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http://dx.doi.org/10.1080/26410397.2020.1849951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887904PMC
December 2020

Sexual and reproductive health of asylum seeking and refugee women in South Africa: understanding the determinants of vulnerability.

Sex Reprod Health Matters 2020 Dec;28(1):1758440

Post-Doctoral Researcher, HEARD, Univerity of KwaZulu-Natal, Durban, South Africa.

Women asylum seekers and refugees face huge challenges related to their sexual and reproductive health (SRH) and rights. In this article we explore the structural determinants of vulnerability to poor SRH for these women in South Africa, and focus particularly on the political, legal and economic structures which render them vulnerable. Based on a qualitative study carried out in Durban, South Africa, we argue that it is vital to go beyond analyses which prioritise the socio-cultural barriers to sexual and reproductive health and rights for asylum seekers and refugees, and to consider the wider national and international policies and legislation which create barriers to these women's rights to SRH.
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http://dx.doi.org/10.1080/26410397.2020.1758440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888032PMC
December 2020

Menstrual health management and schooling experience amongst female learners in Gauteng, South Africa: a mixed method study.

Reprod Health 2020 Apr 15;17(1):48. Epub 2020 Apr 15.

Legal Resources Centre, P.O. Box 9495, Johannesburg, 2000, South Africa.

Background: There has been increased attention to the menstrual health management (MHM) needs of girls and young women in Eastern and Southern Africa, relating to dignity, and to the potential link between the lack of access to sanitary products and school absenteeism. In the South Africa, there is inadequate evidence to guide appropriate national responses. This study explored the extent of access to modern sanitary products amongst female high school learners and the range of needs and challenges that they face in managing their menses in school settings in Gauteng, South Africa.

Methods: We collected mixed method data from 10 schools in Sedibeng district between June and August 2018. The qualitative component consisted of in-depth interviews with female learners (n = 30), educators (n = 8) and mothers of female learners (n = 9) and focus group discussions (FGDs) with male learners (n = 7) and female learners (n = 10). Five hundred and five female learners were recruited into the quantitative component consisting of a self-administered survey focussing on factors associated with access to sanitary products.

Results: The median age of survey participants was 17 years (interquartile range 16-18 years) and average age at menarche was 13.36 years. One in seven female learners reported not having enough sanitary products for every period in the last 3 months and this was reflected across the school quintiles. There was a complex interaction between menstrual-related challenges (physical discomfort, teasing, and feeling distracted in class) experienced by female learners, often amplified or compounded by factors in the school environment (unhygienic sanitation facilities and inadequate rest areas), and schooling participation and attendance. Girls who did not have enough products for every period in the last 3 months more likely reported missing school than those who reported sufficient products (46.27% vs 22.49% respectively, p < 0.001). However, there was no statistically significant difference between the groups in number of days missed.

Conclusions: Provision of sanitary products is important but only one component of a comprehensive MHM response. Ongoing attention over the link between product access and absenteeism risks overlooking complex systemic and structural factors which can negatively impact the sexual and reproductive health of learners in the school context, and more broadly.
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http://dx.doi.org/10.1186/s12978-020-0896-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158143PMC
April 2020

"As we have gathered with a common problem, so we seek a solution": exploring the dynamics of a community dialogue process to encourage community participation in family planning/contraceptive programmes.

BMC Health Serv Res 2019 Oct 17;19(1):710. Epub 2019 Oct 17.

MatCH Research Unit (MRU), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Witwatersrand, Durban, South Africa.

Background: Community dialogues have been widely used as a method for community engagement and participation to cover a broad range of areas. However, there has been limited documentation and evaluation of the process, particularly as a method towards achieving family planning and contraception (FP/C) programme goals. As part of the development of an intervention package aimed at increasing community and health care provider (HCP) participation in the provision of FP/C, feasibility testing of the intervention approach (a community dialogue between communities and health facilities) was carried out. Our findings offer a systematic description and evaluation of the community dialogue process, with key recommendations towards future implementation.

Methods: The dialogue was evaluated in three ways: 1) through participant observation during the community dialogue, 2) via a standardised feasibility testing tick-list for all observers of the dialogue, and 3) through three focus group discussions (FGDs) consisting of different groups of stakeholders who participated in the community dialogue. In total, 28 community members, HCPs, and key stakeholders attended the community dialogue (22 females, 6 males). Twenty-seven of the community dialogue participants participated in one of 3 FGDs held after the dialogue. Six evaluators assessed feasibility of the dialogue process.

Results: There was good attendance, representation and participation amongst community and provider sectors based on the participant observations using the standardized feasibility check-list. The community dialogue process received positive feedback in the FGDs and was demonstrated to be feasible and acceptable. Key factors contributing to the success of the community dialogue included a skilled facilitator, good representation of participants, establishing ground rules, good timekeeping, and using a Theory of Change to facilitate goal identification and dialogue. Issues to consider are the underlying power differentials related to age, profession and gender which caused initial feelings of anxiety amongst some participants.

Conclusions: Our formative findings offer a systematic description and evaluation of a community dialogue process with key recommendations that may be considered when constituting similar community dialogues in the future.
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http://dx.doi.org/10.1186/s12913-019-4490-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6798361PMC
October 2019

The status of provision of post abortion care services for women and girls in Eastern and Southern Africa: a systematic review.

Contraception 2018 Mar 14. Epub 2018 Mar 14.

Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban.

Objective: To conduct a systematic review of the status of post-abortion care (PAC) provision in Eastern and Southern Africa with particular reference to reach, quality and costs of these services.

Study Design: We searched Pubmed, EMBASE, Science Direct, POPLINE and Web of Science for articles published between 2000 and October 2017 presenting primary or secondary data from one or more countries in the region.

Results: Seventy articles representing data from fourteen countries were abstracted and included in the review. Implementation of PAC services was found to be patchy across countries for which data was available. However, there is evidence of efforts to introduce PAC at lower level health facilities, to use mid-level providers and to employ less invasive medical techniques. Eleven countries from the region were not represented in this review, exposing a considerable knowledge gap over the state of PAC in the region. The disparate access for rural women and girls, the suboptimal service quality and the neglect of adolescent-specific needs were critical gaps in the current PAC provision.

Conclusion: PAC provision and research in this domain cannot be detached from the broader legal and societal context, as social stigma constitutes a major blockage to the advancement of the service. Adolescent girls are a particularly vulnerable and underserved group in the region.

Implications: The next generation research on PAC should favor multi-country and interdisciplinary study designs with a view to understanding inter-regional differences and supporting advancement towards universal access of PAC by 2030.
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http://dx.doi.org/10.1016/j.contraception.2018.03.014DOI Listing
March 2018

Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa.

J Int AIDS Soc 2017 03;20(Suppl 1):21271

Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.

Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV-affected persons to safely meet reproductive goals. However, aside from select research-supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield.

Discussion: Four key implementation barriers were identified by combining authors' safer conception service delivery experiences with available literature. First, strategic implementation frameworks stipulating where, and by whom, safer conception services should be provided are needed. Integrating safer conception services into universal test-and-treat (UTT) and elimination-of-mother-to-child-transmission (eMTCT) priority programmes would support HIV testing, ART initiation and management, viral suppression and early antenatal/eMTCT care engagement goals, reducing horizontal and vertical transmissions. Embedding measurable safer conception targets into these priority programmes would ensure accountability for implementation progress. Second, facing an organizational clinic culture that often undermines clients' reproductive rights, healthcare providers' (HCP) positive experiences with eMTCT and enthusiasm for UTT provide opportunities to shift facility-level and individual attitudes in favour of safer conception provision. Third, safer conception guidelines have not been incorporated into HCP training. Combining safer conception with "test-and-treat" training would efficiently ensure that providers are better equipped to discuss clients' reproductive goals and support safer conception practices. Lastly, HIV-affected couples remain largely unaware of safer conception strategies. HIV-affected populations need to be mobilized to engage with safer conception options alongside other HIV-related healthcare services.

Conclusion: Key barriers to widespread safer conception service provision in South Africa include poor translation of policy into practical and measurable implementation plans, inadequate training and limited community engagement. South Africa should leverage the momentum and accountability associated with high priority UTT and eMTCT programmes to reinvigorate implementation efforts by incorporating safer conception into implementation and monitoring frameworks and associated HCP training and community engagement activities. South Africa's experiences should be used to inform policy development and implementation processes in other HIV high-burden countries.
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http://dx.doi.org/10.7448/IAS.20.2.21271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577693PMC
March 2017

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

Unmet counselling need amongst women accessing an induced abortion service in KwaZulu-Natal, South Africa.

Contraception 2016 11 8;94(5):473-477. Epub 2016 Jul 8.

School of Clinical Medicine, University of KwaZulu-Natal, Private Bag 7, Congella, KwaZulu-Natal, South Africa, 4013. Electronic address:

Objectives: Provision of objective, evidence-based counselling in the context of induced abortion services is considered global good practise. However, there is limited understanding over the counselling needs of women accessing abortion services, particularly in sub-Saharan Africa. This study aimed to explore the content and quality of pre-abortion counselling amongst women accessing an abortion service in South Africa as well as client experience of the counselling process. Perceptions of nurse counsellors were also sought.

Study Design: This was a mixed methods study conducted at a Choice of Termination of Pregnancy clinic based at a district level hospital in KwaZulu-Natal, South Africa. Sixty women requesting an abortion were interviewed via a semi-structured questionnaire. In-depth interviews were conducted with four nurses who provided pre-abortion counselling at the clinic. Interviews were coded for emergent themes and categories.

Results: Clinic nurses had widely variable counselling training and experience, ranging from less than 2 months to 8 years, but all clients reported that they had been treated with respect at their counselling session. The group-based counselling format and biomedical and health promotion content did not accommodate clients' differential counselling needs, which included requests for support from women experiencing intimate partner violence (IPV). There was limited provider awareness of client's additional counselling needs.

Conclusion: Abortion counselling services should be tailored to clients' differential counselling needs. Group-based counselling followed by optional one-on-one counselling sessions is one possible strategy to address unmet client need in South Africa. Provision of abortion provider training in IPV is recommended as well as establishment of referral pathways for women experiencing IPV.

Implications: Paying attention to the differential counselling needs of women seeking an abortion should be a key component to the provision of abortion services. In this way, abortion services can provide a gateway to additional support for women living in violent relationships and/or other adverse social circumstances.
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http://dx.doi.org/10.1016/j.contraception.2016.07.002DOI Listing
November 2016

Placing contraception at the centre of the HIV prevention agenda.

Afr J AIDS Res 2016 Jul;15(2):157-62

b MatCH Research (Maternal, Adolescent, & Child Health Research) Unit, Department of Obstetrics and Gynaecology , Faculty of Health Sciences , University of the Witwatersrand , South Africa.

Over the past decade, the global response to the HIV epidemic has been unprecedented, and enormous progress has been made. Significant investment in the roll out of antiretroviral treatment (ART) and efforts to increase treatment coverage have greatly reduced the number of AIDS-related deaths worldwide. There are a growing number of promising innovations to expand the HIV prevention mix. However, the reach of these interventions is still very limited in adolescent girls and young women (15-24 years) and the full realisation of the intervention mandates has not yet been achieved. The HIV prevention field has been criticised for the tendency to adopt a narrow focus. The Fast-Track Strategy offers a unique opportunity for the HIV prevention field to broaden its gaze and to begin to identify synergies (and efficiencies) with prevention approaches from other global development priorities, namely sexual and reproductive health and rights (SRHR). This paper applies a SRHR lens to HIV prevention by highlighting the critical relationship between unintended pregnancy and HIV, and seeks to expand on earlier debates that prevention of HIV and prevention of unintended pregnancy are inextricably linked, complementary activities with interrelated and common goals. We call for the prioritisation of prevention of unintended pregnancy amongst two overlapping population groups - girls and young women (15-24 years old) and women living with HIV - as a key tactic to accomplish the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track Strategy and as a way to fully realise existing HIV prevention efforts. We discuss the intersecting pathways between HIV prevention and unintended pregnancy prevention and build a case for contraception to be placed at the centre of the HIV prevention agenda.
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http://dx.doi.org/10.2989/16085906.2016.1204330DOI Listing
July 2016

Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates.

J Glob Oncol 2016 Dec 4;2(6):375-380. Epub 2016 May 4.

and , Brigham and Women's Hospital; , , and , Harvard Medical School; , Massachusetts General Hospital Center for Global Health; , Boston Children's Hospital; , Dana-Farber Cancer Institute; , Boston University, Boston, MA; , University of KwaZulu-Natal, Durban; , Western Cape Province Department of Health, Cape Town; , R.K. Khan Hospital, Chatsworth, South Africa; and , Canadian Red Cross, Ontario, Canada.

Purpose: To determine the prevalence of screening, cervical dysplasia, and malignancy on the basis of histologic diagnoses from colposcopy and large loop excision of the transformation zone among women living with HIV (WLWH) who attended an urban antiretroviral treatment (ART) clinic in KwaZulu-Natal, South Africa.

Materials And Methods: We performed a retrospective cohort study to examine a random sample of 462 WLWH during a 5-year period from 2004 to 2009. Women on ART for < 3 months were excluded. Data were abstracted from electronic records and paper charts to assess rates of cervical abnormalities detected on Pap smears as well as time to colposcopy.

Results: During the study period, 432 women (93.5%) had at least one evaluable Papanicolau test. At baseline, 237 women (54.9%) had an abnormal Papanicolau test, and of these patients, 181 (76.3%) had a Papanicolau test that qualified for further colposcopic evaluation. In addition, 115 women (63.5%) received colposcopy within a median of 39 days from referral. This yielded 74 evaluable histologic samples (64.3%), of which 21.6%, 27.0%, 27.0%, and 1.4% had cervical intraepithelial neoplasia (CIN) 1, CIN2, CIN3, and invasive cervical cancer, respectively.

Conclusion: In a large sample of WLWH who received ART in KwaZulu-Natal, South Africa, where Papanicolau test coverage and rates of referral for colposcopy and large loop excision of the transformation zone were high, > 75% of women with evaluable histologic samples had evidence of cervical dysplasia or malignancy. These findings underscore the importance of routine cervical screening upon entry into HIV care to optimize survival.
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http://dx.doi.org/10.1200/JGO.2015.002469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493244PMC
December 2016

Understanding HIV-infected patients' experiences with PEPFAR-associated transitions at a Centre of Excellence in KwaZulu Natal, South Africa: a qualitative study.

AIDS Care 2015 24;27(10):1298-303. Epub 2015 Aug 24.

e Harvard University Center for AIDS Research (CFAR) , Boston , MA , USA.

South Africa was the largest recipient of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) for antiretroviral therapy (ART) programs from 2004 to 2012. Funding decreases have led to transfers from hospital and non-governmental organization-based care to government-funded, community-based clinics. We conducted semi-structured interviews with 36 participants to assess patient experiences related to transfer of care from a PEPFAR-funded, hospital-based clinic in Durban to either primary care clinics or hospital-based clinics. Participant narratives revealed the importance of connectedness between patients and the PEPFAR-funded clinic program staff, who were described as respectful and conscientious. Participants reported that transfer clinics were largely focused on dispensing medication and on throughput, rather than holistic care. Although participants appreciated the free treatment at transfer sites, they expressed frustration with long waiting times and low perceived quality of patient-provider communication, and felt that they were treated disrespectfully. These factors eroded confidence in the quality of the care. The transfer was described by participants as hurried with an apparent lack of preparation at transfer clinics for new patient influx. Formal (e.g., counseling) and informal (e.g., family) social supports, both within and beyond the PEPFAR-funded clinic, provided a buffer to challenges faced during and after the transition in care. These data support the importance of social support, adequate preparation for transfer, and improving the quality of care in receiving clinics, in order to optimize retention in care and long-term adherence to treatment.
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http://dx.doi.org/10.1080/09540121.2015.1051502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548805PMC
February 2018

South Africans with recent pregnancy rarely know partner's HIV serostatus: implications for serodiscordant couples interventions.

BMC Public Health 2014 Aug 14;14:843. Epub 2014 Aug 14.

Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA 02114, USA.

Background: Implementation of safer conception strategies requires knowledge of partner HIV-serostatus. We recruited women and men in a high HIV-prevalence setting for a study to assess periconception risk behavior among individuals reporting HIV-serodiscordant partnerships. We report screening data from that study with the objective of estimating the proportion of individuals who are aware that they are in an HIV-serodiscordant relationship at the time of conception.

Methods: We screened women and men attending antenatal and antiretroviral clinics in Durban, South Africa for enrollment in a study of periconception risk behavior among individuals with serodiscordant partners. Screening questionnaires assessed for study eligibility including age 18-45 years (for women) or at least 18 years of age (for men), pregnancy in past year (women) or partner pregnancy in the past 3 years (men), HIV status of partner for recent pregnancy, participant's HIV status, and infected partner's HIV status having been known before the referent pregnancy.

Results: Among 2620 women screened, 2344 (90%) met age and pregnancy criteria and knew who fathered the referent pregnancy. Among those women, 963 (41%) did not know the pregnancy partner's HIV serostatus at time of screening. Only 92 (4%) reported knowing of a serodiscordant partnership prior to pregnancy. Among 1166 men screened, 225 (19%) met age and pregnancy criteria. Among those men, 71 (32%) did not know the pregnancy partner's HIV status and only 30 (13%) reported knowing of a serodiscordant partnership prior to pregnancy.

Conclusions: In an HIV-endemic setting, awareness of partner HIV serostatus is rare. Innovative strategies to increase HIV testing and disclosure are required to facilitate HIV prevention interventions for serodiscordant couples.
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http://dx.doi.org/10.1186/1471-2458-14-843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4246447PMC
August 2014

Challenges with couples, serodiscordance and HIV disclosure: healthcare provider perspectives on delivering safer conception services for HIV-affected couples, South Africa.

J Int AIDS Soc 2014 12;17:18832. Epub 2014 Mar 12.

School of Built Environment and Development Studies, University of KwaZulu-Natal, Durban, South Africa.

Introduction: Safer conception interventions should ideally involve both members of an HIV-affected couple. With serodiscordant couples, healthcare providers will need to manage periconception risk behaviour as well tailor safer conception strategies according to available resources and the HIV status of each partner. Prior to widespread implementation of safer conception services, it is crucial to better understand provider perspectives regarding provision of care since they will be pivotal to the successful delivery of safer conception. This paper reports on findings from a qualitative study exploring the viewpoints and experiences of doctors, nurses, and lay counsellors on safer conception care in a rural and in an urban setting in Durban, South Africa.

Methods: We conducted six semistructured individual interviews per site (a total of 12 interviews) as well as a focus group discussion at each clinic site (a total of 13 additional participants). All interviews were coded in Atlas.ti using a grounded theory approach to develop codes and to identify core themes and subthemes in the data.

Results: Managing the clinical and relationship complexities related to serodiscordant couples wishing to conceive was flagged as a concern by all categories of health providers. Providers added that, in the HIV clinical setting, they often found it difficult to balance their professional priorities, to maintain the health of their clients, and to ensure that partners were not exposed to unnecessary risk, while still supporting their clients' desires to have a child. Many providers expressed concern over issues related to disclosure of HIV status between partners, particularly when managing couples where one partner was not aware of the other's status and expressed the desire for a child. Provider experiences were that female clients most often sought out care, and it was difficult to reach the male partner to include him in the consultation.

Conclusions: Providers require support in dealing with HIV disclosure issues and in becoming more confident in dealing with couples and serodiscordance. Prior to implementing safer conception programmes, focused training is needed for healthcare professionals to address some of the ethical and relationship issues that are critical in the context of safer conception care.
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http://dx.doi.org/10.7448/IAS.17.1.18832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956311PMC
September 2014

Double disclosure bind: complexities of communicating an HIV diagnosis in the context of unintended pregnancy in Durban, South Africa.

AIDS Behav 2014 Jan;18 Suppl 1:S53-9

Department of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa,

Disclosure of HIV status is widely promoted in the prevention of mother-to-child transmission (PMTCT), but a number of context-specific factors may mediate disclosure outcomes. To better understand HIV-disclosure dynamics, we conducted in-depth interviews among 62 HIV-positive pregnant women accessing PMTCT services in Durban, South Africa. Transcripts were coded for emergent themes and categories. Thirty-nine women (63 %) had been recently diagnosed with HIV; most (n = 37; 95 %) were diagnosed following routine antenatal HIV testing. Forty-two women (68 %) reported unplanned pregnancies. Overall, 37 women (60 %) reported an unintended pregnancy and recent HIV diagnosis. For them, 2 life-changing diagnoses had resulted in a double-disclosure bind. The timing and stigma surrounding these events strongly influenced disclosure of pregnancy and/or HIV. PMTCT-related counseling must be responsive to the complex personal implications of contemporaneous, life-changing events, especially their effect on HIV-disclosure dynamics and, ultimately, on achieving better maternal mental-health outcomes.
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http://dx.doi.org/10.1007/s10461-013-0521-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3823675PMC
January 2014

A conceptual framework for understanding HIV risk behavior in the context of supporting fertility goals among HIV-serodiscordant couples.

Reprod Health Matters 2012 Dec;20(39 Suppl):50-60

McCord Hospital, Durban, South Africa.

Integrated reproductive health services for people living with HIV must address their fertility intentions. For HIV-serodiscordant couples who want to conceive, attempted conception confers a substantial risk of HIV transmission to the uninfected partner. Behavioral and pharmacologic strategies may reduce HIV transmission risk among HIV-serodiscordant couples who seek to conceive. In order to develop effective pharmaco-behavioral programs, it is important to understand and address the contexts surrounding reproductive decision-making; perceived periconception HIV transmission risk; and periconception risk behaviors. We present a conceptual framework to describe the dynamics involved in periconception HIV risk behaviors in a South African setting. We adapt the Information-Motivation-Behavioral Skill Model of HIV Preventative Behavior to address the structural, individual and couple-level determinants of safer conception behavior. The framework is intended to identify factors that influence periconception HIV risk behavior among serodiscordant couples, and therefore to guide design and implementation of integrated and effective HIV, reproductive health and family planning services that support reproductive decision-making.
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http://dx.doi.org/10.1016/S0968-8080(12)39639-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608509PMC
December 2012

A retrospective study of Human Immunodeficiency Virus transmission, mortality and loss to follow-up among infants in the first 18 months of life in a prevention of mother-to-child transmission programme in an urban hospital in KwaZulu-Natal, South Africa.

BMC Pediatr 2012 Sep 10;12:146. Epub 2012 Sep 10.

Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa.

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Background: Follow up of Human Immunodeficiency Virus (HIV)-exposed infants is an important component of Prevention of Mother-to-Child Transmission (PMTCT) programmes in order to ascertain infant outcomes post delivery. We determined HIV transmission, mortality and loss to follow-up (LTFU) of HIV-exposed infants attending a postnatal clinic in an urban hospital in Durban, South Africa.

Methods: We conducted a retrospective cohort study of infants born to women in the PMTCT programme at McCord Hospital, where mothers paid a fee for service. Data were abstracted from patient records for live-born infants delivered between 1 May 2008 and 31 May 2009. The infants' LTFU status and age was based on the date of the last visit. HIV transmission was calculated as a proportion of infants followed and tested at six weeks. Mortality rates were analyzed using Kaplan-Meier (K-M), with censoring on 15 January 2010, LTFU or death.

Results: Of 260 infants, 155 (59.6%) remained in care at McCord beyond 28 weeks: one died at < 28 days, three died between one to six months; 34 were LTFU within seven days, 60 were LTFU by six months. K-M mortality rate: 1.7% at six months (95% confidence interval (CI): 0.6% to 4.3%). Of 220 (83%) infants tested for HIV at six weeks, six (2.7%, 95% CI: 1.1% to 5.8%) were HIV-infected. In Cox regression analysis, late antenatal attendance (≥ 28 weeks gestation) relative to attending in the first trimester was a predictor for infant LTFU (adjusted hazards ratio = 2.3; 95% CI: 1.0 to 5.1; p = 0.044).

Conclusion: This urban PMTCT programme achieved low transmission rates at six weeks, but LTFU in the first six months limited our ability to examine HIV transmission up to 18 months and determinants of mortality. The LTFU of infants born to women who attended antenatal care at 28 weeks gestation or later emphasizes the need to identify late antenatal attendees for follow up care to educate and support them regarding the importance of follow up care for themselves and their infants.
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http://dx.doi.org/10.1186/1471-2431-12-146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468389PMC
September 2012
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