Contraception for young girls living with HIV: barriers and facilitators to service provision in western Kenya

Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: a qualitative assessment of providers' perceptions in western Kenya.

Hagey JM, Akama E, Ayieko J, Bukusi EA, Cohen CR, Patel RC. J Int AIDS Soc. 2015 Sep 16;18(1):20123. doi: 10.7448/IAS.18.1.20123. eCollection 2015.

Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.

Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.

Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.

Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

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Editor’s notes: The article offers a clear picture of barriers and facilitators to access and uptake of contraceptive services for young girls living with HIV. It provides valuable evidence of providers’ views regarding integrated HIV and contraceptive services. The study was carried out with HIV care providers in different areas of western Kenya. The authors found that young girls find it difficult to access services, especially on their own, for fear of being seen as sexually active and/or promiscuous. Parental presence during consultations in HIV services can be a barrier to requesting contraceptives. But some parents are supportive and wish to prevent unintended pregnancies for their daughters. Young girls living with HIV might find it challenging to manage questions from their peers about their HIV medication and contraceptives. Providers’ themselves prioritise abstinence and condoms over offering hormonal contraceptives. Providers can feel protective towards the patients, whom they may see as ‘children’. The authors suggest that further involvement of parents, young boys and male partners can facilitate uptake of contraceptives for young girls living with HIV. The integration of HIV and contraceptive services for young girls can provide a crucial platform to reduce sexually transmitted infections, unintended pregnancies and vertical HIV transmission.

Africa
Kenya
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