In This Issue:

New Study Examines Integrated Family Planning and HIV Services in Western Kenya

New Publications

Staff Updates

Dear Friend,

I am excited to share details about one of Ibis’s newest projects with which I’m thrilled to be involved. Along with colleagues at the University of California, San Francisco and the Kenya Medical Research Institute, Ibis has been working for three years on improving family planning services for women in western Kenya who are HIV-positive or at risk of infection. We are now about to launch a trial that will evaluate a new model of integrating family planning counseling and provision into the care at HIV treatment facilities. This project exemplifies Ibis’s commitment to a vision of comprehensive reproductive health care which addresses all of women’s needs and enables reproductive autonomy.

We are also pleased to share our newest publications, which include several blog posts related to US health care reform as well as peer-reviewed articles.

All of us at Ibis thank you for your continued interest in and support of our work.


Dr. Daniel Grossman, Senior Associate

New Study Examines Integrated Family Planning and HIV Services in Western Kenya

Women in sub-Saharan Africa bear a significant burden in the HIV epidemic: two-thirds of those living with HIV/AIDS live in the region, and an estimated 60% of those infected are women. Evidence is building that the reproductive health needs of many HIV-infected women are unmet, one result of which is high rates of unintended pregnancy. Though largely preventable, mother-to-child transmission of HIV and maternal death increase when women do not have adequate access to reproductive health services.  

One potential way to better meet the full range of health needs for women who are HIV-positive or who are at risk of infection is to offer family planning and HIV services in one facility. For many HIV-positive women, contraceptive access is limited because they are required to visit two different clinics, which requires additional resources in time and travel.

A growing number of stakeholders are advocating for integrated services; however, little evidence exists to confirm that this model is effective, feasible, and acceptable to women. Ibis Reproductive Health has collaborated with the University of California, San Francisco (UCSF) and the Kenya Medical Research Institute since 2007 on a pilot project focused on answering such questions about integrating family planning and HIV services. So far, the research team has completed an assessment of the barriers to providing integrated services, interviews with clinic staff, and surveys of the family planning knowledge, attitudes, and practices of clients at HIV clinics, as well as their interest in obtaining family planning services at an HIV clinic. The team is now building on that work with a new phase of the project that will evaluate a model for offering family planning services at HIV care and treatment facilities and for training staff at 18 clinics in Nyanza Province, Kenya.

The study, which is designed as a cluster randomized trial, will compare the contraceptive prevalence and unintended pregnancy rates between 12 integrated sites and six control sites, where women are referred to family planning services and which has been the standard model of care. The research team will also collect data on the costs of family planning provision in both models. In addition, interviews will be conducted with clients and staff at the clinics about knowledge, attitudes, and practices related to family planning, as well as the acceptability and feasibility of providing services in the integrated model. The study will begin in the coming weeks with the implementation of a training curriculum on contraceptive counseling and provision for community health workers and clinicians at the study sites. The training will address family planning counseling, method provision, and contraception follow up.

Documenting the outcomes of the integration of services will inform follow-up activities, which may include attempts to increase the use of this model throughout the region. The research team plans to engage with policymakers in Kenya to ensure that effective models of integration can be implemented beyond the study sites. The training materials will be shared so that public sector facilities can continue training on a widespread basis. Ibis is committed to projects such as this which demonstrate that a comprehensive approach to services makes them more accessible to women, and better meets all of their health needs.

The formative work for this project has been supported by the Tides Africa Fund over the past 18 months, and UCSF was recently awarded a grant for three years from the Bill & Melinda Gates Foundation to carry out the cluster randomized trial; Ibis is a subgrantee on both awards.

Photo: Dan Grossman (far left) trains HIV service providers on IUD insertion.

New Publications

In addition to three new peer-reviewed publications (described below), Ibis’s work has been featured in the blogosphere. In December, RH Reality Check posted blogs from Ibis President Kelly Blanchard and Project Manager Amanda Dennis, both members of the study team that conducted research to highlight issues of access to contraception for low-income women in Massachusetts after health care reform. Though the research identified many positive outcomes, including evidence that many more low-income women have access to preventive and reproductive health care services, challenges were also discovered. Blanchard and Dennis pose the question of whether low-income women can be counted as insured when they can’t afford and access care, even with insurance, and enumerate the new challenges to contraceptive access that have arisen as a result of health care reform in the Commonwealth, including inconvenient prescription requirements, women being moved on and off the plans, difficulty of proving eligibility, and confusing plan information that both providers and patients have trouble deciphering. All of these findings are important lessons that should be taken into consideration as national health care reform legislation is crafted and considered and as other states look to overhaul their own health systems.

In January, Ibis Senior Associate Dan Grossman and colleagues from Princeton and UCSF examined data about out-of-pocket health expenses by the uninsured in a post on the blog for Health Affairs, a health policy journal. The data help to demonstrate the burden of cost that could result if proposed restrictions to abortion coverage are made into law through health care reform in the US. The analysis shows that out-of-pocket costs are higher for young, uninsured women than for young, uninsured men. The average cost for first-trimester abortion is about double, and second-trimester abortions cost almost four times, the current average out-of-pocket expenditures for young, uninsured individuals. Excluding abortion coverage from health care reform not only places an unfair financial load on women, but it betrays the goals of health care reform to equalize access and reduce barriers to care.

New peer-reviewed publications:

Grossman D, Fernández L, Hopkins K, Amastae J, Potter JE. Perceptions of the safety of oral contraceptives among a predominantly Latina population in Texas. Contraception. March 2010; 81(3):254–260.
For this study, we aimed to examine women’s perceptions about the safety of hormonal contraception, including how medically accurate their concerns were. Information about women’s self-assessment regarding the safety of using oral contraceptives (OCs) was collected from 1271 women 18-49 years old in El Paso, TX, and their responses were compared to a medical evaluation by a nurse practitioner. The study team also asked participants about their interest in obtaining OCs over the counter (OTC). Among 794 women potentially at risk of unintended pregnancy, 56.0% said that OCs were medically safe for them. Reasons given for OCs being unsafe were related to fears of side effects and prior negative experiences rather than true contraindications. Older women and participants recruited at the less affluent recruitment site were significantly more likely to report that OCs were medically unsafe for them (p<.05). Nonusers who thought OCs were medically unsafe for them were as likely to be medically eligible for use as current hormonal users. Among nonusers or nonhormonal users and potential OC candidates (n=601), 60.2% said they would be more likely to use OCs if they were available OTC. Results of the study show that women's perception of OC safety does not correlate well with medical eligibility for use. More education about the safety and health benefits of hormonal contraception is needed. OTC availability might contribute to more positive safety perceptions of OCs compared to a prescription environment.

Montgomery ET, Blanchard K, Cheng H, Chipato T, Bruyn G, Ramjee G, Padian N, van der Straten A. Diaphragm and lubricant gel acceptance, skills and patterns of use among women in an effectiveness trial in Southern Africa. The European Journal of Contraception & Reproductive Health Care. December 2009; 14(6):410-419.
This paper examines the diaphragm and gel-related skills, patterns of use, and problems among women who participated in the Methods for Improving Reproductive Health in Africa (MIRA) diaphragm study. This sub-study to MIRA looked at whether any characteristics of participants were associated with the ability to correctly insert/remove the diaphragm before participating. The results of the study showed that fully 72.5% of women correctly inserted/removed the diaphragm within one attempt; the only characteristic associated with this ability was being from the Johannesburg site, rather than other sites in South Africa and Zimbabwe. At the end of the MIRA trial, over 90% of women were very comfortable inserting, wearing, cleaning, and removing the diaphragm. However, 31.8% of participants reported that they often removed of the diaphragm before the prescribed six hours after sex. During the 12–24 month follow-up period there were only 133 (<1%) reported problems with the diaphragm and gel in over 14,544 follow-up visits. The results of this study demonstrate that diaphragm skills were easily acquired and few problems were reported during the course of the trial. Though it is ineffective as a method of HIV prevention, reviving the diaphragm as a contraceptive option or as a reusable microbicide delivery mechanism seems feasible in these settings.

Lara D, Grossman D, Munoz J, Rosario S, Gomez B, Garcia S. Acceptability and use of the female condom and diaphragm among sex workers in Dominican Republic: Results from a prospective study. AIDS Education and Prevention. December 2009; 21(6):538-551.
The study was conducted among a population of 243 female sex workers in Puerto Plata and Santiago, Dominican Republic. Women were followed for five months, and at each visit received 30 male and female condoms and a diaphragm, along with counseling about each method. Participants reported higher acceptability and use of the female condom than the diaphragm. Seventy-six percent reported use of the female condom at least once during the final month of the study, compared with 50% that used the diaphragm with male condoms and 9% that used the diaphragm alone. The proportion of women reporting every sex act protected with some barrier method increased from 66% during the first month to 77% after the final month. The introduction of female-controlled barrier methods resulted in the use of a wide range of prevention methods and a significant reduction in unprotected sex.

Staff Updates

In December, Mthokozisi Radebe, a project manager who had been employed at Ibis since 2006, left to pursue a degree in design. Mthoko, who was based in our Johannesburg office, contributed to projects like the MIRA diaphragm trial and collaborative research with UCSF assessing providers’ views on female-controlled HIV prevention methods in South Africa and the US. Mthoko’s enthusiasm for and dedication to Ibis’s work, along with his sunny disposition and humor, made him a joy to work with. Ibis staff around the world will miss Mthoko and wish him well in his new pursuit!