Integrated HIV and maternal/reproductive health service utilization: trajectory for prevention of mother to child transmission of HIV in Zimbabwe
Thesis or dissertation
- © 2018 Marufu Gazimbi. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.
Background: The persistent high mortality related to HIV infection in sub-Saharan Africa has prompted calls for scaling-up access to sexual and reproductive health services including family planning as a trajectory to prevent HIV infection. Thus, HIV prevention programs have been integrated into family planning and reproductive health care services as a means to reach out to men and women who are HIV positive and those who are vulnerable to HIV infection. While the rationale for integration of HIV and reproductive health (RH) services is strong, there is paucity of information on which population groups most utilize these services. Due to the considerable stigma attached to HIV/AIDS, people living with HIV and those who perceive themselves to be at risk of HIV infection may be less likely to use integrated health care services. This thesis aims to inform policy and programs on better integration of HIV testing, maternal health care, and family planning services in order to optimize HIV prevention programs such as prevention of mother to child HIV transmission and condom use with the broader aim to reduce the HIV pandemic.
Objectives: Focusing on individual and community-level predisposing, enabling and perceived need factors (PREP), the specific objectives of the study are to: (i) examine the effects of HIV on reproductive health care services; (ii) identify the determinants of HIV testing, antenatal and delivery care services; (iii) examine contraceptive methods choice among women who know their HIV-sero status; and (iv) establish community-level variation in service utilization.
Data and Methods: The study applied multilevel binary and multinomial logistic regression models to nationally-representative samples of women and men who participated in the 2005/6 and 2010/11 Zimbabwe Demographic and Health Surveys.
Results: Overall, those who were ever tested for HIV and with low HIV stigma were more likely to use maternal health services than their counterparts who had never been tested or with high HIV stigma. These groups were also more likely to use condoms and long-term contraceptive methods as a means to prevent both unwanted pregnancies and HIV infection. The results from the analysis of HIV testing showed an evidence of improvement in HIV testing uptake between 2005/6 and 2010/11, especially for women. Most individual level socio-economic and demographic factors associated with HIV testing are largely consistent with patterns in Southern Africa (e.g higher uptake by women and those who are wealthier), but important patterns have also emerged. In particular, results reveal notable gender differences in the determinants of HIV testing: rural residence is associated with lower uptake of HIV testing for women but higher for men; for women, average wealth in a community is a more important factor in enabling HIV testing than household wealth, but the converse is true for men; individual-level, rather than community-level stigma is important for women, while for men, it is community-level stigma that is important.
The analysis of determinants of maternal health care shows that use of antenatal and delivery care services in Zimbabwe are improving and are determined by a wide range of individual-level factors relating to women’s economic and demographic status as well as HIV factors relating to stigma, HIV awareness, ever been tested for HIV during pregnancy, knowing someone who died due to HIV, and factors relating to availability and access to health care and media within the community. The individual-level enabling factors that were particularly strong for women included high socio-economic status and not having observed HIV stigmatisation and discrimination. These groups of individuals have an extremely high likelihood of having been ever tested for HIV during pregnancy, or having an early or more than four ANC visits; and have delivered their babies in a health institution with a professional delivery attendant, particularly if they live in richer communities or in communities with low stigma and HIV prevalence.
The analysis of determinants of contraceptive methods choice among women who know their HIV status identified a number of potential pathways of the determinants of this outcome. The analysis revealed that women who know their HIV-positive status were more likely to use condoms and long-term methods than those who know their HIV-negative status. The study also revealed that even though wealth status has no direct effect on the choice of contraceptive methods, it has an indirect impact on the choice of condom versus hormonal methods through intermediate factors such as HIV sero-status.
Conclusions: First, the observed gender disparities in determinants of HIV testing calls for a gender specific response. Couple-oriented HIV counselling and testing services where men accompany their spouses to HIV screening during pregnancy may help increase HIV testing uptake for males and reduce gender disparities. Second, the fact that enabling factors such as socioeconomic status, having been tested for HIV as part of ANC and stigmatization are predictors of maternal health care utilization suggests that being wealthier, having been HIV tested during pregnancy; and having low HIV stigma do translate into expected behavior for pregnant women. Third, knowing own HIV status emerges as a major predictor of condom use and long-term contraceptive methods for women who are HIV positive. These findings have important policy and integrated programme implications for addressing unmet need for HIV and RH services in Zimbabwe.
- School of Social Sciences, The University of Hull
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