First established in 1986, the Rwanda Zambia HIV Research Group (RZHRG) operates 10 freestanding couples voluntary counseling and testing (CVCT) clinics and 3 clinical research centers in two countries in Africa: Project San Francisco (PSF) in Kigali, Rwanda, and the Zambia Emory HIV Research Project (ZEHRP) in Lusaka and Ndola, Zambia. This study was carried out at the Lusaka, Zambia, research site. Couples received joint, same-day HIV counseling and testing at the CVCT clinics using standardized procedures, including extensive condom counseling and condom skills training (www.cdc.gov/globalaids/resources/prevention/chct.html
CVCT is an intervention with proven efficacy in reducing HIV incidence among high-risk populations, namely, heterosexual couples in the African setting.13–17
Influence network agents (INAs) from the health, religious, nongovernmental, and private sectors were trained to invite couples for CVCT.18
Previous analysis of the cohort shows that male positive, female negative couples were more likely to enroll than male negative, female positive couples.19
More detailed information about CVCT recruitment strategy and procedures, HIV results, and demographic characteristics of RZHRG study participants have been published elsewhere.18–23
The data analyzed come from a cohort of couples from Zambia enrolled in Family Planning in Couples with HIV (FP), a randomized controlled trial (RCT) investigating two different video-based family planning interventions with the goal of reducing fertility in concordant HIV-positive and HIV-discordant couples. The FP interventions provided information on family planning, contraceptive methods, and future planning behaviors (including help in preparing a will and appointing guardians for existing children) to encourage contraceptive adoption among serodiscordant and concordant positive couples. Eligibility criteria for couples included cohabiting for at least 12 months, planning to stay in Lusaka for at least 1 year from the date of enrollment, and age 18–45 for women and 18–65 for men. For the FP study, both serodiscordant and concordant HIV-positive couples were eligible. Additional eligibility criteria for the FP study included no evidence of infertility and no medical contraindications to contraception. The couples were not selected based on their receptivity to family planning, although we cannot ascertain the extent to which desire to use family planning created a self-selection bias. Enrollment included medical history, physical examination, and demographic and knowledge, attitudes and practice (KAP) questionnaires. One to two weeks later, couples returned for randomization, during which behavioral interventions targeting family planning behaviors were administered. This article presents results from cross-sectional data collected at the randomization visit, examining the uptake of contraceptive use across the four study arms.
Before enrollment into the FP study, couples underwent a video-based informed consent process, detailing the scope of the study, a brief description of the contraceptive methods available at the project, their expected participation as well as issues of confidentiality, participant protection, and voluntary nature of the participation. Approval for the studies was granted by the Emory University Institutional Review Board and the University of Zambia Research Ethics Committee. After completing the informed consent process, couples completed a baseline questionnaire, which included information on previous and current contraceptive use. Couples in the FP study were then randomized to one of the four study arms in a factorial design with independent randomization to two video-based interventions: information on contraceptive methods with an emphasis on intrauterine device (IUD) and implant (although all other methods of family planning were also discussed) (methods group), a motivational video modeling desirable future planning behaviors, including will preparation, financial planning, and pregnancy prevention (motivational group), or both groups. There were thus four groups: control, methods only, motivational only, and methods and motivational. The content of the videos was based on the known efficacy of contraceptive methods, starting with the most effective long-acting methods (IUD, implant, tubal ligation) followed by injectables, OCPs, and finally condoms. (Condom use had been discussed extensively during the first couples' testing session 1–2 weeks before enrollment in the RCT.) This represented a reversal of the usual hierarchy of FP messages, which typically begin with condoms, followed by OCPs, injectables, and so on. The aim of the intervention was to promote long-term method use; hence, these methods were explained first in an attempt to focus the audience's attention on them.
Control videos with educational messages about handwashing, bednet use, and good nutrition were used to balance the time spent in each of the four intervention arms. The control group was treated as a compassionate care group, in that they still had access to family planning services at the clinic site, but the videos they watched did not address contraceptives or family planning. The provision of family planning services to the control group avoided ethical problems of withholding services to groups who may be in need. However, previous work at this study site with these cohorts has shown that although providing family planning services on-site leads to their use, high rates of attrition occur without continued support and counseling of these couples.24
Each of the videos was approximately 30 minutes long and was presented in the local language (Bemba or Nyanja depending on the group). In addition to descriptions of the contraceptive methods, the videos also detailed their known side effects in an attempt to address health concerns over contraceptive use. The videos were presented to couples in groups, after which a counselor was available to answer any questions arising from the videos. After receiving the intervention, couples were given the option to initiate, add, or switch contraceptive methods. Couples were offered a choice of OCPs, injectable contraceptives, the Norplant implant, a nonhormonal copper IUD, emergency contraception, and surgical sterilization for either partner (tubal ligation or vasectomy). OCPs, injectables, IUD, and implant were provided at the research clinic, and those who chose surgical sterilization were given an appointment with a study physician (BV) at the University Teaching Hospital. All methods were offered free of charge.
Data were collected by trained counselors at the CVCT centers. Completed data forms were scanned daily on-site with TeleForm software, and data were then transferred into Microsoft Access databases. These databases were uploaded to RZHRG servers on a weekly basis, facilitating the transfer of data to the research headquarters in Atlanta, Georgia. Statistical analyses were performed using SAS software, version 9.1. In total, 1502 couples were randomized into the FP study, including 324 baseline contraceptive users and 1178 nonusers. In the current analysis, we are concerned with the adoption of contraception only. For this reason, we categorize couples who are relying on condoms for pregnancy prevention with no contraception, given the known lower effectiveness of condoms for pregnancy prevention. Thus, the no contraception/condoms only category refers only to condoms used for pregnancy prevention. Couples in all other categories of contraceptive use also have high levels of condom use for HIV prevention. The analysis thus looks at the factors associated with contraceptive use in addition to the high levels of condom use that already exist in the cohort.
Method use before and after the intervention is presented by intervention arm for the group as a whole and separately for the 324 baseline users. A multivariate analysis of predictors of contraceptive uptake in baseline nonusers models a categorical outcome: OCPs (referent), injectables, IUD, Norplant, and tubal ligation. This categorical variable conceptualizes contraceptive methods as least effective temporary (OCPs), more effective temporary (injectables), and longer-term (IUD, Norplant, and tubal ligation). The model controls for couple HIV status (concordant positive or serodiscordant), household income, English language ability, number of living children, male desire for more children, and health concerns around contraception. Initial analysis showed that no nulliparous couples were either using contraception at baseline or adopted contraception after the intervention. In pronatalist settings, such findings are not unusual; we thus limit our sample size to couples who are at risk of adopting contraception. The final sample size for the multivariate analysis is thus 957, with at least one living child, who chose to adopt a method of contraception after the intervention.