Lusaka is home to almost 2 million people [14
]. The HIV prevalence rate among pregnant women is 21% [15
], and the majority of women infected with HIV are of reproductive age. The Ministry of Health's ART program was established in 2004 and covers the entire city. Over 100,000 HIV-infected individuals in Lusaka are now receiving care in this system. Due to the large volumes of patients and human resource shortages [16
], peer educators conduct most ART counseling sessions. Prior to our intervention, neither routine family planning nor dual method counseling was provided during peer counseling sessions. To expand the scope and effectiveness of these counseling visits, we designed and implemented a reproductive health peer counselor program integrated within 16 primary care HIV clinics in Lusaka.
We trained 109 peer counselors to deliver a standardized counseling message, emphasizing dual methods. The counseling intervention was implemented within the context of routine clinical care. With the aid of a printed counseling tool, peer educators delivered a comprehensive reproductive health message, including information on the range of barrier methods, hormonal and intrauterine contraception, and permanent sterilization. Women who desired access to reproductive health services were referred to a separate, on-site family planning department. In order to support public-sector reproductive health service provision, we also trained 42 family planning nurses. Training was based on the national family planning curriculum and nurses who successfully completed both a classroom-based course and a mentored, clinical practicum-received certification. Public-sector family planning clinics provided condoms, oral contraceptive pills (OCPs), depot medroxyprogesterone acetate (DMPA), Jadelle levonorgestrel implants, and copper intrauterine devices (IUDs). Women who wished to undergo permanent sterilization were referred to a center with surgical facilities, such as the University Teaching Hospital.
Our analysis cohort included HIV-infected women aged 16–50 years and on ART at one of the 16 intervention clinics. To be eligible, a woman had to have at least one reproductive health counseling visit documented in her medical record between November 2009 and November 2010. We report baseline sociodemographic data, CD4+ cell count (cells/uL), hemoglobin level (g/dL), and history of tuberculosis. These data were ascertained through review of women's electronic medical and laboratory records. Laboratory results were assessed within 90 days of the woman's counseling visit. We also report use of modern contraception, including dual method use. Peer counselors collected data relating to reproductive health counseling and contraceptive use on a clinical form developed for the project. We considered condoms, OCPs, DMPA, Jadelle, IUDs, and sterilization as modern contraception. Dual method use was defined as use of condoms to prevent STIs coupled with use of a short- or long-term reversible contraceptive or sterilization. Contraceptive use data were self-reported.
Univariate and multivariate regression analyses were used to identify sociodemographic and other predictors independently associated with modern contraceptive and dual method use, as well as with access to family planning services within 90 days of a counseling visit. Crude odds ratios (ORs) and 95% confidence intervals (CIs) were computed using logistic regression models. Adjusted odds ratios (AORs) and their corresponding 95% CIs were generated using generalized estimating equations to account for clustering at the site level. All statistical analyses were performed using SAS version 9.1.3 (SAS Institute Inc, Cary, North Carolina). Ethical approval for this study was obtained from the University of Zambia Biomedical Research Ethics Committee (Lusaka, Zambia) and the University of Alabama at Birmingham Institutional Review Board (Birmingham, AL, USA).