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Workshop for a Research Agenda for Family Planning in the Era of AIDS

Nairobi, Kenya, 2-4 October 1996
organized by the IUSSP Committee on Fertility and Family Planning and
the IUSSP Committee on AIDS


Two of the union’s scientific committees joined forces to organize an innovative workshop dealing with the research issues arising from the problems faced by Family Planning (FP) programmes operating in populations with a high prevalence of HIV. This workshop departed from the usual format of conferences and seminars organized by IUSSP scientific committees, in that the main activity was not the presentation of academic papers - the field is so new, that there is little substantive research to report. The aim of this meeting was to formulate a realistic and relevant social science research agenda on the interface between family planning and HIV/STD prevention for east and southern Africa, where the matter is of particular urgency. The workshop started with background papers outlining the nature of the problems for the region as a whole, and a series of presentations about the situation in specific countries. But the aim of identifying a future research programme was achieved primarily through small group discussions focused on particular research themes, which were reported back to the group as a whole. The more developed research ideas were then elaborated into draft research protocols by committee members.

The idea of organizing such a workshop originated with John Cleland, a member of the IUSSP Fertility and Family Planning Committee, who was also responsible for all the planning stages. It was hosted by the Population Council office in Nairobi, and supported by the joint uN programme on HIV/AIDS and the WHO programme on Human Reproduction.

Problems described in the background papers and country presentations

Most participants were of the view that the primary obstacle facing FP programmes operating in areas with a high prevalence of HIV and other STDs was a lack of knowledge in the community about STDs, their transmission, symptoms and treatment. Peter Riwa, from Tanzania, reported that although STD prevalence rates are high, they are often asymptomatic, particularly in women. Various African studies have shown that about half of females suffering with chlamydia or gonorrhoea have no symptoms at all, another third may have a discharge but fail to recognize it. Even amongst those who have symptoms and recognize them, including males for whom symptoms can be very painful, a large proportion do not seek appropriate treatment, a point which was reinforced in some of the country presentations - for example, Masauso Nzima claimed that in Zambia, many people believed that STDs are caused by witchcraft, and that remedies are sought principally from traditional healers. In his background paper, James Ntozi stressed that the protective role of condoms is not fully understood, and Evazius Bauni from Kenya emphasised that a knowledge of what constitutes 'safe sex' does not necessarily lead to its practice.

Another important problem at the individual level, emphasised by many presenters, was the negative attitude to condoms. Florence Ebanyat, from uganda, spoke about the association of condoms with casual sex, and Ravai Marindo-Ranganai from Zimbabwe reported that the use of a condom was equivalent to a sign of mistrust in one’s sexual partner. Kofi Awusabo-Asare reported in his background paper, that there was a fairly widespread tolerance of male promiscuity, and this, combined with the low status of women, made it difficult for women to negotiate safe sex, especially with their regular sexual partners. In most African countries, this has led FP programmes to promote contraceptive methods which can be used by women without their partner’s knowledge or consent. In South Africa, for example, where contraceptive use is very high (over half of currently married women use a modern method), Eleanor Preston-Whyte reported an overwhelming reliance on pills and injectables, with less than 1% using condoms. But in most countries of this region high fertility norms still predominate, and even those who know or suspect that they are HIV positive may want to have children, or may feel under pressure from their partner or extended family to do so, as reported by Yusuf Ahmad from Zambia.

Individual attitudes to condoms and to the promotion of 'safe sex' practices are echoed in the attitudes of institutions. In uganda, Stella Neema reported that the opposition of the Catholic Church was preventing the wider adoption of condoms for FP and for STD protection, and inhibiting the spread of sex education in schools. M.T. Leshabari from Tanzania reported that health policy makers feared that the respectability of the FP programme, which was supposed to be aimed at responsible married couples, might be compromised if it was also seen as a provider of STD protection.

Within existing FP programmes the attitudes of service providers may constitute a barrier to the effective integration of STD and contraceptive services. John Cleland explained that FP workers may feel inhibited about discussing their client’s sexual behaviour, which would be a necessary part of counselling about appropriate contraceptive methods. Staff would have to be prepared to take on an extra burden of work, if they were called upon to provide treatment for STDs. They may also have legitimate concerns for their own health, and feel at risk if called upon to do genital examinations. Training in diagnostic procedures would have to be provided to FP workers, and Mike Mbivzo from Zimbabwe highlighted the need to develop new referral systems and ensure the provision of appropriate drugs in FP clinics. In some countries legislation would be needed to allow FP staff to prescribe the antibiotics used in treating STDs. In places such as Tanzania, where contraceptive prevalence was low, Peter Riwa pointed out that STD treatment services provided through FP clinics would only reach a very small proportion of the population, and that alternative service channels would in any case be needed to look after the needs of men and adolescents.

The last set of problems identified in the meeting, pertained to heightened risks of HIV transmission in the face of contraceptive use. These ranged from suspicions about the effects of progesterone only contraceptives which may affect the vaginal mucus in such a way as to facilitate the transmission of the virus (as reported by James McIntyre from South Africa), to the well documented tendency of IuDs to encourage the spread of vaginal infections into the cervix. Basia Zaba emphasised that the most widespread traditional form of fertility control in Africa, post partum abstinence, over the course of a woman’s lifetime, could reduce the time period of exposure to the risk of HIV infection by several years - if this traditional form of child spacing is replaced by hormonal contraception, the period of exposure to risk is increased. Whether overall risk of infection is increased depends critically on the behaviour of male partners during and after the post partum period.

Research issues identified in the seminar

There is a need for simple situation analyses at national level in many countries. These background studies should focus on collecting information about the prevalence of HIV and other STDs, estimating rates of contraceptive use, and describing the characteristics of users and the distribution of methods at their disposal. Information about the structure and functioning of family planning and STD/HIV control programmes is also needed. Such data would mainly be gathered from an analysis of secondary data sources. Identification of locally available sources of information, and compilation of bibliographies describing the relevant documents would serve as a useful preparation for many other research topics. Case studies of successful integrated programmes are also needed.

Perhaps the most important research area identified in the seminar was probing into the attitudes of individuals to sexual activity, disease risk and contraception. Areas of interest include sexual negotiation, attitudes to risk taking and the perception of risk, and how these differ when it comes to pregnancy risk and risk of infection. Investigations are needed into how the availability of contraception influences sexual behaviour, and into attitudes to various types of contraceptive methods in different sexual relationships. It was felt that such studies should focus on couples, not just men and women separately. Investigation of attitudes to sexual activity will mean interviewing people in the community, and getting meaningful answers to sensitive questions on personal topics will involve in-depth interviews. The challenge here is to design an enquiry that will ensure that the in-depth interviews are in some way representative of a broad range of sexually active adults, both users and non-users of FP, and both those whose behaviour (or whose partners’ behaviour) places them at high risk of contracting an STD, and those at low risk.

A two-stage study design, borrowing certain methods from epidemiological 'case-control' studies was proposed as one way of achieving such a distribution of in-depth interviews. A community based sample survey using structured questionnaires could be used to find out about FP use, marital status, childbearing intentions, knowledge about STDs and some limited information on sexual behaviour in a recent reference period. The results of such a survey could then be used to select a limited number of individuals for further questioning, the selection this time being purposive, with some attempt to match individuals ('cases') whose behaviour places them in a high risk category with respect to STD infection with those at low risk of STD infection ('controls') with respect to other variables, such as use/non-use of FP; desire for children; rural/urban residence etc.

Another important research area which was discussed in some detail was service provision. The field of enquiry covered in this section includes provider-client interaction, the beliefs and attitudes of service providers, and the cost effectiveness of expanding family planning services to provide STD treatment and counselling about STD risks. The workshop participants felt that investigations could be undertaken into the extent of the service providers' knowledge of STD/HIV transmission risks, and their perceptions of how they could question their clients about sexual activity which put them at risk. This could be done by organising group discussions at FP clinics, structured surveys and in-depth interviews with clinic staff. The attitudes of service providers to the extra workload implied by providing STD diagnosis, referral and/or treatment on top of the normal FP advice and services could also be investigated using these approaches. Service providers should also be consulted about changes to the physical infrastructure of clinics which would be needed if they were to expand the range of services provided.

It was also proposed that research be carried out at facilities into the attitudes of clients to an increase in the range of services or counselling available through FP clinics. Surveys and in-depth interviews could be used to see if current users of FP services would find it acceptable if during FP consultations they were asked the sort of questions about their own sexual activities and those of their partners, which would be necessary to determine their risk status and ensure appropriate FP method recommendation. In order to find out how much educational work FP staff would have to do, it would also be necessary to find out how aware clients already were of their degree of risk exposure to STD infection. Similar client interviews should also be conducted amongst STD clinic attendees, to see how they would respond to the possibility of obtaining diagnoses and treatment services through FP outlets.

under the broad heading of policy analysis it was recommended that research should be carried out into conflicts of interest between government departments and ministries in organising collaborative or integrated programmes, and examining the policy perspectives of donors, non-governmental organisations, pressure groups and local institutions. These investigations should establish the attitudes of key actors in government ministries, donor agencies and the private sector, and attempt to identify the factors which constrain policy in the general field of reproductive health. Financial data is needed on the implementation and running costs of different modes of delivering FP and STD services. Information is also needed on the nature, quality and accessibility of services currently provided, with a view to identifying which components of FP and STD services could be integrated. Existing policies in related areas should be scrutinised to examine their impacts on reproductive health service provision. This would include investigating legal or administrative limits set on client group membership, drug prescription regulations and priority drug lists, taxation and regulation of imports. Policy research should also focus on the process of policy development and implementation, the context in which policies are made, and the actors who influence policy. It is essential to recognize and document the links and conflicts between external donors and policy makers on the one hand, and health service managers and providers on the other.

Research is also needed into the effect of known HIV status on reproductive behaviour, with the aim of investigating the desire of HIV infected persons to have children and their concerns for protecting their partners from becoming infected. This will entail an understanding of attitudes to childbearing in whole communities affected by HIV, and ascertaining appropriate forms of counselling for aspiring mothers and for those who are pregnant or breastfeeding. Although it is acknowledged that only a small proportion of those infected with HIV may be aware of their status, understanding the behaviour of those who know themselves to be infected is important for several reasons. Some of these people will have taken a blood test, and the ethics of testing dictate that counselling should be provided - effective counselling will depend on a knowledge of the problems faced by these individuals. Others will suspect that they are HIV positive because their sexual partners may have died from AIDS or be suffering from HIV related illness - their behaviour may hold the key to the spread of the epidemic, and may influence future behaviour change in the wider community. Finally, special research efforts will be needed into the needs of under-served populations. Those identified in the workshop included adolescents, males, refugees and migrants. In some cases, the techniques for community based surveys could be adapted to collect information from these groups, though in the case of refugees and migrants rapid appraisal techniques might be more appropriate if they are not living in settled communities. Research amongst adolescents will be more difficult - they cannot or do not use FP and STD services openly, and so they will be missed by research centred on service outlets. Their experience of sexual activity will be rather limited, so that many of the questions in a community based survey addressed to sexually active adults - including marital history, partner networks and knowledge of FP - they will find irrelevant or difficult to answer. In addition, research on adolescents requires interviewers and facilitators of the same age group. Experience in Tanzania, for example, has shown that peers can obtain much more reliable information than older interviewers. Among the methods that have been successful in stimulating the discussion of matters such as sexual health and pregnancy is the narrative research method, in which workshops are held during which young people develop their own range of stories about sexual negotiation, pregnancy risks, etc., perform these role plays, and discuss them.


The full report on this workshop, "Family Planning in the Era of AIDS: A Social Science Research Agenda", written by Basia Zaba, Ties Boerma and Tanya Marchant, is available from IUSSP. The report includes detailed protocols for research projects covering two of the topics discussed at the workshop: the community based surveys into individual and couple attitudes, and facility based surveys into attitudes of service providers. These research proposals have recently been reviewed by the uNDP/ uNFPA / WHO / World Bank Special Programme of Research, Development and Research Training in Human Reproduction, and funding has been agreed for a multi-country study based on the protocols, planned to start in the second half of 1997.

Basia Zaba