Dual Needs: Contraceptive and Sexually Transmitted Infection Protection in Lusaka, Zambia

Article excerpt

CONTEXT: Lusaka, Zambia, has both a high prevalence of HIV infection and relatively high contraceptive prevalence for Sub-Saharan Africa. In this context, family planning clinics have the potential to play an important role in the prevention of HIV and other sexually transmitted infections (STIs).

METHODS: Data from a 1998 situation analysis of eight public-sector family planning clinics in Lusaka are used to measure the readiness of these clinics to provide STI prevention and diagnostic services. Observations of 2,452 client-provider interactions and data from interviews with 42 providers and 3,201 clients are used to look at the exchange of information on nonbarrier methods' inability to protect against STIs. Finally, multivariate analysis is used to investigate the determinants of both having received that information and having retained it among users of methods other than the condom.

RESULTS: Multivariate results indicate that clients who did not use condoms who were told that their method offers no protection against STIs had three times the odds of knowing this at their exit interview as did women who were not told that fact. Among clients who were informed by their provider, those with higher educational attainment, those whose providers had fewer years of schooling, and those attending smaller clinics were all more likely than other women to have correctly "received" the STI prevention message.

CONCLUSIONS: Although efforts are being made to integrate STI services into family planning clinics in Zambia, these efforts need reinforcement. The educational levels of both providers and their clients may be barriers to a successful transfer of STI prevention in formation during client-provider interactions.

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A reproductive health approach to family planning service delivery takes a comprehensive view of individuals' circumstances and moves beyond their contraceptive needs alone. In an environment with high rates of HIV and other sexually transmitted infections (STIs), * a reproductive health approach must therefore include some degree of integration of STI services with traditional family planning services.

Before the 1994 International Conference on Population and Development in Cairo, the demographic emphasis in family planning strategies resulted in a focus on effective contraceptive methods. This focus often precluded barrier methods, which were considered less likely to be used consistently and correctly, and therefore less effective in pregnancy prevention. Although family planning services clearly provide contraceptive protection to clients, STI prevention through the use of condoms has received less attention. The dual-protection message--i.e., the promotion of the simultaneous use of two methods (the condom along with another method) or promotion of condoms alone for both pregnancy and STI prevention--needs to overcome some aspects of traditional family planning messages and providers' negative bias toward nonmedical methods.

Providing information on ways to protect against both unwanted pregnancy and STIs during a family planning consultation is an obvious first step toward integrating STI and family planning services. Integrating STI case management, however, is not as feasible as providing information alone, as these special services require additional infrastructure and provider training, which may overburden relatively new family planning programs. (1) Furthermore, because laboratory facilities are rarely available in resource-poor settings, STI diagnosis often relies on the syndromic approach, which has generally shown weak sensitivity and specificity for many STIs among women, particularly cervical infections. (2) Nevertheless, few would disagree that, at a minimum, the integration of primary STI prevention into family planning programs is a feasible and desirable goal. (3)

Providing a dual-protection message is especially relevant in Zambia, where the HIV prevalence rate is among the highest in Sub-Saharan Africa. …