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Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population. Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services – supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers’ perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis. Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services. Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.
We administered a facility-level questionnaire between July and August 2014 to assess contraceptive service provision at 21 facilities supported by Family AIDS Care & Education Services (FACES), a collaboration between the University of California, San Francisco and the Kenya Medical Research Institute [22]. These facilities ranged from county and sub-county hospitals to dispensaries (Supplementary file 1 [23–25]). Facilities were located in Homabay, Kisumu and Migori counties in western Kenya with 27.1, 18.7 and 13.4% prevalence of HIV, respectively, the highest prevalence in Kenya [26]. Providers at these facilities provide comprehensive HIV and primary healthcare services, including contraception. The facility-level questionnaire was administered to a convenience sample of one to three health providers at each facility. The lead investigator, JMH, along with Kenyan FACES staff members, visited each facility during clinic hours, and the nurses in-charge introduced us to the HIV providers involved in contraceptive service provision at their facilities. Approximately, half of these providers further specialized in antenatal care and maternal health services. All of the health providers we approached agreed and provided written consent to participate in the study. The facility-level questionnaire included open- and closed-ended questions on provision of contraception education, counselling, commodities, referrals, provider training and clinic structure (Supplementary file 2). RCP and JMH led the questionnaire development with input from all co-authors. JMH administered the questionnaire and took field notes during the interviews. In addition, 77% of providers provided written consent to be audio recorded during the open-ended questions. All health providers were compensated for their time, equivalent to approximately US$8 (680 KSh). Content analysis was used to identify themes regarding barriers and facilitators for adolescent females living with HIV in obtaining contraceptive services. JMH and RCP independently conducted the initial coding of a sample of transcripts, and discrepancies in coding were resolved through discussion. Inductive codes were further developed as concepts emerged. Finally, codes were grouped to identify thematic trends and variant views. JMH and RCP with guidance from EA, JA and EAB organized these themes within an ecologic model [27,28]. Study data were transcribed using REDCap version 6.0, and all qualitative analyses were completed using NVivo version 10.1.1 [29,30]. The study was approved by the UCSF Committee on Human Research (CHR #13-12304) and the KEMRI Ethics Review Committee (SSC #2770).
