1. Fertility intentions and family planning preferences among HIV- infected men in Nyanza Province, Kenya Rachel Steinfeld, Sara J, Newmann, Maricianah Onono, Craig R. Cohen, Elizabeth A. Bukusi, Daniel Grossman Rachel Steinfeld, MHS October 15, 2010

2. Nyanza, Kenya Map: http://www.kenya-advisor.com/images/kenya-map-provinces.jpg

3. Study Objectives Background for a cluster randomized trial To explore views expressed by HIV- infected men in Nyanza Province, Kenya o Fertility desires o Contraceptive needs and barriers o Attitudes about integration of FP services into HIV care and treatment programs

4. HIV & Unmet Need for Contraception Large unmet need for contraception among HIV+ women o Uganda: >90% ART clients’ pregnancies undesired 1 o South Africa: 84% PMTCT clients’ pregnancies undesired 2 Prevention of unintended pregnancy has implications for o Perinatal HIV transmission 3 o Maternal/neonatal morbidity & mortality 4 Nyanza Province, Kenya: o 16% HIV prevalence among women 5 o 15% HIV prevalence among men 5 1. Homsy, J. PLOS ONE 2009. 2. Rochat,TJ. JAMA 2006. 3. Renolds, HW. Sex Trans Dis 2006. 4. Brocklehurst, P. Br J Obstet Gynaecol 1998. 5. Kenya Demographic Health Survey 2008-09.

5. Fertility Preferences: Survey on Knowledge, Attitudes and Practices Data were presented at RH2010 conference by S.J.Newmann, Contraceptive use and receptivity to integration of family planning services into HIV care among HIV-infected men and women in Nyanza province, Kenya. N = 402

6. Methods 30 in-depth interviews o Men ≥18 years o Accessing HIV care at government health facilities Translation/transcription: 12 / 30 interviews Coding framework: based on emerging themes Coding/analysis: Atlas.ti 6 Grounded theory approach

7. Study Participants MedianRange Age (years)33.527 - 42 Number of living children4.00 -11 Percent Highest level of education - Primary73% Married96% Polygamous relationship31% Disclosed HIV status to partner85% Primary partner is HIV+90% Self-rated health status is fair or poor50% On ARVs or about to start73% Peri-urban / Commercial center21%

8. Fertility Intentions/Motivations Perinatal HIV transmission o “What is worrying is that if I get children now, I can’t tell if they will also get the virus” Inability to care for children financially o “…we have to educate the children, feed them and generally take good care of them…I am only able to take care of the ones I already have.” Deteriorating health o “…lately I have grown weak and sickling such that I am not able to work hard as before. It is even becoming difficult to provide for my family and because of that I no longer desire to have more children.”

9. Fertility Intentions/Motivations Desire more children now/future o “I would want to have a child…you can’t tell now if the children I already have will live. You see with HIV one can get sick and die, but another one may remain later even if the others are infected with HIV.” o “You see it is said that children are like wealth to the parents… a child can help me…in many ways. Like now I help my parents”

10. Importance of planning your family for HIV+ men o “it enables the last born to grow health unlike when one gives birth while the other one is still breastfeeding, it then makes the child weak. That is the reason why I support family planning.”

11. Knowledge about contraceptive methods Injectables & pills were commonly known Fewer knew about implants, IUCDs, and permanent methods Learned at the HIV clinic or the radio

12. Contraceptive prevalence:Survey on Knowledge, Attitudes and Practices Data were presented at RH2010 conference by S.J. Newmann, Contraceptive use and receptivity to integration of family planning services into HIV care among HIV-infected men and women in Nyanza province, Kenya. * Male condom + hormonal, intrauterine, or permanent contraception

13. Barriers: Health Effects Side effects, particularly irregular bleeding o “I have heard that at times when a woman is on family planning medications they have longer periods and the flow of blood never cease... As a man at times you want to have sex but you realize she has blood yet she was on her periods just the other day!” Myths and Misconceptions o “I have also heard rumors that the drugs can make somebody not to ever get pregnant again.” o “I would only want to do it [vasectomy] after knowing more about it and after being taught on how to go about it and what happens after the operation.”

14. Barriers: Facility Related Distance o “It is far enough and the terrain is what complicates it, you see this place has a lot of hills.” Staffing shortages o “On the day she went she didn’t get the services as the provider was away. When she went the next time she was still away, that happened on four different times then on the fifth visit she got the services.”

15. Barriers: Lack of Male Focus FP services do not meet the needs of men o “You see us as men, our options are limited, it is the women who have variety of options to choose from..” o “there are times I hear presentations over the radio on family planning services and where the services are, however personally I have not gone to see for myself since it is mostly women who visit those clinics...”

16. Mens’ Views on Integration of HIV care and FP Convenience and continuity of care o “You see here at the PSC [HIV clinic] is where I get treatment whenever I come to the hospital. All my medical records are here and that is why I feel I should also get the family planning services from here.” o “Because here [HIV clinic] is a busy place, and when you come you are likely to find people. But in the other clinics …you may even find it closed and there are times when patients go back home without treatment because both the nurse and the doctor are away.”

17. Mens’ Views on Integration of HIV care and FP Providers have HIV-related expertise o “Because when one is HIV positive, they need close attention, and if your wife gets pregnant and you are both positive, you get to know that the child needs to be given birth to at the hospital...” o “Because they are the ones who know and will understand my problems and hence will handle me well.”

18. Concluding thoughts We need to better engage men in family planning to improve uptake Efforts to include men: o Family planning health talks given daily to all clients o At each visit, male & female clients are asked about their fertility desires & family planning preferences o At integrated facilities, FP services are offered in the HIV clinic, at other facilities, a referral form is given o Community Advisory Group provides feedback from the community to the facility staff and researchers

19. Thank you! Study participants in Nyanza, Kenya Sara Newman Daniel Grossman Craig Cohen Elizabeth Bukusi Maricianah Onono FACES Salome Ogola Benard Ochuka TIDES Africa and Bill & Melinda Gates Foundation