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Promotion and integration of couples' HIV voluntary counseling and testing (CVCT) with other health services for HIV prevention

Wall, Kristin Marie (2012)
Dissertation (169 pages)
Committee Chair / Thesis Advisers: Allen, Susan A; Sullivan, Patrick S
Committee Members: Kleinbaum, David ; Nizam, Azhar ; Stephenson, Robert
Research Fields: Health Sciences, Epidemiology
Keywords: couples' voluntary HIV counseling and testing
Program: Laney Graduate School, Epidemiology
Permanent url: http://pid.emory.edu/ark:/25593/cn1c9

Abstract

Couples' HIV voluntary counseling and testing (CVCT) is a high-impact testing
strategy in which sexual partners jointly test for HIV, disclose results, and formulate
counselor-mediated risk reduction plans. CVCT decreases HIV transmission and HIV
risk behaviors. The WHO 2012 CVCT guidelines emphasize the need for increased
CVCT access, as well as the synergistic impact of CVCT when integrated with other
couple-focused health services on outcomes including increased family planning uptake
and reduced intimate partner violence (IPV). This dissertation is comprised of three
studies focusing on strategies for CVCT promotion and integration with family planning
and IPV services, which remain operational challenges despite clear mandates.


In our first study, we identify predictors of CVCT uptake in Lusaka, Zambia to
improve CVCT promotional strategies. Using multivariable logistic regression models
with generalized estimating equation methods, we found recruiting CVCT promoters who
had previously tested with partners, inviting acquaintances of CVCT promoters, inviting
couples (versus individuals) in discreet locations, and utilizing non-government and
health network (versus private) CVCT promoters increased CVCT uptake.

Our second study evaluated the impact of a family planning intervention on
incident pregnancy among HIV positive couples receiving CVCT services in Lusaka,
Zambia. This randomized controlled trial (RCT) of two video-based interventions
showed that, among baseline contraceptive users, viewing a video focusing on longer-
acting contraceptive methods was associated with a significantly lower pregnancy
incidence.


Our final study identified factors associated with experiencing recent IPV or
coercion within men who have sex with men (MSM) couples enrolled in a RCT of CVCT
in the US. Using multilevel actor-partner interdependence models, factors associated
with experiencing recent IPV were non-black/African American actor race, lower actor
education, and lower partner education. Factors associated with experiencing coercion
were younger actor age and lower partner education.


These findings will inform the design of promotional strategies, family planning
interventions, and screening tools for IPV and coercion within the context of CVCT to
further leverage the impact of CVCT and couple-focused health services. Our results can
be extended as a framework to understanding CVCT promotions and integration with
health services in other populations at high risk for HIV.

Table of Contents

Table of Contents
PROJECT SUMMARY ............................................................................................................ 1
PROJECT NARRATIVE .......................................................................................................... 3
SPECIFIC AIMS ..................................................................................................................... 4
CHAPTER 2: PROMOTION OF COUPLES' VOLUNTARY HIV COUNSELING AND
TESTING IN LUSAKA, ZAMBIA BY INFLUENCE NETWORK LEADERS AND
AGENTS ( ACCEPTED, BMJ OPEN [21]) ........................................................................ 5
TABLE 1. INL AND INA CHARACTERISTICS BY INVITATIONS DISTRIBUTED, SUCCESS
RATE, AND COUPLE COHABITATION STATUS ..................................................................... 25
TABLE 2. BIVARIATE ASSOCIATION BETWEEN INA CHARACTERISTICS AND COUPLES'
TESTING BY COUPLES' COHABITATION STATUS ................................................................ 31
TABLE 3. BIVARIATE ASSOCIATION BETWEEN COUPLE AND INVITATION
CHARACTERISTICS AND COUPLES' TESTING ACCOUNTING FOR CLUSTERING WITHIN
INAS AND INLS ................................................................................................................. 35
TABLE 4. MULTIVARIATE MODEL OF INA LEVEL, COUPLE LEVEL, AND INVITATION
LEVEL CHARACTERISTICS ASSOCIATED WITH COUPLES' TESTING .................................. 41
CHAPTER 3: IMPACT OF LONG-TERM CONTRACEPTIVE PROMOTION ON
INCIDENT PREGNANCY: A RANDOMIZED CONTROLLED TRIAL AMONG HIV
POSITIVE COUPLES IN LUSAKA, ZAMBIA ( SUBMITTED, JAIDS) ........................ 47
FIGURE 1. PARTICIPANT FLOW DIAGRAM (ADAPTED FROM THE CONSORT 2010 FLOW
DIAGRAM) ......................................................................................................................... 66
TABLE 1. SOCIODEMOGRAPHIC, HEALTH, AND FERTILITY CHARACTERISTICS
STRATIFIED BY ARM OF TRIAL AND USE OF CONTRACEPTION PRIOR TO THE
INTERVENTION .................................................................................................................. 67
TABLE 2. FAMILY PLANNING CHARACTERISTICS STRATIFIED BY ARM OF TRIAL AND USE
OF CONTRACEPTION PRIOR TO THE INTERVENTION ........................................................ 73
FIGURE 2. PRODUCT-LIMIT SURVIVAL ESTIMATES AMONG COUPLES IN WHICH THE
WOMAN PARTNER WAS USING A METHOD AT BASELINE ................................................... 80
CHAPTER 4: ACTOR-PARTNER EFFECTS ASSOCIATED WITH EXPERIENCING
INTIMATE PARTNER VIOLENCE OR COERCION AMONG MALE COUPLES
ENROLLED IN AN HIV PREVENTION TRIAL ( IN PROGRESS) ............................... 81
FIGURE 1. SCHEMATIC OF THE ACTOR-PARTNER INTERDEPENDENCE MODEL (APIM)
FRAMEWORK, ADAPTED FROM COOK & KENNY, 2005 .................................................... 98
FIGURE 2. SPECIFICATION OF THE MULTI-LEVEL ACTOR-PARTNER INTERDEPENDENCE
MODEL ............................................................................................................................. 100
TABLE 1. INDIVIDUAL-LEVEL DEMOGRAPHIC CHARACTERISTICS ASSOCIATED WITH
EXPERIENCING IPV OR COERCION ................................................................................. 102
TABLE 2. DYAD-LEVEL DEMOGRAPHIC CHARACTERISTICS ASSOCIATED WITH
EXPERIENCING IPV OR COERCION ................................................................................. 107
TABLE 3. ACTOR-PARTNER INTERDEPENDENCE MODEL OF FACTORS ASSOCIATED WITH
EXPERIENCING IPV ......................................................................................................... 111
TABLE 4. ACTOR-PARTNER INTERDEPENDENCE MODEL OF FACTORS ASSOCIATED WITH
EXPERIENCING COERCION .............................................................................................. 117
CHAPTER 5: DISCUSSION AND CONCLUSIONS .................................................... 123
STUDY 1 - PROMOTION OF CVCT .................................................................................. 123
STUDY 2 - INTEGRATION OF CVCT AND FAMILY PLANNING ........................................ 126
STUDY 3 - INTEGRATION OF CVCT AND IPV/COERCION SCREENING .......................... 130
ABBREVIATIONS ......................................................................................................... 132
REFERENCES ................................................................................................................ 134
APPENDIX: WALL, K.M., ET AL., PROMOTION OF COUPLES' VOLUNTARY HIV
COUNSELLING AND TESTING IN LUSAKA, ZAMBIA BY INFLUENCE
NETWORK LEADERS AND AGENTS. BMJ OPEN, 2012. 2(5). ............................... 151

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