Despite high levels of knowledge about contraception among the general population in Cambodia, contraceptive prevalence rate among married women remains low at 35% for modern methods, of whom, 49% were using oral contraceptive and 29% injectables.1 Although condom distribution, as part of the Government of Cambodia's 100% Condom Use program (CUP), has been high since 1995 and social marketing by NGOs has ensured easy access to condoms, in particular to most-at-risk population (MARP), other methods of contraception are not for free or widely available for many Cambodian women including female entertainment workers (EWs).2 In addition to costs and limited access to family planning (FP) services, there also exist widespread “myths” and misinformation about the adverse events of contraceptive use.3 Other factors, such as the status of women within Cambodian society and their decision-making ability, also contribute to low rates of contraceptive use among Cambodian women.3 Results from a recent survey show that although 94.3% of female EWs reported consistent condom use at last sex with clients, only 52.1% reported consistent condom use at last sex with “sweethearts” or regular partners.4 Condoms are also reported as the primary contraceptive method by the majority of EWs compared with other methods.4–6 As a result, high rates of unwanted pregnancies leading often to unsafe abortions are observed among EWs in Cambodia.3,7 Data on contraceptive use among HIV-positive EWs to prevent unwanted pregnancies are not available, although providing access to effective contraceptive methods represents an important strategy to prevent mother-to-child transmission of HIV.7–11 In this context, it is thus important to address the reproductive needs of women living with HIV (WLHIV) and EWs, to improve their access to modern contraceptive methods, and raise their awareness on dual method contraceptive use. Indeed, dual method of contraception is known to be more effective in this population to prevent unintended pregnancies because of the greater contraceptive efficacy of modern contraceptive methods compared with condom alone, especially in a context of inconsistent condom use with sweethearts or regular partners and high levels of sexual violence.12,13
Access to care at public health structures for HIV-positive most-at-risk populations including EWs is difficult because they are often afraid of being recognized or discriminated. Alternative nongovernment structures are known to reach some most-at-risk groups reluctant to attend public structures. Chhouk Sar (CS) Clinic is a peer-managed structure opened in 1997 with most-at-risk staff living with HIV who were in charge of providing treatment for opportunistic infections and psychosocial support to HIV-positive most-at-risk populations. Since 2003, in collaboration with the National Center for HIV/AIDS, Dermatology and STD (NCHADS) and under FHI 360 support using USAID funding, CS was providing HIV care services before antiretroviral therapy (ART) initiation to most-at-risk groups and, since 2005, ART treatment was made available as well. Since 2010, integration of comprehensive HIV care services for most-at-risk groups was progressively implemented at the clinic including voluntary confidential counseling and testing, sexually transmitted infection services, as well as positive prevention and psychological support. As of August 2012, 141 WLHIV were actively followed in pre-ART care and among 875 who had been ever initiated on ART, 632 were still actively followed.
To respond to the demand from CS clients and in line with NCHADS Standard Operating Procedures to implement Linked Response and Positive Prevention as well as the more recent boosted Linked Response and Continuum of Prevention to Care and Treatment for Most at Risk Populations,14–17 FP services were implemented for CS clients including WLHIV and EWs. This study aims to assess knowledge and self-reported uptake of contraceptive methods by most-at-risk population followed at CS clinic before and after the implementation of contraception/FP services.
All WLHIV accessing pre-ART/ART service at CS were eligible to participate in the study if they were female, between 18 and 45 years of age, followed at CS pre-ART/ART service, Khmer-speaking, willing and able to participate in the assessment study, and able to provide oral informed consent after being provided detailed information about the study. Even if all women followed at CS were EWs at the time they enrolled at CS, a proportion of them stopped their EW activity over time. For clarity in the text, all women followed at CS will be referred to as WLHIV thereafter whatever their current EW activity or not at the time of interview.
Implementation of Contraception/Family Planning Services at Chouk Sar Clinic
In collaboration with Marie Stopes International Cambodia (MSIC), free-of-charge contraceptive services were implemented at CS clinic in September, 2011. During the first 6 months of implementation, MSIC provided theoretical and practical training to CS staff on sexual and reproductive health and contraceptive methods. Comprehensive information, including potential side effects, about all types of FP methods (short-term and long-term) was provided focusing on the promotion of combined use of modern contraceptive methods to prevent pregnancy along with condom to maintain protection against HIV sexual transmission (dual method approach). In addition to condom, the following FP methods were made available for free at CS clinic: emergency pill, implant, intrauterine device (IUD), pill, and injectable contraception. As CS did not perform sterilization procedures, clients who chose this method were referred to MSIC. Female condom use was not integrated among the FP methods because it is not currently proposed in public health facilities in Cambodia. Unmet needs for FP were first screened on a voluntary basis by peer CS staff living with HIV in the waiting room among women attending pre-ART/ART service. Those with identified needs were referred to an individual FP counseling room where a trained midwife or doctor conducted FP demand generation emphasizing on known advantages and disadvantages of each FP method and specifically promoting dual FP method of contraception (condom plus another FP method). Indeed, because women in need were all HIV-positive, they were all counseled for using dual FP method including condom to avoid HIV transmission and another FP method for efficiently preventing unwanted pregnancy. Appropriate information, education and communication (IEC) tools such as flipchart from the National Maternal and Child health Program were used during FP counseling sessions. By March 2012, fully trained CS health care providers (1 medical doctor and 1 midwife) were able to independently deliver FP services to CS clients without MSIC supervision. To further improve access and internal referral to FP services for CS clients, FP service was made available 5 days a week.
Study Design of the Evaluation of FP Services Implementation
A pre–post design was used. The baseline assessment was performed from June to July 2011 before FP service implementation and the postimplementation assessment was performed from June to July 2012, 12 months after FP service implementation. At both preimplementation and postimplementation assessments, an individual semistructured questionnaire translated in Khmer and that lasted approximately 30 minutes was administered by female interviewers to CS clients after giving their oral informed consent. To avoid duplication, before being interviewed, each participant was asked whether she had been already interviewed for the current survey (either preimplementation or postimplementation). Clients were allowed to participate in the postimplementation survey even if they had participated in the preimplementation survey. The questionnaire addressed socio-demographic characteristics, history of HIV testing and care, reproductive history including pregnancies and abortion, current beliefs and knowledge about FP methods, past and current use of FP methods, reasons for using or not using them, FP plans, and factors influencing FP methods choices. All participants were offered packages of canned-fish and noodle (valued at US $2), free condoms, FP educational materials, and referrals to relevant FP services.
Sample Size, Data Management, and Statistical Analysis
In 2009, Population Services International estimated the proportion of Cambodian EWs using FP methods to be 8.6%.18 Based on the assumption of a 9% use of FP methods, the FP intervention will be considered effective if at least a 10% increase of FP method usage among WLHIV could be observed after implementation of the FP service (up to 19% use). To reach 85% likelihood of statistically significant results (power = 0.85, alpha = 0.05, 2-tailed), a sample size of 235 was needed both preimplementation and postimplementation (calculated using Fleiss with continuity correction in STATA 10.0). Considering almost 5% missing data, the final sample size needed was n = 250 for both preimplementation and postimplementation assessments. Because 10 to 20 clients access pre-ART/ART services every day at CS with potentially 7 to 15 of them eligible for interview, data collection for both survey lasted approximately 2 months.
Completed questionnaires and password-protected computer files were stored at FHI 360 office, despite not containing personal identifying information. Data analysis was conducted using STATA software (version 12, Stat Corp., College Station, TX). Descriptive statistics were performed for all variables. Student t test was used to test the significance of the mean of continuous variables between preimplementation and postimplementation assessments. χ2 analysis and the 2-tailed Fisher exact test were used to test the significance of categorical variables. Two-sample Wilcoxon–Mann–Whitney test was also used to test the significance of medians between 2 groups.
The protocol, questionnaire, informed consent form, and other requested documents, along with any subsequent modifications, were approved by the National Ethics Committee for Health Research (NECHR) in Cambodia and by the Institutional Review Boards of FHI 360 and the Institute of Tropical Medicine Antwerp, the University of Antwerp, Belgium.
Socio-Demographic Characteristics of Participants
The median age of participants was 33 years in both preimplementation and postimplementation groups (Table 1). Preimplementation participants were more likely to be married (47.6%) compared with end-line (26.1%, P < 0.001), and many postimplementation participants were found to have a partner or sweetheart (43.0% vs. 20.8%, P < 0.001). However, similar numbers of participants had either husband or regular partner/sweetheart before and after the intervention (68.4% vs. 69.1%, respectively). Participants had low levels of education, with more than 80% who never attended school or only up to primary school. Nearly two thirds reported not being able to read Khmer or to do so with difficulty. Participants were found to be very poor because the median earning per day was only US $2.5. Even if all women followed at CS were EW at the time of enrollment, many of them reported having stopped this activity over time. Indeed, only 32.8% and 35.3% of the participants before and after implementation, respectively, disclosed working as EW at the time of the interview. Similarly, 24.5% (61 of 250) and 35.3% (88 of 249) of participants, before and after implementation, respectively, reported having sold sex during the past 6 months, of whom, only 80.3% (49 of 61) and 65.9% (58 of 88) reported working as EW, before and after implementation, respectively (Table 1). Interestingly, 7.8% (9 of 115) of non-EW and 5.7% (3 of 53) of unemployed participants before and 21.3% (25 of 117) and 9.3% (4 of 43) of them after implementation, respectively, had sold sex during the past 6 months (Table 1).
HIV, Reproductive Health History, and Sexual Activity Among Participants
More than 50% of the participants were followed at CS for more than 3 years, almost 80% of whom were on ART (Table 2). Disclosure of their HIV status to their partner, sweetheart, or husband was common among participants (83.1% and 75.8% preimplementation and postimplementation, respectively). When the HIV status of the partner was known, 43.4% and 42.2% of participants, preimplementation and postimplementation, respectively, had a partner HIV negative and were an HIV discordant couple.
Almost 70% of all participants interviewed have given birth 1 to 3 times with a median number of deliveries of 1 (interquartile range: 1–2). More than 30% of participants expressed a desire to have a baby in the future. About 24% reported having ever been forced to have sex or being raped, primarily by clients (59.3% and 50.8% before and after implementation, respectively) or strangers (13.6% and 18.6%, respectively), and to a lesser extent by husband, police, or venue owner (data not shown). More than half of the participants in both groups reported a past abortion and, among them, more than 40% had 2 to 4 abortions. Some participants experienced more than 10 abortions—up to 20 times—in their lifetime. The median cost of the last abortion was US $25 (interquartile range: 15–40). Interestingly, only 10% of respondents knew that abortion was already legalized in Cambodia (1997 abortion act), whereas 70% still believed abortion was illegal.
Sexual activity during the last 6 months was reported by 73.6% (184 of 250) of the participants before and 77.1% (192 of 249) after implementation. Among them, 33.1% (61 of 184) before and 45.8% (88 of 192) after implementation sold sex to clients during this period. Among those having sex with clients, 40 of 61 (65.6%) before and 68 of 88 (77.3%) after implementation reported also having had sex with their sweetheart, partner, or husband (Table 2).
Awareness of and Beliefs Around Contraception Among Participants
When participants were asked about the different contraceptive methods they were aware about, all mentioned male condoms and more than 90% mentioned pills and IUD. However, many participants after implementation had heard about other modern contraceptive methods. As shown in Table 3, significantly many women after implementation had heard about injection (P < 0.05), IUD (P < 0.05), implants (P < 0.01), female sterilization (P < 0.01), and male sterilization (P < 0.01). However, very few had heard about emergency contraceptive pills or female condoms, even after FP services' implementation. As expected, the knowledge about FP significantly improved after the implementation of integrated FP service (P < 0.001). However, misunderstandings remained because after implementation 73.5% of respondents still believed that people living with HIV (PLHIV) should not have children and 34.5% believed that IUD is not safe for PLHIV (Table 3). However, the great majority of participants understood that FP methods are safe and important for PLHIV to avoid unintended pregnancy and that PLHIV should use condom combined with another FP method. In addition, almost all agreed that abortion is not a quicker and easier method to use instead of FP methods.
Contraceptive Methods Used by Sexually Active Women
Before implementation, 84.6% of sexually active participants reported using condom as the only FP method during the last 6 months (Table 4). Globally, there was no significant increase in the proportion of participants using a noncondom contraceptive method (primarily pills, female sterilization, and injectable) after (16.4%) compared with before implementation (12.6%, P = 0.86) (Table 4). No significant change in the use of FP dual method (using condom plus another contraceptive method) during the last 6 months was reported after the implementation of integrated FP services (14.8% after vs. 11.0% before implementation, P = 0.28). Globally, condom use (i.e. condom only and dual method use) during the last 6 months did not change significantly after implementation (91% vs. 95.6%, P = 0.11). Additional analyses among those having an HIV-negative partner, those who sold sex or not, did not reveal significant changes in condom use (over 90% before and after implementation in each case, data not shown). Sexually active WLHIV were significantly more likely to report planning to use FP in the future after (94.3%) than before FP services implementation (60.9%, P < 0.001).
Reasons for Not Using Noncondom Methods
Among reasons why participants were not using noncondom FP methods, the majority thought that condoms were enough to prevent pregnancies (Table 4). Paradoxically, although the intervention aimed to promote the use of dual method, the number of participants thinking that condom is enough significantly increased after implementation (79.5% vs. 52.8%, respectively, P < 0.05). However, among other reasons mentioned for not using noncondom FP methods, not having sex very often was mentioned by a significantly higher proportion of WLHIV postimplementation. Additional important reasons cited by participants were fear about side effects and having a poor health.
The main observation of this study was that integrating FP service at CS facility greatly improved knowledge and decreased misbeliefs about modern contraceptive methods (including the concept of dual method) among WLHIV but did not significantly change the rate of using noncondom contraceptive method. Similar observations were made when analyzing separately sexually active women who did or did not sell sex during the last 6 months or women with a known HIV positive or negative partner. Long-term follow-up of CS clients might still reveal ongoing changes of FP practices but one might expect a 1-year intervention to be sufficient to observe significant changes. Other studies in high-income countries have shown that, among HIV-positive women, condom is the most used contraceptive method compared with more effective methods.19,20 Similarly, some previous studies of FP service implementation in HIV structures failed to find an increase in the use of nonbarrier contraceptive methods by PLHIV.21,22 However, a recent unique cluster-randomized trial performed in twelve HIV clinics in Kenya to evaluate the impact of FP service integration found a significant increase in the use of more effective contraceptive methods, that is, IUD, implant, injectable, or oral contraceptives, in the clinics with FP integration compared with control sites (odds ratio: 1.81, [95% confidence interval: 1.24 to 2.63]) with a nonsignificant reduction in condom use.23 Because we only evaluated FP service implementation in 1 HIV clinic targeting MARPs PLHIV, further studies will be needed to evaluate the effectiveness of FP implementation for PLHIV and MARPs in other health facilities in Cambodia.
Integration of FP services in HIV care clinics targeting sex workers has not been evaluated so far, and best models to provide a wide range of contraceptive methods to sex workers remain to be defined. It is important to note that our study in Cambodia analyzed knowledge and self-reported contraception/FP uptake but did not evaluate the overall FP service integration process as such. We found high levels of knowledge about contraceptive methods with condoms, pill, IUDs, implant, and injections being the most commonly mentioned methods while male or female sterilization was rarely mentioned. Among sexually active participants, it was clear that condom was the FP method of choice with high usage rates reported both preimplementation and postimplementation probably reflecting the impact of Cambodia 100% CUP on this population. The use of other FP methods than condom was not a common practice (13% preimplementation) but was found slightly higher than the 8.6% reported in previous studies.10 Interestingly, although pills and female sterilization seem to be the most popular methods, implant tended to be chosen when made available on site. However, knowledge about emergency pill remained extremely poor even after service implementation suggesting that the counselors themselves do not provide accurate information. Similarly, some studies also documenting contraceptive use among sex workers in Asia and in Cambodia show that condom is often the most popular method used and that the use of nonbarrier methods remains low.16
Importantly, although specifically promoted during implementation and given the limited sample size studied here, the use of dual method (ie the use of 1 modern nonbarrier FP method in addition to condom) did not increase significantly. Similar observations about dual method and condom use were made by Grossman et al23 in their cluster-randomized study in Kenya. During dual method promotion, potential condom use reduction, especially with noncommercial steady partners, remains an important issue to avoiding HIV transmission while promoting nonbarrier modern FP methods.24 Close monitoring of condom use will be critical for any future program interventions aimed to promoting dual method for WLHIV and MARPs.
The observed low rates of dual method among WLHIV and female sex worker and the failure of dual method promotion is challenging for FP service integration and program implementation. Our study did not address provider attitudes toward each FP method, which might greatly influence FP choices by such vulnerable population. The main reported barriers for not using noncondom FP methods were concerns about side effects and potential poor impact on health, especially on antiretroviral treatment. Specific beliefs and cultural barriers against the use of short-term and long-term FP methods because of wrong or false assumptions regarding potential side effects are known to be strong within the community in Cambodia and might have been insufficiently or inappropriately addressed during FP counseling sessions at CS.3 Similarly, the role of social networks and other women in disseminating such false assumptions and influencing the choice of a FP method should not be underestimated and carefully addressed.25 Thus, as previously shown in South Africa,26 addressing cultural beliefs and behavioral attitudes might be critical as well when introducing modern FP methods and dual methods among WLHIV and MARPs in Cambodia and perhaps more broadly in Southeast Asia. In addition, involving peer-EWs and WLHIV in providing FP counseling might also help to overcome some of these cultural barriers.27–29 Despite the high rates of unwanted pregnancies and abortion in this population, condoms are perceived as a “dual protection” method sufficient to prevent both unwanted pregnancies and HIV/ sexually transmitted infection transmission.6,30,31 In fact, the term “dual method” per se and its potential translation in local languages might create some confusion with the “dual protection” provided by condoms and promoted under the 100% CUP program in Cambodia. It seems that one of the major challenges will remain to convince clients that condoms are not the most effective contraception method and that another method is needed. We are currently addressing these issues by piloting the promotion of a “condom plus” (condom plus another FP method) approach. However, further research and innovative implementing strategies, especially exploring provider's attitudes and/or improved communication on the efficacy of noncondom FP methods as well as their side effects and interactions with antiretroviral, are clearly needed to better understand how to promote the use of noncondom FP methods while maintaining high condom use among EW and WLHIV.
The authors thank Che Katz, Melissa Cockroft, and staffs from Marie Stopes International Cambodia for their help in implementing family planning service at Chhouk Sar and in facilitating access to commodities. The authors also thank all PLHIV and Chhouk Sar staffs who were involved in the study and family planning service integration.
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