Contraceptive counseling and care for HIV-infected and at-risk women in South Africa: A study of practices of health care providers

Contraceptive care for women in high HIV-prevalence settings has saliency for multiple health outcomes. This study assesses pregnancy prevention practices of physicians and nurses in South Africa, where HIV prevalence among women of childbearing age has increased sharply to 30%. Almost half of pregnancies are unintended, and vertical transmission of HIV is 30%. We conducted in-depth interviews, following semi-structured guides, with 30 nurses and physicians providing contraceptive services in KwaZulu Natal, Gauteng and Western Cape provinces. Interviews were recorded on digital voice recorders, transcribed and coded by three independent coders. Results were used to inform a nationwide probability survey, which we are currently fielding among 1,200 providers. Qualitative results showed provider responses to challenges in prevention counseling. Providers saw their own recommendations as idealistic since consistent condom use is rare, but they often employed patient-centered approaches to offer the best possible care in this context. Providers cited male partners as reasons for non-use of condoms as well as contraception, and considered hormonal methods that can be used discretely, such as injectables, as optimal. Providers also discussed their approaches to help women with pressure for unprotected sex, such as empowerment and also distribution of emergency contraception. Survey data will be analyzed to show variation in provider recommendations by patient characteristics, and contraceptive recommendations for HIV-infected women will be compared to evidence-based guidelines. While research has identified effective provider interventions for HIV prevention, evidence on contraceptive recommendations for at-risk women is scarce, and these results can be used to inform future research.