Pathfinder International are intending to scale up the use of Implanon in Ethiopia. This is a hormonal contraceptive implant, inserted under the skin. I hope some care is taken to avoid accidental transmission of blood borne infections, such as hepatitis, HIV and various bactrial conditions.
My attention has been drawn to the 2005 Demographic and Health Survey for Ethiopia, which shows that HIV prevalence is particularly high among women who received care from a health professional during delivery in the past three years, at 9.9%, compared to national prevalence of less than 1.5%. In contrast, HIV prevalence among those who gave birth without care from a health professional was only 1.2%.
There are similarly worrying contrasts for ante-natal care (ANC), with 3.5% prevalence among those who receive ANC by a health professional, compared to only 1% among those who did not.
In common with all high HIV prevalence African countries, HIV prevalence is higher among women than men. It is also many times higher in urban areas, compared to rural areas. And it is higher among the wealthy than it is among the poor.
These figures, and others in a more recent Preliminary Demographic and Health Survey for Ethiopia, suggest that HIV is very unlikely to be transmitted sexually. This raises the question of how it is being transmitted. Could wealthier, city dwelling people, with better access to health professionals face higher risks than poorer, rural dwelling people, who may never see a health professional face to face? Contraceptive use is also far higher in urban than rural areas.
Pathfinder use the popular buzzword, ‘task-shifting’, to reassure us that there may be few health professionals in the country, but some kind of training can be given to those there are, even to those who are not health professionals but are doing work that should be done by professionals. The term ‘task-shifting’ is a bit like ‘coping mechanisms’ and ‘extended families’, which allow us to believe that they’ll be ok, after all, they are Africans.
It is to be hoped that use of Implanon and other invasive family planning methods that involve breaking of the skin are carried out in sterile conditions by people who know the risks and are taking the necessary precautions to avoid them.
It would also be good to think this campaign involves informing Ethiopians about non-sexual risks of HIV transmission, such as those faced by those using certain forms of birth control, such as Implanon and other implants. Implants need to be removed in sterile conditions, as well as inserted in sterile conditions.
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Thanks for this post Simon. Indeed, quality service provision is a high priority. In addition to the year of training HEWs receive as part of the FMOH’s regular training to prepare this new cadre of workers for their responsibilities, Pathfinder’s IFHP staff also provide training with a high level of supervision (both during training and after) that emphasizes infection prevention protocols– which have benefits not only for women receiving Implanon, but for clients receiving any service from HEWs.
Your comment about task-shifting is interesting. I see Pathfinder and IFHP’s support of the FMOH to carry out task-shifting– a policy decision made by the Ethiopian government– as in line with health system strengthening values and government-ownership. Yes, the task-shifting does mean that the FMOH is able to employ its own citizens. It also means that rural communities are now able to receive services from members of their community who are presumably more in touch with their needs and the community context in which they are seeking services than outside providers would be. Given the ratio of health providers to the health seeking population in Ethiopia, task-shifting seems not only a viable but important step in the ongoing push for equitable access to health services. Given the current context, I’d be interested to know what alternatives you would propose?
Hi Claire, thank you for your comment. My worry is about non-sexual transmission of HIV and other blood-borne diseases through unsafe healthcare practices and possible exposure to contaminated blood, in relation to patients in particular, though also health workers.
This is likely to be a problem among healthcare professionals in Ethiopia, so it could be an even bigger problem among non-professionals doing similar work. Given these considerations, I hope that non-invasive forms of birth control are also offered and that blood-borne risks are discussed.
Indeed, non-invasive methods might need to be prioritized. Depo Provera is a case in point, where people using injectable versions of hormonal BC may be exposed to contaminated equipment. Task-shifting may involve teaching those carrying out skin-piercing procedures about blood-borne risks or it may not. If it doesn’t, the program could do a lot of harm.
The same applies to professional health personnel, of course. I realize that infection prevention is mentioned a few times (“providers of Implanon require knowledge of proper insertion
and removal, as well as anesthesia and infection prevention protocols”) but most professionally run health services in many African countries do not have high capacity when it comes to infection control, therefore this may be particularly challenging for health extension workers.
I am not against task-shifting per se but it would be comforting if the issue of blood-borne and other risks were mentioned clearly where non invasive methods are available and may be more appropriate to the context. There were problems with the use of Implanon in the UK, where conditions are a lot safer.
Thanks Claire for your comment and for your interest. You ask about alternatives. As far as the organization of health care delivery goes, there are many ways to go forward — task shifting, relying on private providers, etc. I’m not so engaged in those alternatives. The “alternative” that interests me is how to ensure safety. Training is not enough. Other steps that could/should be added to training, including: (a) investigating; (b) ensuring that the techniques promoted are consistent with Patient Observed Sterile Treatment — single use equipment, single-dose vials (see other sections of this website).
Investigations are crucial. Ensuring that health care does not transmit HIV requires a readiness to acknowledge and investigate unexplained HIV infections. Health care ethics requires reporting unexplained infections and investigations to the public — telling people about risks is part of informed consent.
Women’s health aid programs have some parallels with the Expanded Program on Immunization (EPI), which began in 1974. From the 1980s, EPI partners arranged surveys of injection practices; these surveys repeatedly found lots of unsafe injections. In 1999 a WHO committee acknowledged that 30% of vaccination injections were unsafe.
One parallel between health aid for women and EPI is that both have been sponsored by foreign organizations that train and equip and aver they are trying to make everything safe. But the parallel breaks down: Unlike EPI, organizations promoting health aid for women have not sponsored systematic effort to examine safety of that care — reused gloves, specula, syringes for depo, etc. As we know from EPI’s surveys of injection practices, training and equipment do not assure safety. What is happening in health care for women?
As Simon has reported, Ethiopia’s recent Demographic and Health Survey documents suspiciously higher HIV prevalence in women with more access to health care. What to do with suspicions? If a bartender serves alcohol to a drunk, the bartender is implicated in subsequent driving accidents. Is funding and extending health care that we have good reason to believe is not safe similar to serving alcohol to a drunk driver?
The remedy is fairly straightforward: as a condition of aid, demand investigations of unexplained HIV infections. Demand investigations of urban ANC and delivery wards in Ethiopia which are associated with high rates of HIV prevalence in women. Ethiopian women will be protected by such investigations. When health care providers see what has been happening under their noses — that what they thought was safe was not safe — then training and equipment will be much more effective.
Note: the US PEPFAR program has an effectively unlimited amount of money for investigations and infection control — the challenge is to get CDC and/or USAID to use more of their huge piles of PEPFAR funds that way.
David Gisselquist