Ensuring Health Care Providers Have Comprehensive Communication Tools for Future Microbicide Introduction in Kenya: A Formative Research Study

Correct Knowledge of Microbicides

As indicated previously, equipping providers with correct knowledge about new ARV-based HIV preven-tion products, including information on proper use instructions, and product effectiveness is critical. We strategically developed the microbicide communication materials with this in mind, and most providers felt the materials sufficiently covered these necessary topics.

Because the BAT-24 microbicide use regimen was fairly complicated, there were several cards in the flip chart dedicated to describing it. After reviewing the cards with providers, we assessed providers’ understanding of the current use regimen based on their knowledge of necessary gel insertion before sex, after sex, and no more than two doses within 24 hours. Less than half of all providers were able to correctly explain the BAT 24 regimen in their own words, without assistance. Yet one provider from a family planning facility accurately summarized:

The gel should be inserted not more than 12 hours before sex but at least 15 minutes before the actual interval . . . once you have had the first sexual intercourse . . . it should also be immediately inserted after the sexual intercourse or not more than 12 hours after sex . . . so within 24 you should have inserted the two gels. (Nairobi non-HTC provider)

A few additional providers from a range of facilities, however, were able to correctly explain the regimen after the interviewer provided minor clarification. Insertion before sex seemed to be the easiest component for providers to describe, with most providers recognizing that the gel needed to be inserted at least 15 minutes before sex. In contrast, the appropriate timing for insertion after sex seemed to be the most difficult component of BAT 24 for providers to grasp. For example, one provider thought the regimen was to “insert again after the act . . . insert after 24 hours” (Nairobi non-HTC provider).

To communicate the partial effectiveness of microbicides and to discourage potential condom migration, defined as the movement from more effective condom use to less effective gel use only, the flip chart also contained a card depicting an HIV risk hierarchy: with those who use no protection at greatest risk, gel only at reduced risk, condoms only at low risk, and condoms and gel together at very low risk. More than half of providers reported that the information on the chart was very clear and that the hierarchy was well explained. Moreover, all but one provider demonstrated an understanding that microbicides alone are only partially effective against HIV acquisition, and that in order to increase protection, they can be combined with condom use.

I think the flip chart has information that using the condom plus the gel is highly effective in preventing HIV transmission: like in case the condom bursts, the cream acts as a backup. So, it gives enough information. (Nairobi non-HTC provider)

Attitudes Toward Microbicides and Related Introduction Concerns

Nearly all providers had a positive overall opinion of microbicides, indicating that incorporating microbicides into the available mix of HIV prevention options would benefit women in general. As depicted in the following quotes, these providers also specifically liked the idea that vaginal microbicide gel could provide women with a prevention option they could initiate for themselves:

I think the introduction of microbicides will be very effective as it will improve the already available methods. For instance, even if a man refuses to use condoms, the woman will somehow be protected by using the microbicide gel. (Nakuru non-HTC provider)

I am looking at it so positively because, as you know, female clients are not able to negotiate about safe sex. And if this microbicide gel will really prevent HIV, I find it being a plus. . . . The effect is that they will find they have options in preventing, in taking care of their status—unlike with the condom. Like I said earlier, the condom is normally seen as a male thing. So the male is the one who takes charge of the use of the condom. But for the microbicide, the woman is the one who takes charge. (Nairobi HTC provider)

The vast majority of providers expressed particular interest in the HIV prevention benefit of microbicides. For these providers, HIV was seen as “the major concern most of our clients have. . . . So if they feel that maybe the microbicide is going to help minimize that risk of getting exposed, then they are bound to use it” (Nairobi HTC provider). However, most providers also expressed interest in the non-HIV related benefits of microbicides, including the potential for increased lubrication and sexual pleasure, as well as female empowerment. As one provider noted: “[Our clients] will like the enjoyment part of it—that is, it gives them pleasure during their sex. Most of them will be happy with that” (Nairobi non-HTC provider).

Although the majority of providers reported that they counsel a wide range of clients, including female sex workers, youth, married women, and couples, they most often suggested that young, single women and female sex workers would be the most interested in using microbicides. Providers explained that these groups “don’t persistently use the condoms; if they have the gel, I think that will help” (Nairobi non-HTC provider).

Only a handful providers thought married women would be interested in and could benefit from using microbicides, even if the women were HIV-negative and living in serodiscordant relationships. Most acknowledged married women as strictly unable to negotiate condom use: “[married women are] those people you are explaining to about the condoms and they tell you there is this and this and this [excuse]” (Nairobi non-HTC provider). Similarly, providers noted that these women may “want to have a child so they are not using condoms” (Nairobi HTC provider). However, providers did not appear to recognize that the non-HIV prevention benefits of microbicides, such as increased sexual pleasure, could serve as a way to negotiate microbicides, regardless of condom use, nor did they consider covert use of microbicides by married women.

Moreover, despite recognizing that many women either do not use condoms at all, or do not use them consistently, roughly half of all providers interviewed expressed some concern when discussing the hierarchy of risk. These providers were primarily concerned about the potential for risk disinhibition or condom migration, and they noted that microbicide introduction could potentially “destabilize condom promotion,” lead to “reckless sex,” or “self-sabotage.” This was particularly concerning to them, not only because of the increased potential for HIV acquisition but also because the Kenya Ministry of Health, local clinics, and partners have worked hard to popularize and destigmatize condom use. The following are illustrative quotes:

I’m looking at it as something that will destabilize all that has been put down in terms of prevention of HIV transmission. . . . I’m seeing by the end of the day, many women will not use condoms and men will prefer to go for this [microbicides]. In the process, the condom may lose value, yet it has been a very good something . . . (Nakuru HTC provider)

Microbicides is a double-edged sword. The reason why I say that is, on one side, it can really help in preventing HIV infection. But on the other side, you find that there are those who might not get this information the right way and they might use this microbicide as a way of being reckless with their sexual lives. So I feel strongly that as much as we are trying to introduce this, then we really have to be keen on the way we disseminate that information. (Nairobi HTC provider)

There is a place here where it [the flip chart] is saying that the gel will only be effective at 40%. If I tell my clients that maybe the gel will protect at 40%, then already that’s like self-sabotage. (Nairobi non-HTC provider)

Providers also expressed other concerns related to potential product introduction. Most providers raised concerns about microbicide insertion. Some felt that the insertion process would be “cumbersome” or “messy.” Others indicated that their clients might be uncomfortable with the idea and/or process of vaginal gel insertion. While most spoke generally, some thought young women, in particular, would be most uncomfortable with insertion. Nearly a third of providers also raised concerns about women potentially reusing an unhygienic insertion applicator, while others expressed concern about the potential for the gel to leak out of the vagina after insertion.

Regarding product usage, some providers expressed concern that women may wish to share the gel with their friends or family members, regardless of the fact that users will likely need to be regularly tested for HIV and properly counseled on microbicide use. For example, one provider described a potential situation involving female sex workers: “You find one of your colleagues has forgotten hers; you can put some of yours for her to use” (Nairobi non-HTC provider).

Roughly half of all providers expressed concern about gel storage. Most indicated that storing the gel in a secure location, away from curious children, would be a challenge for some women. A few providers also expressed some concern that their clients may not be able to keep the gel in a cool, dry place. This is highlighted in the following quote:

Keep the gel in a cool dry place . . . you know our community here where we live? Slum all over. You will see the gel being placed even on the bed, just next to the iron sheets; it can even melt because of the heat, but all in all, we will just explain. I’m just trying to see our set-up. But, I think these are easy things they can be able to avoid. (Nairobi HTC provider)

Some providers expressed concerns about the safety of vaginal microbicide gel. Most of these were providers from non-HTC facilities who expressed general concerns about product safety, including product composition. Similarly, a few providers were specifically concerned about the safety of gel use by pregnant women. For example, a family planning provider from Nairobi commented, “Maybe a client comes . . . and maybe she is pregnant and she wants to use that microbicide gel. What do we do?” (Nairobi non-HTC provider). Although less common, concern was also raised about HIV-positive women wishing to use the gel. A couple of providers indicated that HIV-positive women may wish to use the gel to protect their male partners from infection, while a couple others thought that HIV-positive women may either wish to use the gel to protect themselves from herpes or from reinfection with HIV, both common concerns among positive women.

Integration Into Existing Clinic Environment and Flow

In addition to promoting accurate knowledge of and favorable attitudes toward microbicides, it is critical that microbicide materials and counseling be seamlessly integrated into existing clinic environments. To this effect, we asked providers whether and how they might use the informational brochure in their clinics. Most providers reported they would likely hand the brochures out during counseling sessions or make them available in the waiting room. However, a couple of providers were concerned that a few of the images may be inappropriate for children accompanying their mothers to the clinic, even if by chance encounter. These providers were, therefore, not comfortable with the idea of leaving the brochure in their waiting rooms, preferring instead to keep the brochures for counseling sessions only.

Providers were shown one of two counseling algorithms, depending on their facility type. Most providers thought that the counseling algorithm they were shown fit within the current guidelines and practices of their facility. This was true of providers from half of HTC facilities and almost three-fourths of non-HTC facilities. Providers at HTC facilities appreciated that microbicide introduction could be integrated into their current counseling procedures of discussing prevention options immediately following risk assessment. For example, one provider noted: “It fits well. We also test after risk assessment” (Nakuru HTC provider). Similarly, a provider from a non-HTC facility felt that the non-HTC algorithm was beneficial because, in non-HTC settings, “after the client has known about the product, is when you ask about testing. I think it’s good for the client because she has known everything” (Nairobi non-HTC provider).

However, a handful of providers from a range of facilities felt that the algorithm they were shown did not fit their clinic practices. Their reasons were varied but included the need to be flexible during the counseling session (i.e., the use of an algorithm would limit their ability to be flexible); and a bias that microbicides should only be introduced to those who consistently demonstrate an ability to use condoms (i.e., believing that microbicides should only be used in combination with condoms).

Most providers felt that microbicide counseling sessions could be integrated into existing clinical protocols and that only one session would be needed to cover the topics outlined in the flip chart. Although most of these providers did not elaborate on why, nearly all acknowledged that the HIV risk assessment questions in the flip chart were similar to those they already asked as part of their clinical protocols. To avoid unnecessary repetition, providers suggested they would likely integrate and merge the two sets of questions. Therefore, for these providers, adding microbicide information into their counseling sessions would reportedly not require much additional work: “As I counsel my clients on other things, I will also counsel on microbicides” (Nairobi non-HTC provider).

However, despite alignment with clinical flow and overlap in risk assessment questions, some providers insisted that microbicide counseling could not or should not be provided in one session, given the large quantity of information to be conveyed and discussed. Their reasons primarily included the perception that there was simply too much material to cover.

It can be hard, if there are many questions. It can take a long time for others who also want to see the counselor. (Nairobi HTC provider)

One session? People will sleep in the room! (Nakuru non-HTC provider)

Providers were also asked how easy they thought it would be for their clients to return to the health facility for follow-up counseling and a resupply of gel. Most providers felt that it would be easy for their clients to return if they had any concerns about gel usage; they trusted their partners and felt free to return; they had been appropriately counseled on the benefits of the gel; and/or they had been given or texted appointment reminders.

The few providers who felt their clients would have trouble returning to the facility for follow-up counseling indicated that follow-up rates would likely depend on the client’s own experience with microbicides. For example,

How did it react with them? How was the partner? Because if the partner doesn’t support that, the client may never come again, or may opt to go to a place where they are getting adherence counseling, but not for microbicides. (Nakuru non-HTC provider)

Appropriate Client-Tailored Counseling

Provider interviews revealed some evidence of rote counseling tendencies, in which providers typically counseled young women to be abstinent, female sex workers to use condoms, and married women to be faithful. By using hypothetical counseling scenarios, we sought to uncover more nuanced counseling techniques. During these scenarios, the vast majority of providers reported that they would be comfortable suggesting microbicides to women who were unable to use condoms. All but one provider were able to properly assess the HIV risk of the woman in their assigned scenario, and most providers were also able to suggest appropriate, realistic and tailored HIV prevention options.

For example, with young or single women, including female sex workers, providers tended to suggest microbicide gel and condom use. However, if the scenario mentioned that the women had a difficult time using condoms with their partner(s), providers typically suggested that the women use microbicides alone and/or in combination with other HIV prevention strategies such as HIV testing, partner reduction, or, where possible, abstinence. The following provide illustrative quotes:

Use of condoms . . . consistently. If the partner doesn’t want to use, she (Lucy) could use the female condom. You can introduce microbicides to her. (Nakuru non-HTC provider)

Realistic for her . . . we could talk about reducing the number of partners, and also having herself tested, because she (Leila) has not been tested recently. She doesn’t even know her status in the first place, so she should be tested, get to know her HIV status. Then, if she is negative for HIV, we will be talking about reduction of sex partners, . . . persistent use of the condom and now, the gel. (Nairobi HTC provider)

A minority of providers demonstrated challenges in suggesting appropriate HIV prevention options for the women in their assigned scenarios. For example, a few providers who received scenarios about young, single women or female sex workers either failed to suggest microbicide gel or condoms as potentially appropriate prevention methods. Similarly, only a minority of those who received scenarios about married women or women in stable relationships failed to suggest that microbicide gel was potentially appropriate within those scenarios; these providers suggested instead that condom use was realistic. This was noted in the following quote: