Africa: No Changing Mindset on Contraception 'Overnight'

Dr. Quarraisha Abdool Karim
2 February 2012

Dr. Quarraisha Abdool Karim is an infectious diseases epidemiologist and associate scientific director of the Centre for the Aids Programme of Research in South Africa (Caprisa). AllAfrica's Julie Frederikse spoke to the 51-year-old and asked her about the challenges facing her team as they search for effective ways to prevent HIV and other sexually transmitted infections.

We appreciate that there are many challenges. To simply walk in and say, doctors and nurses, you must now provide this or that - it won't work. We are aware that services are very strained in the public health sector. Morale is low, staff feel overwhelmed, and nurses often don't get sufficient support in the implementation of policy decisions.

So we have been working with the family planning nurses, using a Quality Improvement Strategy model that's been used extensively to improve the quality of health care delivery and access to important health interventions. It's similar to Paolo Freire's work in education, in that we aim to work with health care staff using empowering and enabling approaches.

How would you assess the government's sexual and reproductive health services in South Africa?

This country has one of most enviable lists of contraceptive methods available at no cost, yet the main method used is Depo Provera (which a recent study has shown to double the risk of transmission of HIV to women). There are IUDs and implants, which may be much better, safer options. So why are they not being promoted? Even with the injectables, there is NET-EN (norethisterone enanthate), which has a lower dose of progesterone and has a favourable safety profile for use by young people.

The point is that we have as policy on our essential drug list an extensive group of fertility control methods, so why is this not translated into access at point of delivery? The answer relates to the fact that the normal interaction time between a health professional and a client is very short, sometimes as short as 30 to 40 seconds. This doesn't leave time to consider other contraceptive options. We know you can't change people overnight, especially when their prescribing patterns are limited to just giving an injection, and perhaps asking a question like, 'do you know your HIV status?' But we know that we've got to change health care provision - to include HIV testing, screening for STIs and cervical cancer, just to mention a few. It's got to be part of a comprehensive model for prevention and treatment - but the challenges are in how to integrate this in over-stretched clinics.

So how can these important goals be achieved on the ground, especially in light of negative reports from women who use the government clinics?

We need to change mindsets, to show public health care workers how to offer the client in front of them, a comprehensive, high quality service. In the three months since we started doing this in a group of rural family planning clinics - the change has been phenomenal. Women are sharing their experiences, and the number of women coming through the clinic is already an indication of improved services - so now we have to keep it up!

And also, we are finding that nurses are feeling pride at returning to what brought them into the profession in the first place. So I feel very strongly that we should not be prejudicial and let people say nasty things about the attitudes of doctors, nurses and health care workers.

Being a woman yourself, has this been a factor in shaping your approach to health care around family planning and HIV and Aids?

I wouldn't put it down to a single factor, there is a whole conglomeration of issues impacting on me. I'm a woman, but I'm also a wife and a mother (of three). The fact that I'm born Muslim is part of my identity, and part of what I draw from Islam is service to humanity and respect for others. I am also an Indian - even though I count myself as a South African first and Indian second - but it is part of who I am.

I can't separate out my identity - being born in South Africa during the apartheid era and being part of the anti-apartheid movement has also shaped my identity. So in being a scientist I hope I can change women's lives for the better. What I do is driven by that fundamental belief.

You mentioned your Islamic background; does religion impact on your field of HIV prevention?

The issue of religion is most pronounced in the HIV epidemic with regard to condoms and male circumcision. In countries where circumcision is practiced there are lower rates of HIV; this may be due to circumcision or to more conservative sexual mores. In Islam, as with Judaism, it is not simply about the removal of the foreskin at birth - there is a whole set of religious beliefs and practices. It is about what else is promoted, for example, no sex before marriage. And respect for your body is very much part of children's upbringing. Some view these directives as constraining and old-fashioned, but on the other hand, religion has offered protective environments for minimizing the spread of HIV, for example in Senegal (where HIV prevalence is estimated to be less than one percent).

Which other African countries have made strides against HIV and AIDS?

I'm involved in a training and capacity-building programme that includes Swaziland, Lesotho and Namibia, and I co-chair the HIV Prevention Trials Network, at the National Institutes of Health-funded global network that sets prevention priorities and undertakes research. We undertake HIV prevention studies work in Uganda, Tanzania, Malawi, Zimbabwe and South Africa because we tend to work more in Anglophone countries. Zimbabwean scientists and health workers have done great work under trying conditions. Uganda has been held up for so many years as shining star, but sadly now we are seeing reversals in some of that country's gains.

Botswana has done amazingly well, though some would argue that they didn't build their internal capacity. On the other hand, we are a global community so if others come and assist, that's not a problem.

A country that has actually been a very good example is Tanzania, which has quietly, but constructively gotten on with things. And Kenya has had many challenges, but has begun to scale-up its testing programs and male circumcision. So we are seeing good signals coming out of many parts of Africa.

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