Implants for HIV prevention in young women: Provider perceptions and lessons learned from contraceptive implant provision

Preventing new HIV infections, especially amongst young women, is key to ending the HIV epidemic especially in sub-Saharan Africa. Potent antiretroviral (ARV) drugs used as pre-exposure prophylaxis (PrEP) are currently being formulated as long-acting implantable devices, or nanosuspension injectables that release drug at a sustained rate providing protection from acquiring HIV. PrEP as implants (PrEP Implants) offers an innovative and novel approach, expanding the HIV prevention toolbox. Feedback from providers and future users in the early clinical product development stages may identify modifiable characteristics which can improve acceptability and uptake of new technologies. Healthcare workers (HCWs) perspectives and lessons learned during the rollout of contraceptive implants will allow us to understand what factors may impact the roll-out of PrEP implants. We conducted eighteen interviews with HCWs (9 Nurses and 9 Community Healthcare Workers) in rural KwaZulu-Natal, South Africa. HCWs listed the long-acting nature of the contraceptive implant as a key benefit, helping to overcome healthcare system barriers like heavy workloads and understaffing. However, challenges like side effects, migration of the implant, stakeholder buy-in and inconsistent training on insertion and removal hampered the roll-out of the contraceptive implant. For PrEP implants, HCWs preferred long-acting products that were palpable and biodegradable. Our findings highlighted that the characteristics of PrEP implants that are perceived to be beneficial by HCWs may not align with that of potential users, potentially impacting the acceptability and uptake of PrEP implants. Further our data highlight the need for sustained and multi-pronged approaches to training HCWs and introducing new health technologies into communities. Finding a balance between the needs of HCWs that accommodate their heavy workloads, limited resources at points of delivery of care and the needs and preferences of potential users need to be carefully considered in the development of PrEP implants.

Family Planning Films: Fact or Fiction? A Qualitative Study Assessing Changes in Knowledge, Attitudes, and Intentions to use Family Planning After Watching Documentary and Drama Health Education Films

Background: There is a paucity of literature on the effectiveness of drama or documentary films in changing knowledge, beliefs, attitudes, and behavior of people towards family planning. This study aimed to compare and assess the acceptability of health promotion films based on documentary or drama, and their effect on knowledge, attitudes, and intention to use family planning.Methods: We developed short documentary and drama films about contraceptive implants, using the person-based approach. Their acceptability was assessed in focus group discussions with younger women below 23 years, women over 23 years, men of reproductive age, and health workers in four different areas of Uganda (Bwindi/Kanungu, Walukuba/Jinja, Kampala, and Mbarara). Transcripts of the focus group discussions were analyzed using thematic analysis, to generate themes and examine the key issues. We assessed changes in knowledge, attitudes, and intentions to use family planning after watching the films. Results: Sixteen focus groups with 150 participants were carried out. Participants said that the documentary improved their knowledge and addressed their fears about side effects, myths, and implant insertion. The drama improved their attitudes towards the implant and encouraged them to discuss family planning with their partner. The final versions of the documentary and the drama films were equally liked. Conclusions: Viewing a short documentary on the contraceptive implant led to positive changes in knowledge, while a short drama improved attitudes and intentions to discuss the implant with their partner. The drama and documentary have complementary features, and most participants wanted to see both.

Three-year observational study of immediate post-abortion insertion versus menstrual insertion of etonogestrel contraceptive implant

Objective This study aimed to estimate the difference in vaginal bleeding pattern, discontinuation rate, and satisfaction between immediate after abortion and menstrual insertions of etonogestrel contraceptive implants. Study design Between May 2013 and November 2015, 66 women were recruited in the abortion group who selected etonogestrel implants as their contraceptive immediately after induced abortion. 84 women who underwent the placement of the etonogestrel implant during their menstrual period were enrolled as the menstrual group. The two groups participated in 3-year follow-up outpatient visits at 1, 6, 12, 24, and 36 months after implantation. The vaginal bleeding pattern, discontinuation rate, satisfaction rate were recorded and compared. Results No woman had pregnancy over the study period of 3 years. The incidence of amenorrhea/infrequent bleeding did not differ between the two groups after 12, 24, and 36 months of implantation (53.0% vs. 58.4%, 47.8% vs. 51.6%, and 48.6% vs. 55.6%, respectively). In the abortion group, the incidences of frequent/prolonged bleeding were 15.1%, 32.6%, and 27.0% after 12, 24, and 36 months of implantation, respectively, while the other group showed 27.3%, 25.8%, and 20.4%, respectively. After 12 and 24 months, the continuation use rates were 69.7% and 56.1% in the abortion group and 73.8% and 64.2% in the menstrual group. The 12-month satisfaction rate between abortion group and menstrual group was 69.6% versus 72.6%. Statistical analyses show that there was no difference in vaginal bleeding pattern, discontinuation rate or satisfaction between the two groups. Conclusions Immediately post-abortion may be also a favorable time to undergo etonogestrel implantation.

Women’s experiences on the use of Implanon as a contraceptive method in a selected primary healthcare facility in KwaZulu-Natal

Background: The South African department of health recently introduced subdermal Implanon contraceptive implant with the aim to reduce teenage pregnancy and maternal mortality. First used in all public healthcare facilities across the country since early 2014, this method of contraception has been described as highly effective. However, some women have reported unbearable side effects, forcing them to remove the contraceptive implant early before its expiry date. Negligible emphasis has been placed on staff training and development to equip the nurses with new protocol and policies on Implanon.Objectives: The objective of this study was to explore experiences of women using Implanon as method of contraception at a selected primary healthcare facility in KwaZulu-Natal province of South Africa.Methods: A qualitative, descriptive and exploratory study design was used. A purposive sampling technique was used and a sample of seven women aged between 15 and 50 years was selected for this study. Semi-structured interviews were used in the data collection process. The Tesch’s method for data coding and data analysis was utilised. Necessary ethical measures were taken to ensure that the study is trustworthy. The study was conducted at Community Health Centre, KwaZulu-Natal between June 2017 and December 2018.Results: The findings showed that some participants were still willing to continue using this method of contraception regardless of the unwanted side effects. Major side effects reported were heavy menstrual bleeding, pain and discomfort, weight loss, insomnia and decreased sexual interest, which resulted in most participants stopping the use of Implanon.Conclusion: Most of the participants’ experience unwanted side effects because of poor screening, counselling and support. There is a clear demand to develop a screening tool and facilitate training of healthcare workers when initiating the use of Implanon.

The Prevalence and Side Effect of Nexplanon in Baghdad

BACKGROUND Nexplanon is a pregnancy-prevention device that is both safe and reliable. It is a novel reversible long-term contraceptive technique. It's a modern long-acting contraceptive device with a subcutaneous implant that releases etonogestrel (ENG). The main objective of this research was to determine the distribution, tolerability, and adverse reactions of Nexplanon among females who used it in Baghdad and find any relationship between these side effects and the acceptability of the device among contraceptive users. METHODS This study was done via the participation of 80 women who were using Nexplanon at the time of study or had recently removed the implant; the data was obtained from a direct interview and medical records. RESULTS The total number of women enrolled for the study was 80. The mean age of contributors was 33.24 (± 2.69) years. None of the participants was nulliparous; 15 % had two children, 85 % had three or more children. Of the participants, 26.25 % and 65 % had secondary and higher education degrees respectively, while only 7 % had primary education and none of the participants had any education. 6.25 % were smokers, only 28.75 % had irregular cycle and the remaining percentage had a regular one. 57 (71.25 %) of them underwent adverse events while using the contraceptive implant, the most common one was bleeding disorders most likely in the form of light intermittent bleeding. 69 (86.25 %) from those only 18 (26.08 %) removed implant because of this irritant bleeding, the next common adverse event was headache 44 (55 %), 8 (18.18 %) of them removed the implant because of headache, 41 (51.25 %) underwent variable mood swing changes, 36 (45 %) suffered from weight gain with use of the implant, 33 (41.25 %) nausea and bowel habits changes, androgenic effects presented in 19 (23.75 %) and 10 (12.5 %) in the form of acne and hirsutism, respectively. 3 (10.34 %) of them removed the device as they could not cope with this complication, only 6 (7.5 %) suffered from low sexual desire. CONCLUSIONS Nexplanon can be a suitable alternative for women who have been adequately informed about long-term contraception but bleeding disturbances and cycle durations (> 8 days) are also key indicators for early removal. The process of consulting the patient and giving them the appropriate educational advice on this subject should be a priority before using the implant, in addition to establishing special induction and educational programs. KEY WORDS Nexplanon, Contraception Method Contraception Method, A Subcutaneous Implant and Etonogestrel.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe

Objectives The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance. Methods The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included. Results All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction). Conclusions Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication. Key Points • Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm). • The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain. • This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.