Ten providers, all professional nurses, trained in and currently providing family planning and contraception services, and 10 stakeholders were interviewed. Stakeholders were three government women’s health and HIV programme managers, two HIV clinical researchers, two obstetricians/gynaecologists (OB/GYNs), a specialist contraception provider, a family planning trainer, and a pharmacologist.
None of the clinics at which providers were working currently offered the contraceptive implant to women living with HIV, regardless of whether potential implant users were receiving efavirenz-based ART, other ART regimens, or no ART. At all clinics, implants were being offered to HIV-negative clients. Stakeholders confirmed that restrictions on implant provision to women living with HIV were common in clinics across the greater Cape Town area.
Perceptions of the implant introduction and experiences of implant provision
Providers and stakeholders reported enthusiasm surrounding the implant’s introduction in 2014, as a welcome new method important to expanding contraceptive options, particularly LAR Coptions, for South African women. A family planning trainer, with several decades’ experience at an HIV-focused non-governmental organisation, stated, 'when [implants] came here…Wow! Here is something that is going to save [time], and which does not need the clients to come to the clinic very often. It was a saviour, in our eyes' (family planning trainer, female).Providers likewise reported initial optimism about the implant, with one describing it as 'revolutionary when it came' (professional nurse, female). However, some stakeholders lamented the early portrayal of the implant as a wide-reaching, singular solution to South Africa’s high rates of unintended pregnancy: 'The method was sold to the public and to the staff as if this is going to be the solution for all the family planning woes that we’ve had until now. Which of course it isn’t' (health manager, female). Stakeholders involved in the provider training during the initial implant introduction perceived the implant introduction process as 'rushed', 'target-driven', 'not well-coordinated', and 'a poor reflection' of the 2012 guidelines’ intentions to expand and respect women’s informed contraceptive choices: 'The implant was completely foreign to [providers], so I think the training on its provision was quite rapid and the focus was insertion - to train them how to put it in, but the training on how to counsel women about their options was lacking' (OB/GYN, female). Another stakeholder involved in the national implant provider training programme acknowledged that, ‘whilst everyone denies it, I think there was very much acascading of ‘see one, do one, teach one" (specialist contraception provider, female).
Confirming stakeholders’ perceptions of a rapid decline in implant uptake after initially high levels, providers reported that, while the implant had been very popular when it was first introduced, insertions at their clinics had declined quickly thereafter and continued to do so. Providers perceived that large numbers of clients requested their implants be removed soon after insertion. In these cases, providers reported feeling ill-equipped to manage women’s concerns about the method in an evidence-informed way, often being unsure of whether particular side effects reported by clients, such as irregular bleeding, weight changes, headaches, and hair loss, were likely to be linked to the implant and/or how to appropriately counsel on and manage these side effects. Providers also reported that their clients were concerned about information they had heard about the implant in their communities, and that they were ill-equipped to respond to this. Such information included that the implant may be a ‘chip’ used for surveillance of women, as well as reported incidents of gangs violently removing implants from women’s arms. Provider’s believed that this negative information about implants had circulated widely in communities from soon after introduction and deterred women from initiating or retaining the method. Several stakeholders corroborated that they had heard reports of this kind of information from providers and clients.
Impact on provider practice of the NDoH implant-efavirenz guidance
Providers and stakeholders generally reported that the late 2014 implant-efavirenz guidance from the NDoH was received at the same time as the general enthusiasm about the implant’s introduction was diminishing among potential users and providers. Providers reported that during this period, in late 2014, clients were expressing growing and multidimensional concerns about the method, removal requests were increasing, and uptake had started to decline. This lead to general provider apprehension about suggesting or providing the implant to women seeking contraception.
Providers and stakeholders generally remarked that the 2014 NDoH circular which stated that “women who are on [efavirenz] should not use […] implants”  and the subsequent brief which used language related to “safety” as opposed to “contraceptive effectiveness” to describe the issue  intensified general provider apprehension about the implant method, and also introduced specific concerns about the safety of its use in women living with HIV. Most stakeholders believed that there was an inadequate consultation process prior to the issuing of the NDoH guidance. They mentioned several problems with the guidance that they believed were a result of inadequate consultation: that important differences between medical safety and contraceptive effectiveness were not clarified; that there was no mention of relative contraceptive effectiveness of different contraceptive methods; and that the guidance had not adequately acknowledged the importance of informed contraceptive method choice and the role of women’s varying individual needs, values and preferences when making decisions about which contraceptive method to use. Most stakeholders and providers viewed the guidance as having effectively removed the implant as an option for women on efavirenz-based ART, which then was applied at the primary healthcare level to all women living with HIV. They described the guidance variously as ‘pre-emptive’, ‘dogmatic’, ‘rushed’, ‘lacking perspective [with respect to the fact that absolute contraceptive effectiveness is only one of several factors a woman considers when choosing a contraceptive and that later research has shown that other methods such as injectables and oral pills when used with efavirenz may have higher rates of contraceptive failure than the implant]’. The guidance was described by the majority of those interviewed in both groups to have been worded such that providers might conclude from it that implants were ‘not medically safe, so let’s just remove them’ (OB/GYN, female).
All providers confirmed that they believed implants to be totally contraindicated in the context of HIV infection, and that this was the general interpretation and implementation of the NDoH guidance at their clinics and elsewhere. This confirmed stakeholders’ general perceptions of restricted provision of the implant to women living with HIV across Cape Town primary healthcare clinics. Illustrating this, a health manager believed that providers in her sub-district were reluctant to offer a method they perceived might harm clients, with concerns about side effects seen as a deterring factor: ‘No one is being offered – no HIV-positive woman is being offered [implants]. I think they’re just playing safe’ (health programme manager, female).
Current levels of knowledge and understanding among providers as to the NDoH rationale behind the implant-efavirenz directives ranged from vague notions that the implant should never be provided to ‘chronic clients [including those living with HIV]’ (professional nurse, female); to, ‘I’m not sure which one, exactly, the ARV that is contraindicated with this [implant] …’ (professional nurse, female); to, ‘We were told the ART, it lowers the effectiveness - we were told, but how? I never went through it, or understood it quite clearly’ (professional nurse, female); to, ‘They say, it’s contraindicated with the drugs that they’re using, and that person can still fall pregnant when they are using the [implant] because it is not stronger than the three-months injection’ (professional nurse, male).
While some providers were aware of the WHO’s MEC recommendations on implant use with efavirenz, all were reluctant to provide implants to women living with HIV pending clear, updated instructions from the NDoH. Providers described feeling a sense of personal responsibility for client safety and personal vulnerability, as well as fears of legal repercussions. ‘It’s not that I’ll find it difficult to insert, but at the end of the day, I’ll be held accountable. Anything bad that may happen… Some may lay charges, you know?’ (professional nurse, male).
Stakeholders were more aware of the evidence surrounding the NDoH’s recommendations and viewed it in accordance with their own understandings of the risk and benefit decision-making key to providing implants in the context of efavirenz. They were also more aware than providers that the guidance was specific to efavirenz-based ART rather than to all ART regimens or all women living with HIV. Rather than denying the implant as an option altogether for women living with HIV on efavirenz-based ART regimens, specialist contraception providers generally endorsed the following approach with clients: explaining the increased risk of implant failure with efavirenz, the reasons for this, the relative effectiveness of other methods, and the importance of dual contraceptive method use with condoms in addition to the implant to increase effectiveness, Justifying this, they cited the WHO’s MEC, the original 2012 guidelines which emphasize the importance of giving all women choice (including women living with HIV), and evidence indicating higher comparative typical-use failure rates of most other available methods. One specialist contraception provider had written letters for her clients living with HIV using implants for them to take along to their primary healthcare providers, stating they could retain the method if they chose to, ‘so they can carry it with them, because they go to the clinic and clinic says, ‘No, you must have that out!’ (specialist contraception provider, female).
Influence of training, capacity and health systems issues on implementation of implant-efavirenz guidance
Some providers and stakeholders observed that public sector healthcare providers had limited time to provide comprehensive client counselling and choice of contraceptive methods. This was considered especially true for LARCs, as well as for the implant in the context of efavirenz and other enzyme inducing drugs. Hence, the default position was to not counsel on or offer such methods. One provider described an integrated service environment where ‘the family planning sister must do everything. It’s more like a one stop shop that we’re currently busy doing. So, there are some services that you are going to neglect. When you’re there, and I must put in an [implant], and I know there’s a sick child – I must still see the sick children. I’m not going to put in the [implant]. I’m going to opt for something else. It won’t be the client’s choice, it will be the provider’s choice, because of the clients that must still be seen’ (professional nurse, female). An OB/GYN was also concerned that providers were often overburdened by the responsibility to ‘understand every single detail about every single condition that they’re dealing with’ (OB/GYN, male). He believed it was ‘impossible’ to expect providers to properly convey all necessary information to clients during single consultations and still find time to facilitate informed contraceptive choice, leading providers to focus on what they considered to be the more familiar methods which require less nuanced counselling.
Some stakeholders corroborated this, noting that, particularly in areas where there was limited provider training, they had observed a pattern of simplified rule-following amongst primary healthcare providers. This was understood as a way for providers to retain their ability to make efficient decisions whilst managing heavy workloads and wide-ranging responsibilities: ‘So, a lot of the clinicians are doing things that they aren’t necessarily fully trained and equipped for, particularly the nurse clinicians, and so, they adopt one rule, and that’s just the way it happens’ (pharmacologist, female). In the specific case of the implant-efavirenz guidance, ‘I do think it’s probably easier just to take out the implant – you just learn the rule and then you follow it’ (HIV clinician, female).
Notably, some stakeholders believed that inadequate training on implant provision and counselling (and subsequent confusion about implant-efavirenz guidance) affected both doctors and nurses in the public healthcare sector. ‘There was an assumption that doctors don’t need [implant] training’ (health manager, female) and, when it came to incorrect insertions, ‘doctors are worse than nurses’ (specialist contraception provider, female). HIV clinicians were believed to be more likely to misinterpret the NDoH advice ‘because a lot of the people who get referred to the family planning clinic to take the implant out come from the HIV clinics’ (OB/GYN, female).
Suggestions for future contraceptive policy-making and service delivery initiatives
In light of their experiences around implant introduction and guidance on implant use for women living with HIV, participants were asked to suggest recommendations for improving contraceptive choice and services for women living with HIV in South Africa. Themes emerged related to: multi-stakeholder consultation when developing guidance; ensuring that contraceptive care is focussed on quality of counselling and services, which build client-provider trust, as opposed to numerical targets; and the NDoH undertaking efforts to improve the reputation of the implant specifically.
At the guidance and policy-making level, stakeholders emphasized that, when issuing guidance to providers, NDoH needed to take more time to consult with stakeholder groups, particularly in circumstances where available evidence indicates no immediate physical danger associated with an intervention or service. One health manager proposed a system of policy ‘panel-beating’. She explained that policy-makers ‘would improve a lot if they had things read and interpreted by somebody else. Sometimes, I get something, and I see it one way, and then somebody else reads it another way… So, I frequently call on the secretary, the cleaner, the clerk, and say, ‘Okay, read this for me. What did you understand?’ (health manager, female). Several stakeholders stated that significant gaps in primary healthcare provider knowledge about contraception generally, and the implant specifically, necessitated widespread retraining. This was due to the widespread non-provision of implants to all women living with HIV based on unfounded safety concerns, and regardless of ART regimen. It was viewed as urgent and timely given the anticipated upcoming changes in the first-line ART regimen in South Africa to a dolutegravir-based regimen (an ART considered highly unlikely to decrease the effectiveness of implants).
Provider and stakeholders suggested that when new contraceptive methods are introduced, implementation should focus more on ensuring that providers are equipped to facilitate client-centred, rights-based, informed contraceptive choice, rather than placing pressure on clinics to meet numerical targets for method coverage. Participants in both groups expressed frustration that ‘pushing for numbers’ (professional nurse, female) in the case of the implant rollout had compromised client method choice. Related to this, emphasis in training is needed on building provider-client trust in contraceptive care and facilitating choice, especially in offering long-acting options such as the implant. As one provider explained: ‘We [providers] have this way of, you know, subtly forcing them to take something and, ultimately, they walk out and they’re angry with you as a nurse, as a facility. They’re angry because you’ve given them something that they didn’t want, and a three-year device is… It’s a three-year device. So, irrespective of if they have HIV or they don’t have HIV, I think if the client has the knowledge and consent – we need to treat clients as if they were adults’ (professional nurse, female).
Providers and stakeholders identified a need for the NDoH to actively address the implant’s broader negative reputation and misinformation about the implant amongst providers, women and communities. With regard to the implant-efavirenz directives in particular, providers stated that they need clarification about its safety and effectiveness in women living with HIV, and the rights of women living with HIV to choose the method. A health manager suggested engaging HIV activist groups, who ‘play a very important role in whether a method or system, or drug, or whatever, is going to be adopted or not. They are very strong activists, and most of them were scared that they had an [implant] inserted and they were on ARVs. What do you think they are going to tell the rest of the community?’ (health manager, female).