Bixby program celebrates 20 years of research in Zimbabwe

This year marks the 20th anniversary of the Bixby Center's partnership with the University of Zimbabwe (UZ) in HIV/AIDS research. The collaborative research program has released a new report and website to commemorate this anniversary and highlight some of its noteworthy findings and accomplishments.

Since its launch in 1994, UZ-UCSF studies have helped shape national and global responses to the HIV/AIDS pandemic, and defined policies and standards regarding HIV acquisition, prevention, treatment and care. Examples include: 

  • Groundbreaking research in antiretroviral therapy (ART) for HIV prevention, including ART in patients co-infected with tuberculosis.
  • ART for prevention for couples with one HIV-positive and one HIV-negative partner.
  • Initiation and monitoring of pediatric ART. 
  • Microbicides for HIV prevention.
  • Community HIV testing strategies.
  • Prevention of mother-to-child HIV transmission.

Over the past 20 years, UZ-UCSF researchers have led 63 research studies with more than 15,000 participants. Additionally, the program has mentored the next generation of Zimbabwean and global researchers, supporting more than 200 upper-level students and postgraduates to date. The partnership is leading 22 ongoing studies, continuing to develop capacity to identify and respond to emerging scientific priorities.


Women pay significant out-of-pocket costs for abortion care

Under the Affordable Care Act, millions of women in the United States will have increased access to public and private health insurance. However, any potential gains in women’s access to health insurance will be limited by federal and state restrictions on coverage for abortion care. Even though an estimated 30% of U.S. women will have an abortion by age 45, longstanding restrictions limit the use of federal Medicaid funds for the procedure, and new restrictions limit private insurance coverage for abortion care.

New research from the UCSF Bixby Center reveals that due to these restrictions, many women pay substantial out-of-pocket costs for abortion care. Based on interviews with women visiting 30 abortion clinics nationwide, the researchers found that:

  • Twenty-nine percent paid the full cost out-of-pocket.
  • Two-thirds (71%) received some financial assistance in covering the cost of an abortion, mainly state Medicaid (34%) and other organizations (29%). 
  • Even with financial assistance, most women had some out-of- pocket costs for abortion. Out-of-pocket costs for abortion paid by the woman, family, or friends ranged from $0 to $3,700, with an average of $474. 
  • For more than half of the study participants, total out-of-pocket costs (including abortion and travel) were more than one-third of their monthly income. 
  • More than half of women (54%) reported that raising money for an abortion delayed obtaining care.

There are significant gaps in the system for providing financial assistance, insurance and Medicaid coverage for abortion care. New state-level laws further restricting insurance coverage for abortion will only exacerbate existing challenges. The researchers call for studies to examine how new restrictions on private insurance coverage for abortion burden women seeking safe reproductive health care.


Measuring women’s reproductive autonomy

Researchers are increasingly recognizing the importance of women’s reproductive autonomy for their health and well-being. Reproductive autonomy is having the power to decide and control contraceptive use, pregnancy, and childbearing. For example, women with reproductive autonomy can control whether and when to become pregnant, whether and when to use contraception, which method to use, and whether and when to continue a pregnancy.

Despite the importance of such decisions for women’s health, few studies have assessed reproductive autonomy using a validated measure or examined how autonomy affects contraceptive use. Researchers from the UCSF Bixby Center sought to address this issue by creating a validated instrument to measure women's reproductive autonomy. The measure:

  • Is applicable to women in any type of sexual relationship (married or unmarried, cohabitating or not) and to women living in a variety of gender-equity contexts worldwide. 
  • Captures the influence of other individuals in addition to women's sexual partners, such as parents, in-laws, and friends. 
  • Is concise, so that it could be easily inserted into standardized questionnaires, evaluations, or clinical assessments.

Researchers hope this tool will help addresses the significant void in studies of women's empowerment and health. Over time, the tool may show that sexual and reproductive health interventions that explicitly address women's reproductive autonomy are more effective at helping women realize their reproductive goals.


Over-the-counter access to oral contraceptives could help increase use

Unintended pregnancy is a significant public health issue in the United States, accounting for half of all pregnancies. One significant contributing factor is that many women have problems accessing contraceptives. Additionally, women who have abortions are at high risk for future unintended pregnancy, and are therefore an important population to include when examining barriers to contraceptive access.

Making oral contraceptive pills accessible over-the-counter (OTC) may improve the availability of this effective method. OTC access could also be attractive to women who have difficulty obtaining prescriptions, including some women seeking abortion. Researchers with the UCSF Bixby Center surveyed women seeking abortions across the United States to gauge their interest in obtaining the pill OTC.

The researchers found a high level of interest in OTC access: 

  • 81% of participants supported OTC access to oral contraceptives.
  • 42% planned to use the pill after their abortion. This increased to 61% if it were available OTC.
  • 33% who planned to use no contraceptive following abortion said they would use an OTC pill, as did 38% who planned to use condoms afterward.
  • Uninsured participants showed greater interest in OTC access than those with private insurance.

Oral contraceptive use among women at high risk of unintended pregnancy may increase if the pill were available without prescription. Women consider OTC access convenient and timesaving compared to clinic visits. The pill is already formally or informally available without a prescription in many countries.


Improving family planning and abortion training for physicians

Medical residents training to become Obstetrician-Gynecologists in the United States can opt out of training on abortion for religious or moral reasons. Some data suggests that most residents who opt out of abortion training do go on to gain skills in other aspects of family planning, but we know little about their experiences.

Researchers from the UCSF Bixby Center conducted interviews with current and former residents who opted out of some or all of the family planning training at ob-gyn residency programs. The programs were affiliated with the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. They found that residents who opted out of abortion training valued the ability to participate in family planning training.  These residents identified specific knowledge and skills that they thought would impact how they care for patients: 

  • Physicians commonly described contraceptive counseling and knowledge as particularly useful skills they obtained from the training. 
  • They appreciated the efforts of the faculty to allow them to learn up to the level of their comfort. 
  • Physicians gained confidence in caring for patients facing unintended pregnancies. They also improved their communication skills, especially in offering options counseling.
  • Broadly, interviewees described being able to step back from their personal beliefs about abortion and instead focus on caring for patients. Many also reported a change in their beliefs about women seeking abortions and abortion providers.

Given these findings, the researchers recommend that all residency programs offer students the opportunity to participate in family planning and abortion care training regardless of their attitude about abortion. Such training should go beyond procedural skills to include in-depth contraceptive training and exposure to abortion counseling.