Zika and women's sexual and reproductive health: Critical first steps to understand the role of gender in the Colombian epidemic

Abstract Objectives To describe the mechanisms of implementation of Zika virus diagnosis, prevention, and management guidelines in Colombia, and to characterize their influence on efforts to defend sexual and reproductive rights. Methods A qualitative study performed between February and April 2018 in three municipalities in Colombia. We conducted 30 semistructured interviews and five focus groups with key informants who played a role during the epidemic. These included decision‐makers, program coordinators, healthcare providers, pregnant women diagnosed with Zika virus, and members of affected communities. Results We identified barriers to and facilitators for the implementation of the national Zika virus response plan. Barriers included a lack of coordination between vector control efforts and in the realms of sexual and reproductive rights. Facilitators included healthcare providers’ response to the epidemic, the development of technical skills, and the establishment of coordination and referral networks across different institutions. Conclusion A multidimensional approach that considers healthcare services, gender issues, and the environment is crucial. We highlight the epidemic's effects on women's sexual and reproductive rights, mainly related to inequalities in sexual and reproductive health such as the increased risk of sexually transmitted infections experienced by the poorest and most vulnerable women.


| INTRODUCTION
The global agenda of the Sustainable Development Goals (SDGs) for 2030 emphasizes the importance of understanding the interactions between gender, sexual and reproductive health (SRH), and efforts to mitigate climate change. 1 Vulnerability to the forces of climate change and to emerging epidemics is not determined exclusively by biology. Differences in roles and responsibilities expose women and girls to additional risks. 2 In addition to gender, other axes of power and inequalities such as race, socioeconomic status, occupation, age, disability, and sexual preference all influence people's vulnerability. 3 This makes the intersectional analysis of global health problems, including SRH, extremely relevant. 4 In poor communities in northeast Brazil, an increase in the number of infants born with microcephaly during a Zika virus epidemic led to the discovery that Zika virus infection during pregnancy was the cause. Currently, Zika virus exists in 69 countries, and birth defects linked to infection during pregnancy have been described in 29 countries. 5 The sexual transmission of Zika virus has been documented, [6][7][8] but there are additional implications for women's SRH that have not been reported and which are related to inequalities in SRH. These include the increased risk of sexually transmitted infections; barriers to accessing quality primary healthcare; lack of adherence to programs and protocols; and stigma and discrimination experienced by the poorest and most vulnerable women. Climate change also impacts the health of women in lowand middle-income countries. 2,9 In Colombia, between 2015 and 2017, vector-borne diseases like malaria, dengue, chikungunya, and Zika virus affected more women than men. 10 For Zika virus, since the beginning of the epidemic phase, 66.4% of suspected and confirmed cases were in women. 11 In total, there were 6363 confirmed cases and 13 383 suspected cases among pregnant women who reported some symptoms compatible with Zika virus infection. 11 Zika virus has profound consequences for women's SRH 12,13 because it is sexually transmitted 6-8 and carries high risks for pregnant women 14,15 through mother-to-child transmission, which can cause microcephaly and other central nervous system anomalies. [16][17][18] In addition, the emergence of Zika virus is related to environmental causes and climate change, which in turn influence the epidemic and women's SRH. For these reasons, a multidimensional approach to the epidemic is warranted.
In this context, a plan to address Zika virus should go beyond classic health-related actions or vector control strategies (such as improving living conditions and water sources) and should incorporate actions that address sexual and reproductive rights (SRR). Addressing the epidemic should include recognition that Zika virus affects women and men differently, that the virus is sexually transmitted, and that early diagnosis of symptomatic pregnant women is key, as is access to contraception and safe abortion.
In 2016 the Colombian government prioritized Zika virus in the political agenda and started the implementation of the Zika Virus Fever Response Plan. 19 The focus of the plan was to strengthen public health surveillance systems for vector-transmitted diseases and to increase health education, prevention, and vector control efforts. The program also included funding for supplies such as insecticides, larvicides, and mosquito nets. It also addressed contingencies derived from climate change and encouraged research and monitoring of pregnant women and children's health.
The present study puts forth a multidimensional approach to Zika virus as a first step to understanding the epidemic's impact on SRH issues. The objective was to describe the mechanisms of implementation of the national guidelines to detect, prevent, and treat Zika virus; then describe their impact on SRR in Colombia. The focus was on three municipalities that were affected differently by the epidemic: Barranquilla, Cúcuta, and San Andrés.

| MATERIALS AND METHODS
This qualitative study was conducted in Colombia between February 21 and April 10, 2018. The study was approved by the Pan-American Health Organization Ethical Review Committee (PAHOERC) and the Ethical Committee of Profamilia. All participants signed an informed consent form. We conducted semistructured interviews and focus groups with key informants who belonged to one of the following groups: (1) national government; (2) local/regional government; (3) healthcare providers; (4) community members; and (5)

| RESULTS
We identified facilitating factors that spurred the implementation of actions to address the Zika virus epidemic. We also identified barriers and aspects to improve in the implementation process.

| Healthcare sector response
In all study locations, healthcare providers and community members all agreed that the needs of pregnant women needed to be prioritized because they represent the highest risk group. Some respondents highlighted that healthcare providers emphasized SRR by conducting educational activities with affected communities. These included information about delaying pregnancy, using barrier methods of contraception, and abortion. Educational campaigns were also conducted outside of healthcare centers, and healthcare personnel received training on Zika virus. These activities reduced barriers to care and enhanced the detection of cases among pregnant women as well as their follow-up care. Teams of technical experts also improved their skillset by working at the local and regional level. After the first cases were reported, efforts were made to characterize the virus and devise epidemiologic surveillance and clinical practice protocols. However, obstacles were encountered with sending biologic specimens to the National Institute of Health in Bogotá, and long wait times were noted before a confirmatory result was available. This impacted the clinical follow-up of affected patients.

| Interinstitutional cooperation
Public and private healthcare providers and research institutions coordinated efforts and shared objectives, which helped strengthen the surveillance capacity of the public health system as well as the capacity to diagnose and treat cases at the health system level. This also allowed members of varying institutions to access the trainings described above. At the national and regional level, as well as among healthcare providers, there was consensus that the Ministry of Health and the National Institute of Health had been key in determining the successful implementation of national guidelines.

| Barriers to implementing the response plan
The following paragraphs describe the three barriers that emerged, as a critique to the implementation of the National Zika Virus Response plan: (1) focus on sexual and reproductive health; (2) focus on regional initiatives; and (3) attitudes and knowledge at the community level.

| Focus on human rights and sexual and reproductive rights in the National Response Plan
The profound implications of Zika virus on SRR were not completely recognized and integrated into the Response Plan; for example, recognition that Zika virus is a sexually transmitted infection and that access to health services is key for the affected population. Zika virus outbreak prevention and management efforts focused on vector control rather than on SRH consequences.
The focus on SRH was promoted at the national level, but these efforts were not sufficiently integrated with the National Policy on Sexuality, Sexual and Reproductive Rights. 20 One of the barriers was religious and cultural beliefs, which stigmatized abortion as an option for pregnant women infected with Zika virus. Some healthcare providers admitted that they did not provide patients with comprehensive information, and that their counseling focused on the newborn's microcephaly risk instead.

| Local/regional efforts focused primarily on vector control
Training and preparation efforts were primarily oriented toward developing competencies directly related to Zika virus, rather than toward the epidemic's impact on women's SRR. All of the interviewees discussed Zika virus vector control programs, including cleanup of mosquito breeding grounds and management of water and sewage systems. Community education programs encouraged people to wear covering clothing and mosquito repellent to prevent bites. Public information campaigns included information about how to reduce the risk of infection, how to identify the symptoms, and how to access healthcare services. These campaigns targeted people who lived in or transited through areas at high risk of transmission.

| Attitudes, behaviors, and knowledge at the community level
In terms of attitudes, what stood out was the use of knowledge to implement preventative actions against the spread of the vector, as well as the attention to the disease at the individual, family, and community level. However, lack of information and barriers to accessing services persisted, and some infected individuals who did not access healthcare services decided to self-medicate with "home remedies." Pregnant women with suspected or confirmed infection expressed the need to reinforce communication and prevention campaigns and to focus on their needs as women. We also found that the modes of transmission of the virus were not well explained to the public, and the recommendation to use barrier methods of contraception was not strong enough. In summary, the response to Zika virus at the community level and in terms of personal behavior change was inadequate.

| DISCUSSION
Our study identified facilitating factors for and barriers to the implementation of the National Response Plan to the Zika virus epidemic in Colombia. The most significant lesson learned was that a multidimensional approach to Zika virus is necessary to address the interaction of the epidemic with gender roles, sexual and reproductive health and rights, and the environment.