Behavioral interventions for improving contraceptive use among women living with HIV

Topical microbicides for preventing sexually transmitted infections

BACKGROUND

This is a updated version of our Cochrane Review published in Issue 6, 2012. Sexually-transmitted infections (STIs) continue to rise worldwide, imposing an enormous morbidity and mortality burden. Effective prevention strategies, including microbicides, are needed to achieve the goals of the World Heath Organization (WHO) global strategy for the prevention and control of these infections.

OBJECTIVES

To determine the effectiveness and safety of topical microbicides for preventing acquisition of STIs, including HIV.

SEARCH METHODS

We undertook a comprehensive search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CLIB, Web of Science, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and reference lists of relevant articles up to August 2020. In addition, we contacted relevant organisations and experts.

SELECTION CRITERIA

We included randomised controlled trials of vaginal microbicides compared to placebo (except for nonoxynol-9 because it is covered in related Cochrane Reviews). Eligible participants were sexually-active non-pregnant, WSM and MSM, who had no laboratory confirmed STIs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and selected studies, extracted data, and assessed risks of bias in duplicate, resolving differences by consensus. We conducted a fixed-effect meta-analysis, stratified by type of microbicide, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included eight trials from the earlier version of the review and four new trials, i.e. a total of 12 trials with 32,464 participants (all WSM). We did not find any eligible study that enrolled MSM or reported fungal STI as an outcome. We have no study awaiting assessment. All 12 trials were conducted in sub-Saharan Africa, with one having a study site in the USA, and another having a site in India. Vaginal microbicides tested were BufferGel and PRO 2000 (1 trial, 3101 women), Carraguard (1 trial, 6202 women), cellulose sulphate (2 trials, 3069 women), dapivirine (2 trials, 4588 women), PRO 2000 (1 trial, 9385 women), C31G (SAVVY) (2 trials, 4295 women), and tenofovir (3 trials, 4958 women). All microbicides were compared to placebo and all trials had low risk of bias. Dapivirine probably reduces the risk of acquiring HIV infection: risk ratio (RR) 0.71, (95% confidence interval (CI) 0.57 to 0.89, I² = 0%, 2 trials, 4588 women; moderate-certainty evidence). The other microbicides may result in little to no difference in the risk of acquiring HIV (low-certainty evidence); including tenofovir (RR 0.83, 95% CI 0.68 to 1.02, cellulose sulphate (RR 1.20, 95% CI 0.74 to 1.95, BufferGel (RR 1.05, 95% CI 0.73 to 1.52), Carraguard (RR 0.89, 95% CI 0.71 to 1.11), PRO 2000 (RR 0.93, 95% CI 0.77 to 1.14), and SAVVY (RR 1.38, 95% CI 0.79 to 2.41). Existing evidence suggests that cellulose sulphate (RR 0.99, 95% CI 0.37 to 2.62, 1 trial, 1425 women), and PRO 2000 (RR 0.95, 95% CI 0.73 to 1.23) may result in little to no difference in the risk of getting herpes simplex virus type 2 infection (low-certainty evidence). Two studies reported data on tenofovir's effect on this virus. One suggested that tenofovir may reduce the risk (RR 0.55, 95% CI 0.36 to 0.82; 224 participants) while the other did not find evidence of an effect (RR 0.94, 95% CI 0.85 to 1.03; 1003 participants). We have not reported the pooled result because of substantial heterogeneity of effect between the two studies (l² = 85%). The evidence also suggests that dapivirine (RR 1.70, 95% CI 0.63 to 4.59), tenofovir (RR 1.27, 95% CI 0.58 to 2.78), cellulose sulphate (RR 0.69, 95% CI 0.26 to 1.81), and (Carraguard (RR 1.07, 95% CI 0.75 to 1.52) may have little or no effect on the risk of acquiring syphilis (low-certainty evidence). In addition, dapivirine (RR 0.97, 95% CI 0.89 to 1.07), tenofovir (RR 0.90, 95% CI 0.71 to 1.13), cellulose sulphate (RR 0.70, 95% CI 0.49 to 0.99), BufferGel (RR 0.97, 95% CI 0.65 to 1.45), Carraguard (RR 0.96, 95% CI 0.83 to 1.12), and PRO 2000 (RR 1.01, 95% CI 0.84 to 1.22) may result in little to no difference in the risk of acquiring chlamydia infection (low-certainty evidence). The evidence also suggests that current topical microbicides may not have an effect on the risk of acquiring gonorrhoea, condyloma acuminatum, trichomoniasis, or human papillomavirus infection (low-certainty evidence). Microbicide use in the 12 trials, compared to placebo, did not lead to any difference in adverse event rates. No study reported on acceptability of the intervention.  AUTHORS' CONCLUSIONS: Current evidence shows that vaginal dapivirine microbicide probably reduces HIV acquisition in women who have sex with men. Other types of vaginal microbicides have not shown evidence of an effect on acquisition of STIs, including HIV. Further research should continue on the development and testing of new microbicides.

Effect of HIV Infection and Antiretroviral Treatment on Pregnancy Rates in the Western Cape Province of South Africa

BACKGROUND

Previous studies suggest that untreated human immunodeficiency virus (HIV) infection is associated with a reduced incidence of pregnancy, but studies of the effect of antiretroviral treatment (ART) on pregnancy incidence have been inconsistent.

METHODS

Routine data from health services in the Western Cape province of South Africa were linked to identify pregnancies during 2007-2017 and maternal HIV records. The time from the first (index) pregnancy outcome date to the next pregnancy was modeled using Cox proportional hazards models.

RESULTS

During 2007-2017, 1 042 647 pregnancies were recorded. In all age groups, pregnancy incidence rates were highest in women who had started ART, lower in HIV-negative women, and lowest in ART-naive HIV-positive women. In multivariable analysis, after controlling for the most recent CD4+ T-cell count, pregnancy incidence rates in HIV-positive women receiving ART were higher than those in untreated HIV-positive women (adjusted hazard ratio, 1.63; 95% confidence interval, 1.59-1.67) and those in HIV-negative women.

CONCLUSION

Among women who have recently been pregnant, receipt of ART is associated with high rates of second pregnancy. Better integration of family planning into HIV care services is needed.

Contraceptive use among sexually active women living with HIV in western Ethiopia

Introduction

Contraception can help to meet family planning goals for women living with HIV (WLHIV) as well as to support the prevention of mother to child transmission of HIV (PMTCT). However, there is little research into the contraceptive practice among sexually active WLHIV in Ethiopia. Therefore, we aimed to examine contraceptive practice among sexually active WLHIV in western Ethiopia and identify the factors that influenced such practice using the Health Belief Model (HBM).

Methods

A facility-based cross-sectional survey of 360 sexually active WLHIV was conducted from 19^th March to 22^nd June 2018 in western Ethiopia. The eligible participants were WLHIV aged between 18 and 49 years who reported being fecund and sexually active within the previous six months but were not pregnant and not wanting to have another child within two years. Modified Poisson regression analyses were conducted to identify factors that influenced contraceptive practice among sexually active WLHIV in western Ethiopia.

Results

Among sexually active WLHIV (n = 360), 75% used contraception with 25% having unmet needs. Of the contraceptive users, 44.8% used injectables, 37.4% used condoms and 28.5% used implants. Among 152 recorded births in the last five years, 17.8% were reported as mistimed and 25.7% as unwanted. Compared to WLHIV having no child after HIV diagnosis, having two or more children after HIV diagnosis (Adjusted Prevalence Ratio [APR] = 1.31; 95%CI 1.09–1.58) was associated with increased risk of contraceptive practice. However, sexually active unmarried WLHIV (APR = 0.69; 95%CI 0.50–0.95) were less likely to use any contraception compared to their sexually active married counterparts. Importantly, high perceived susceptibility (APR = 1.49; 95%CI 1.20–1.86) and medium perceived susceptibility (APR = 1.55; 95%CI 1.28–1.87) towards unintended pregnancy were associated with higher risk of contraceptive use than WLHIV with low perceived susceptibility.

Conclusions

Although contraceptive use amongst sexually active WLHIV was found to be high, our findings highlight the need for strengthening family planning services given the high rate of unintended pregnancies, the high rate of unmet needs for contraception, as well as the lower efficacy with some of the methods. Our findings also suggest that the HBM would be a valuable framework for healthcare providers, programme planners and policymakers to develop guidelines and policies for contraceptive counselling and choices.

Utilizing perspectives from HIV-infected women, male partners and healthcare providers to design family planning SMS in Kenya: a qualitative study

Background

Short message service (SMS) presents an opportunity to expand the reach of care and improve reproductive health outcomes. SMS could increase family planning (FP) use through education, support and demand generation. The purpose of this analysis is to determine the perspectives of potential FP users to inform design of SMS.

Methods

We conducted focus group discussions (FGD) with HIV-infected women and in-depth interviews (IDI) with male partners and health care workers (HCW) at urban and rural clinics in Kenya to design SMS content for a randomized controlled trial.

Results

Women and men indicated SMS could be used as a tool to discuss FP with their partners, and help decrease misconceptions about FP. Women stated SMS could make them more comfortable discussing sensitive topics with HCWs compared to in-person discussions. However, some women expressed concerns about FP SMS particularly if they used FP covertly or feared partner disapproval of FP use. These findings were common among women who had not disclosed their status. Providers viewed SMS as an important tool for tracking patients and clinical triage in conjunction with routine clinical visits.

Conclusion

Our findings suggest that SMS has the potential to facilitate FP education, counselling, and interaction with HCWs around FP.

Correlates of reported modern contraceptive use among postpartum HIV-positive women in rural Nigeria: an analysis from the MoMent prospective cohort study

Background

Nigeria has an annual population of ~ 200,000 women who are both pregnant and HIV-positive. High unmet need for family planning in this population could lead to unintended pregnancies, along with the increased risk of mother-to-child transmission of HIV (MTCT). To identify modifiable barriers and facilitators in effective family planning, we examined correlates of modern contraceptive use among HIV-positive women enrolled in the MoMent prevention of MTCT (PMTCT) implementation research study in rural North-Central Nigeria.

Methods

In this prospective cohort study, HIV-positive pregnant women were enrolled at 20 Primary Healthcare Centers and followed up to 12 months postpartum. Baseline socio-demographic, clinical and obstetric data were collected at enrollment. Participants were to receive routine family planning counselling from healthcare workers during postnatal visits. Analysis utilized baseline data linked to available family planning information collected from each woman at the first postpartum visit. Multivariate logistic regression was performed to determine factors associated with modern contraceptive use.

Results

Out of 497 women enrolled, family planning data was available for 399 (80.3%) women, of whom 349 (87.5%) received family planning counselling, and 321 (80.5%) were 30 years old or less. Two-thirds (268, 67.2%) of the cohort analyzed had 1–2 children at baseline; 24.8% (n = 99) had 3–4 children, and 8.0% (n = 32) had > 4 children. Approximately half (199, 49.9%) of the women reported no modern contraceptive use in the postpartum period. Male condoms (116, 29.1%) were the most reported method of contraception; other methods reported included oral hormones (71, 17.8%) and intrauterine devices (13, 3.2%). Only disclosure of HIV status to male partner or relative (aOR = 2.0, 95% CI: 1.2–3.3; p = 0.01) and receipt of family planning counselling (aOR = 2.3, 95% CI: 1.1–4.8; p = 0.03) were positively associated with reported modern contraceptive use. Age, marital or educational status, religious affiliation, employment status, gravidity and parity were non-correlates.

Conclusions

Family planning counselling and disclosure of HIV status are modifiable positive predictors of contraceptive use among our cohort of postpartum HIV-positive women in rural Nigeria. Rates of unintended pregnancy and concomitant risk of MTCT could be significantly reduced through strategies that facilitate these correlates.

Clinical trials registration

Clinicaltrials.gov registration number: NCT 01936753; registered September 3, 2013.

Contraceptive, condom and dual method use at last coitus among perinatally and horizontally HIV-infected young women in Atlanta, Georgia

Objective

To evaluate factors within the social-ecological framework associated with most or moderately effective contraception, condom and dual method use at last coitus among young, HIV-infected women in Atlanta.

Methods

This is a cross-sectional study conducted from November, 2013 until August, 2015 at the Grady Infectious Disease Clinic in Atlanta, Georgia. We recruited perinatally and horizontally HIV-infected women of ages 14–30 years to complete an audio computer-assisted self-interview. We evaluated factors within a social-ecological framework associated with most or moderately effective contraceptive use (hormonal contraception or an IUD), condom use, and dual method use (use of condom and most or moderately effective contraceptive) at last coitus.

Results

Of 103 women enrolled, 74 reported a history of sexual activity. The average age was 22.1; 89% were African American, 52% were perinatally infected, 89% received combination antiretroviral therapy, and 63% had undetectable viral loads. At last coitus, 46% reported most or moderately effective contraception, 62% reported condom use and 27% reporting dual-method use. The odds of most or moderately effective contraceptive use was significantly reduced among those with detectable viral loads (versus undetectable viral loads; aOR 0.13 [0.04, 0.38]). Older age (aOR 0.85 [0.74, 0.98] and more frequent coitus (>once/week versus < = once/week; aOR 0.24 [0.08, 0.72]) was significantly associated with reduced condom use. Having a detectable viral load (versus undetectable viral loads; aOR 0.13 [0.03, 0.69]) and more frequent coitus (>once/week versus < = once/week; aOR 0.14 [0.03,0.82]), was associated with reduced dual method use, while being enrolled in school (aOR 5.63 [1.53, 20.71]) was significantly associated with increased dual method use.

Conclusions

Most or moderately effective contraception, condom and dual method use remained inadequate in this cohort of young HIV-infected women. Individual-level interventions are needed to increase the uptake of dual methods with user-independent contraceptives.

From Pill to Condom, or Nothing at all: HIV Diagnosis and Discontinuation of Highly Effective Contraceptives Among Women in Northeast Brazil

This is a cross-sectional study examining highly effective contraceptive (HEC) use among HIV-positive women in Salvador, Brazil. We used multivariate logistic regression to look for predictors of alternative contraceptive choices among women who discontinued HEC after HIV diagnosis. Of 914 participants surveyed, 38.5% of participants used HEC before but not after diagnosis. Of these, 65.9% used condoms alone; 19.3% used no protection; and 14.8% reported abstinence. Use of condoms alone was associated with a history of other sexually transmitted infections (AOR 2.18, 95% CI 1.09-4.66, p = 0.029). Abstinence was associated with recent diagnosis (AOR 8.48, 95% CI 2.20-32.64, p = 0.002). Using no method was associated with age below 25 (AOR 5.13, 95% CI 1.46-18.00, p = 0.011); income below minimum wage (AOR 2.54, 95% CI 1.31-4.92, p = 0.006); HIV-positive partner status (AOR 2.69, 95% CI 1.03-7.02, p = 0.043); and unknown partner status (AOR 2.90, 95% CI 1.04-8.05, p = 0.042). Improved contraceptive counseling is needed after HIV diagnosis. Continuation of HEC should be encouraged for women wishing to prevent pregnancy, and may increase contraceptive coverage among HIV-positive women.

Texting and Mobile Phone App Interventions for Improving Adherence to Preventive Behavior in Adolescents: A Systematic Review

Background

Many preventable behaviors contribute to adolescent mortality and morbidity. Non-adherence to preventive measures represents a challenge and has been associated with worse health outcomes in this population. The widespread use of electronic communication technologies by adolescents, particularly the use of text messaging (short message service, SMS) and mobile phones, presents new opportunities to intervene on risk and preventive risk behavior, but little is known about their efficacy.

Objective

This study aimed to systematically evaluate evidence for the efficacy of text messaging and mobile phone app interventions to improve adherence to preventive behavior among adolescents and describe intervention approaches to inform intervention development.

Methods

This review covers literature published between 1995 and 2015. Searches included PubMed, Embase, CENTRAL, PsycINFO, CINAHL, INSPEC, Web of Science, Google Scholar, and additional databases. The search strategy sought articles on text messaging and mobile phone apps combined with adherence or compliance, and adolescents and youth. An additional hand search of related themes in the Journal of Medical Internet Research was also conducted. Two reviewers independently screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Included studies reflect original research—experimental or preexperimental designs with text messaging or mobile phone app interventions—targeting adherence to preventive behavior among adolescents (12-24 years old). The preferred reporting items of systematic reviews and meta-analyses (PRISMA) guidelines were followed for reporting results, and findings were critically appraised against the Oxford Centre for Evidence-based Medicine criteria.

Results

Of 1454 records, 19 met inclusion criteria, including text messaging (n=15) and mobile phone apps (n=4). Studies targeted clinic attendance, contraceptive use, oral health, physical activity and weight management, sun protection, human papillomavirus (HPV) vaccination, smoking cessation, and sexual health. Most studies were performed in the United States (47%, 9/19), included younger adolescents (63%, 12/19), and had sample size <100 (63%, 12/19). Although most studies were randomized controlled trials (RCTs; 58%, 11/19), only 5 followed an intent-to-treat analysis. Only 6 of 19 studies (32%) incorporated a theoretical framework in their design. Most studies reported good feasibility with high acceptability and satisfaction. About half of the included studies (42%, 8/19) demonstrated significant improvement in preventive behavior with moderate standardized mean differences. As early efforts in this field to establish feasibility and initial efficacy, most studies were low to moderate in quality. Studies varied in sample size and methods of preventive behavior adherence or outcome assessment, which prohibited performing a meta-analysis.

Conclusions

Despite the promising feasibility and acceptability of text messaging and mobile phone apps in improving preventive behavior among adolescents, overall findings were modest in terms of efficacy. Further research evaluating the efficacy, effectiveness, and cost-effectiveness of these intervention approaches in promoting preventive behavior among adolescents is needed.