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Marston M, Gregson S. Human Immunodeficiency Virus, Antiretroviral Therapy, and Fertility in Sub-Saharan Africa: Pieces Still Missing in the Jigsaw Puzzle. J Infect Dis 2021; 221:1919-1921. [PMID: 31332439 DOI: 10.1093/infdis/jiz363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Milly Marston
- Department of Population Health, London School of Hygiene and Tropical Medicine, Imperial College London, United Kingdom
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom.,Biomedical Research and Training Institute, Harare, Zimbabwe
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2
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Dadabhai S, Makanani B, Hua N, Kawalazira R, Taulo F, Gadama L, Taha TE. Resumption of postpartum sexual activity and menses among HIV-infected women on lifelong antiretroviral treatment compared to HIV-uninfected women in Africa. Int J Gynaecol Obstet 2020; 149:211-218. [PMID: 32037538 DOI: 10.1002/ijgo.13113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/11/2019] [Accepted: 02/06/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine time from delivery to resumption of sexual activity and menses among HIV-infected women on antiretroviral treatment (ART) and HIV-uninfected women. METHODS HIV-infected women on ART and HIV-uninfected women were recruited from five health facilities at delivery and followed prospectively for a maximum of 1 year in Blantyre, Malawi from January 2016 to September 2017. Sociodemographic, clinical, and laboratory data were collected at delivery and 1.5, 3, 6, 9, and 12 months. Descriptive, time to event Kaplan-Meier, and multivariable Cox proportional hazards analyses were conducted. RESULTS Data on 878 women (460 [52.4%] HIV-uninfected and 418 [47.6%] HIV-infected, P=0.156) who attended at least one follow-up visit were analyzed. Among HIV-uninfected compared to HIV-infected women, respectively, the median number of days to resumption of sexual activity was 180 vs 181; to irregular menses was 82 vs 71; and to regular menses was 245 vs 366. In multivariable models, being married was associated with early resumption of sexual activity (hazard ratio [HR] 1.91, P<0.001), and being HIV-infected and use of an effective method of family planning were associated with later start of regular menses (HR<1.0, P<0.050). CONCLUSION Counseling of women on reproductive intentions should start early irrespective of HIV infection or use of ART.
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Affiliation(s)
- Sufia Dadabhai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Bonus Makanani
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nan Hua
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Rachel Kawalazira
- College of Medicine-Johns Hopkins Research Project, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics and Gynecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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3
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Feyissa TR, Harris ML, Melka AS, Loxton D. Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav 2019; 23:1431-1451. [PMID: 30467712 DOI: 10.1007/s10461-018-2346-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.
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Gemmill A, Bradley SEK, van der Poel S. Reduced fecundity in HIV-positive women. Hum Reprod 2019; 33:1158-1166. [PMID: 29579247 DOI: 10.1093/humrep/dey065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 03/05/2018] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION Is HIV associated with increased time to pregnancy (TTP)? SUMMARY ANSWER HIV-positive women who discontinue a contraceptive method to become pregnant have increased TTP, particularly among those who likely do not know their status. WHAT IS KNOWN ALREADY HIV-positive women have fewer children on average than their HIV-negative counterparts due to both behavioral and biological factors. There is a need to better describe and quantify fecundity patterns associated with HIV in the general population. STUDY DESIGN, SIZE, DURATION This cross-sectional study was based on data from 12 Demographic and Health Surveys (DHSs) conducted between 2003 and 2013 in 11 African countries. All studies collected dried blood spot samples for HIV testing and included a retrospective calendar module that recorded women's monthly reproductive status in the 5 years preceding the survey. TTP was measured among 3181 women discontinuing a contraceptive method within 2 years of the survey in order to become pregnant. PARTICIPANTS/MATERIALS, SETTING, METHODS We use Cox proportional hazard models for discrete survival data to model TTP and estimate fecundability odds ratios (FOR) and 95% CIs for the 12-month period following contraceptive discontinuation. In addition to employing a binary measure of HIV status, we also develop an additional explanatory measure that combines HIV status with information on whether respondents had ever been tested for HIV and received their results (which proxies for knowledge of HIV status) to reduce the threat of confounding from behavioral changes following an HIV diagnosis. MAIN RESULTS AND THE ROLE OF CHANCE In our sample, 10.3% of women were HIV-positive, and a little more than half (51.8%) of women received test results and likely knew their status. Over a 12-month observation period, HIV-positive women had a 25% average reduction in fecundity compared to HIV-negative women [adjusted FOR (aFOR) = 0.75 (0.62-0.92)] after adjusting for confounders. The 12-month fecundity patterns differed by women's likely knowledge of their status such that results were primarily driven by HIV-positive women who likely did not know their status. Moreover, reductions in fecundity attributable to HIV were not uniform over time. Among women who were still trying for pregnancy after 3 unsuccessful months, HIV-positive women had half the odds of becoming pregnant compared to HIV-negative women [aFOR = 0.50 (0.35-0.71)]. Conversely, there were no significant differences in FORs between HIV-negative and HIV-positive women in the first 3 months. LIMITATIONS REASONS FOR CAUTION Because dried blood spot samples for HIV testing were collected at the time of the survey but reproductive calendar data were collected retrospectively, it is possible that we introduced misclassification bias, as we have no knowledge if the acquisition of HIV occurred before or after pregnancy attempt. WIDER IMPLICATIONS OF THE FINDINGS As life expectancy and quality health status improve due to earlier initiation of antiretroviral (ARV) treatment in HIV-positive women, there has been growing awareness that services should also address the fertility desires of HIV-positive women who want children. These findings indicate that if a pregnancy does not occur after 3 months of attempting pregnancy, HIV-positive women and HIV-discordant couples should request access to HIV and reproductive pre-pregnancy counseling and health assessments. STUDY FUNDING/COMPETING INTEREST(S) A.G. was supported by the National Institutes of Health (contract T32-HD007275) during the study. During the conceptualization, data collection and analysis time frame, S.vdP. was supported by WHO/RHR/HRP Special Program in Reproductive Health and Research, Geneva, Switzerland, and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors have no conflicts of interest to declare.
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Affiliation(s)
- A Gemmill
- Program in Public Health and Department of Family, Population and Preventive Medicine, Stony Brook University, Stony Brook, NY 11794-8338, USA
| | - S E K Bradley
- Abt Associates, 4550 Montgomery Avenue, Suite 800 North, Bethesda, MD 20814-3343, USA
| | - S van der Poel
- Population Council, 1230 York Avenue, New York, NY 10065, USA
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5
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Alene KA, Atalell KA. Contraceptive use and method preference among HIV-positive women in Amhara region, Ethiopia. BMC WOMENS HEALTH 2018; 18:97. [PMID: 29914445 PMCID: PMC6006570 DOI: 10.1186/s12905-018-0608-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/13/2018] [Indexed: 11/24/2022]
Abstract
Background Providing preferred methods of contraceptive for HIV-positive women and avoiding unintended pregnancy is one of the primary means of preventing mother to child transmission of HIV. This study assessed the prevalence of contraceptive use and method preference among HIV-positive women in Amhara region, Ethiopia. Methods A cross-sectional survey was conducted among HIV-positive women in three referral hospitals of Amhara region. Data were collected by interviewing HIV-positive women using a pre-tested and structured questionnaire. A binary logistic regression model was used to identify factors associated with contraceptive use, and odd ratio with 95% confidence interval (CI) was calculated to measure the strength of association. Results A total of 803 women living with HIV (with a response rate of 95.4%) were interviewed. The mean age of the study participants was 32.2 years (SD ± 6.2 years). The prevalence of current contraceptive use was 30.3% (95% CI: 27.0–33.7%). The preferred and most commonly used contraceptive methods were injectable (42.8%) and male condom (32.9%). Younger age group (15–24 years) (AOR = 9.67; 95%CI: 3.45, 27.10), one or more number of living children (AOR = 4.01; 95%CI: 2.07, 7.79), HIV diagnosis > 2–4 years (AOR = 2.37; 95%CI: 1.10, 5.08), and having high CD4 count > 500 cell/ul (AOR = 3.25; 95% CI: 1.42, 7.44) were significantly associated with contraceptive use. Conclusion The prevalence of contraceptive use among HIV-positive women in Amhara region referral hospitals is low, which suggests a high risk of unintended pregnancy. Injectable and male condoms are the most preferred type of contraceptive methods. Thus, it is better to integrate these contraceptive methods with ART clinic. Electronic supplementary material The online version of this article (10.1186/s12905-018-0608-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kefyalew Addis Alene
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Kendalem Asmare Atalell
- School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Krashin JW, Haddad LB, Tweya H, Chiwoko J, Ng’ambi W, Samala B, Chaweza T, Tang JH, Hosseinipour MC, Phiri S. Factors associated with desired fertility among HIV-positive women and men attending two urban clinics in Lilongwe, Malawi. PLoS One 2018; 13:e0198798. [PMID: 29897961 PMCID: PMC5999219 DOI: 10.1371/journal.pone.0198798] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/27/2018] [Indexed: 12/24/2022] Open
Abstract
As access to antiretroviral therapy increases, more HIV-infected patients in sub-Saharan Africa may desire fertility. We conducted a cross-sectional study of reproductive health knowledge, attitudes and practices to identify factors associated with desired fertility among women and men receiving care at two large public HIV clinics in Lilongwe, Malawi. Research assistants administered questionnaires to participants. We performed descriptive, bivariable and multivariable analysis of factors related to desired fertility and of factors related to contraceptive non-use among participants who did not desire fertility. One-third of participants desired future children. Having a partner who desired fertility and having lower parity were associated with desiring children among both genders. For women, believing that pregnancy was unhealthy was associated with decreased fertility desire. Fifty-five percent of women and 69% of men who did not want children in the future reported using contraception at last intercourse. Increasing age, lower parity, and making the decision to use contraception herself were associated with contraceptive non-use among women who did not desire fertility. Having discussed family planning with his partner was associated with contraceptive use among men who did not desire fertility. Knowledge of these factors can guide reproductive health counseling and service provision.
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Affiliation(s)
- Jamie W. Krashin
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Lisa B. Haddad
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Hannock Tweya
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jane Chiwoko
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | | | - Thomas Chaweza
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jennifer H. Tang
- Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Mina C. Hosseinipour
- UNC Project-Malawi, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Sam Phiri
- The Lighthouse Trust, Kamuzu Central Hospital, Lilongwe, Malawi
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
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7
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Salters K, Loutfy M, de Pokomandy A, Money D, Pick N, Wang L, Jabbari S, Carter A, Webster K, Conway T, Dubuc D, O’Brien N, Proulx-Boucher K, Kaida A. Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada. PLoS One 2017; 12:e0180524. [PMID: 28727731 PMCID: PMC5519029 DOI: 10.1371/journal.pone.0180524] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 06/17/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pregnancy incidence rates among women living with HIV (WLWH) have increased over time due to longer life expectancy, improved health status, and improved access to and HIV prevention benefits of combination antiretroviral therapy (cART). However, it is unclear whether intended or unintended pregnancies are contributing to observed increases. METHODS We analyzed retrospective data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Kaplan-Meier methods and GEE Poisson models were used to measure cumulative incidence and incidence rate of pregnancy after HIV diagnosis overall, and by pregnancy intention. We used multivariable logistic regression models to examine independent correlates of unintended pregnancy among the most recent/current pregnancy. RESULTS Of 1,165 WLWH included in this analysis, 278 (23.9%) women reported 492 pregnancies after HIV diagnosis, 60.8% of which were unintended. Unintended pregnancy incidence (24.6 per 1,000 Women-Years (WYs); 95% CI: 21.0, 28.7) was higher than intended pregnancy incidence (16.6 per 1,000 WYs; 95% CI: 13.8, 20.1) (Rate Ratio: 1.5, 95% CI: 1.2-1.8). Pregnancy incidence among WLWH who initiated cART before or during pregnancy (29.1 per 1000 WYs with 95% CI: 25.1, 33.8) was higher than among WLWH not on cART during pregnancy (11.9 per 1000 WYs; 95% CI: 9.5, 14.9) (Rate Ratio: 2.4, 95% CI: 2.0-3.0). Women with current or recent unintended pregnancy (vs. intended pregnancy) had higher adjusted odds of being single (AOR: 1.94; 95% CI: 1.10, 3.42), younger at time of conception (AOR: 0.95 per year increase, 95% CI: 0.90, 0.99), and being born in Canada (AOR: 2.76, 95% CI: 1.55, 4.92). CONCLUSION Nearly one-quarter of women reported pregnancy after HIV diagnosis, with 61% of all pregnancies reported as unintended. Integrated HIV and reproductive health care programming is required to better support WLWH to optimize pregnancy planning and outcomes and to prevent unintended pregnancy.
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Affiliation(s)
- Kate Salters
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Mona Loutfy
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra de Pokomandy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Deborah Money
- Oak Tree Clinic, BC Women’s Hospital and Health Centre, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Neora Pick
- Oak Tree Clinic, BC Women’s Hospital and Health Centre, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Lu Wang
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Shahab Jabbari
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Allison Carter
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | - Kath Webster
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Tracey Conway
- Women's College Research Institute, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniele Dubuc
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nadia O’Brien
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Karene Proulx-Boucher
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, Quebec, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
- * E-mail:
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Wilson KC, Mhangara M, Dzangare J, Eaton JW, Hallett TB, Mugurungi O, Gregson S. Does nonlocal women's attendance at antenatal clinics distort HIV prevalence surveillance estimates in pregnant women in Zimbabwe? AIDS 2017; 31 Suppl 1:S95-S102. [PMID: 28296805 PMCID: PMC5677598 DOI: 10.1097/qad.0000000000001337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective was to assess whether HIV prevalence measured among women attending antenatal clinics (ANCs) are representative of prevalence in the local area, or whether estimates may be biased by some women's choice to attend ANCs away from their residential location. We tested the hypothesis that HIV prevalence in towns and periurban areas is underestimated in ANC sentinel surveillance data in Zimbabwe. METHODS National unlinked anonymous HIV surveillance was conducted at 19 ANCs in Zimbabwe in 2000, 2001, 2002, 2004, 2006, 2009, and 2012. This data was used to compare HIV prevalence and nonlocal attendance levels at ANCs at city, town, periurban, and rural clinics in aggregate and also for individual ANCs. RESULTS In 2000, HIV prevalence at town ANCs (36.6%, 95% CI 34.4-38.9%) slightly underestimated prevalence among urban women attending these clinics (40.7%, 95% CI 37.6-43.9%). However, there was no distortion in HIV prevalence at either the aggregate clinic location or at individual clinics in more recent surveillance rounds. HIV prevalence was consistently higher in towns and periurban areas than in rural areas. Nonlocal attendance was high at town (26-39%) and periurban (53-95%) ANCs but low at city clinics (<10%). However, rural women attending ANCs in towns and periurban areas had higher HIV prevalence than rural women attending rural clinics, and were younger, more likely to be single, and less likely to be housewives. CONCLUSIONS In Zimbabwe, HIV prevalence among ANC attendees provides reliable estimates of HIV prevalence in pregnant women in the local area.
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Affiliation(s)
- Katherine C. Wilson
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, W2 1PG, UK
| | - Mutsa Mhangara
- AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Janet Dzangare
- AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Jeffrey W. Eaton
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, W2 1PG, UK
| | - Timothy B. Hallett
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, W2 1PG, UK
| | - Owen Mugurungi
- AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, W2 1PG, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Remera E, Boer K, Umuhoza SM, Hedt-Gauthier BL, Thomson DR, Ndimubanzi P, Kayirangwa E, Mutsinzi S, Bayingana A, Mugwaneza P, Koama JBT. Fertility and HIV following universal access to ART in Rwanda: a cross-sectional analysis of Demographic and Health Survey data. Reprod Health 2017; 14:40. [PMID: 28292306 PMCID: PMC5351174 DOI: 10.1186/s12978-017-0301-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/06/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV infection is linked to decreased fertility and fertility desires in sub-Saharan Africa due to biological and social factors. We investigate the relationship between HIV infection and fertility or fertility desires in the context of universal access to antiretroviral therapy introduced in 2004 in Rwanda. METHODS We used data from 3532 and 4527 women aged 20-49 from the 2005 and 2010 Rwandan Demographic and Health Surveys (RDHS), respectively. The RDHSs included blood-tests for HIV, as well as detailed interviews about fertility, demographic and behavioral outcomes. In both years, multiple logistic regression was used to assess the association between HIV and fertility outcomes within three age categories (20-29, 30-39 and 40-49 years), controlling for confounders and compensating for the complex survey design. RESULTS In 2010, we did not find a difference in the odds of pregnancy in the last 5 years between HIV-seropositive and HIV-seronegative women after controlling for potential biological and social confounders. Controlling for the same confounders, we found that HIV-seropositive women under age 40 were less likely to desire more children compared to HIV-seronegative women (20-29 years adjusted odds ratio (AOR) = 0.31, 95% CI: 0.17, 0.58; 30-39 years AOR = 0.24, 95% CI: 0.14, 0.43), but no difference was found among women aged 40 or older. No associations between HIV and fertility or fertility desire were found in 2005. CONCLUSIONS These findings suggest no difference in births or current pregnancy among HIV-seropositive and HIV-seronegative women. That in 2010 HIV-seropositive women in their earlier childbearing years desired fewer children than HIV-seronegative women could suggest more women with HIV survived; and stigma, fear of transmitting HIV, or realism about living with HIV and prematurely dying from HIV may affect their desire to have children. These findings emphasize the importance of delivering appropriate information about pregnancy and childbearing to HIV-infected women, enabling women living with HIV to make informed decisions about their reproductive life.
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Affiliation(s)
- Eric Remera
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda.
| | - Kimberly Boer
- Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Stella M Umuhoza
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Bethany L Hedt-Gauthier
- College of Medicine and Health Sciences, School of Public Health, University of Rwanda, Kigali, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Inshuti Mu Buzima/Partners in Health, Rwinkwavu, Rwanda
| | - Dana R Thomson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | | | - Alice Bayingana
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Placidie Mugwaneza
- Institute of HIV/AIDS Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
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10
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Yeatman S, Eaton JW, Beckles Z, Benton L, Gregson S, Zaba B. Impact of ART on the fertility of HIV-positive women in sub-Saharan Africa. Trop Med Int Health 2016; 21:1071-85. [PMID: 27371942 DOI: 10.1111/tmi.12747] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Understanding the fertility of HIV-positive women is critical to estimating HIV epidemic trends from surveillance data and to planning resource needs and coverage of prevention of mother-to-child transmission services in sub-Saharan Africa. In the light of the considerable scale-up in antiretroviral therapy (ART) coverage over the last decade, we conducted a systematic review of the impact of ART on the fertility outcomes of HIV-positive women. METHODS We searched Medline, Embase, Popline, PubMed and African Index Medicus. Studies were included if they were conducted in sub-Saharan Africa and provided estimates of fertility outcomes (live births or pregnancies) among women on ART relative to a comparison group. RESULTS Of 2070 unique references, 18 published papers met all eligibility criteria. Comparisons fell into four categories: fertility of HIV-positive women relative to HIV-negative women; fertility of HIV-positive women on ART compared to those not yet on ART; fertility differences by duration on ART; and temporal trends in fertility among HIV-positive women. Evidence indicates that fertility increases after approximately the first year on ART and that while the fertility deficit of HIV-positive women is shrinking, their fertility remains below that of HIV-negative women. These findings, however, were based on limited data mostly during the period 2005-2010 when ART scaled up. CONCLUSIONS Existing data are insufficient to characterise how ART has affected the fertility of HIV-positive women in sub-Saharan Africa. Improving evidence about fertility among women on ART is an urgent priority for planning HIV resource needs and understanding HIV epidemic trends. Alternative data sources such as antenatal clinic data, general population cohorts and population-based surveys can be harnessed to understand the issue.
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Affiliation(s)
- Sara Yeatman
- Department of Health and Behavioral Sciences, University of Colorado, Denver, CO, USA
| | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Zosia Beckles
- Library Services, University of Bristol, Bristol, UK
| | - Lorna Benton
- Institute for Global Health, University College London, London, UK
| | - Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK.,Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Basia Zaba
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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11
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O'Shea MS, Rosenberg NE, Tang JH, Mukuzunga C, Kaliti S, Mwale M, Hosseinipour MC. Reproductive intentions and family planning practices of pregnant HIV-infected Malawian women on antiretroviral therapy. AIDS Care 2016; 28:1027-34. [PMID: 26877194 DOI: 10.1080/09540121.2016.1140891] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The objective of this study was to describe the pregnancy intentions of pregnant HIV-infected Malawian women on antiretroviral therapy (ART) for at least 6 months prior to the current pregnancy, and to assess whether time on ART was associated with pregnancy intention. We conducted a cross-sectional analysis of HIV-infected Malawian women receiving antenatal care at a government hospital with a survey assessing ART history, reproductive history, and family planning use at conception. We used Pearson's chi-square tests and Fisher's exact tests to compare these parameters between women on ART greater than 24 months with those on ART less than 24 months. Modified Poisson regression was performed to assess the association between time on ART and pregnancy intention. Most women (75%) reported that their current pregnancy was unintended, defined as either Mistimed (21%) or Unwanted (79%). Women on ART for longer than 2 years were more likely to report an unintended pregnancy (79% versus 65%, p = .03), though there was no significant association between time on ART and pregnancy intention in multivariate analysis. Most women (79%) were using contraception at the time of conception, with condoms being most popular (91%), followed by injectables (9%) and the implant (9%). HIV-infected women on ART continue to experience high rates of unintended pregnancy in the Option B+ era. As Option B+ continues to be implemented in Malawi and increasing numbers of HIV-infected women initiate lifelong ART, ensuring that the most effective forms of contraception are accessible is necessary to decrease unintended pregnancy.
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Affiliation(s)
| | - Nora E Rosenberg
- a UNC Project-Malawi , Lilongwe , Malawi.,b UNC Institute of Global Health & Infectious Diseases , Chapel Hill , NC , USA.,c Department of Medicine , University of North Carolina , Chapel Hill , NC , USA
| | - Jennifer H Tang
- a UNC Project-Malawi , Lilongwe , Malawi.,d Department of Obstetrics & Gynecology , University of North Carolina , Chapel Hill , NC , USA.,e Department of Obstetrics & Gynaecology , Malawi College of Medicine , Blantyre , Malawi
| | | | - Stephen Kaliti
- f Bwaila Hospital, Lilongwe District Health Office , Lilongwe , Malawi
| | - Mwawi Mwale
- f Bwaila Hospital, Lilongwe District Health Office , Lilongwe , Malawi
| | - Mina C Hosseinipour
- a UNC Project-Malawi , Lilongwe , Malawi.,b UNC Institute of Global Health & Infectious Diseases , Chapel Hill , NC , USA.,c Department of Medicine , University of North Carolina , Chapel Hill , NC , USA
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Souza E, Moultrie TA. Estimating the effect of HIV/AIDS on fertility among Malawian women using demographic and health survey data. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015. [DOI: 10.2989/16085906.2015.1093512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Impact of Availability and Use of ART/PMTCT Services on Fertility Desires of Previously Pregnant Women in Rakai, Uganda: A Retrospective Cohort Study. J Acquir Immune Defic Syndr 2015; 69:377-84. [PMID: 25835605 DOI: 10.1097/qai.0000000000000612] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess fertility desires by availability and use of antiretroviral therapy and prevention of mother-to-child transmission (ART/PMTCT) services in Rakai, Uganda. DESIGN Retrospective analyses of longitudinal data from the Rakai Community Cohort Study. METHODS Study participants were retrospectively identified and categorized by HIV status. Availability of ART/PMTCT services in Rakai was defined in three periods: (1) pre-ART/PMTCT (<2005), (2) ART/PMTCT rollout (2005-2006), and (3) universal ART/PMTCT (>2006); and use of ART/PMTCT was coded as yes if the woman received services. Trends in fertility desires were assessed by χ. "Modified" Poisson regression was performed using generalized linear models with a log link and Poisson family to estimate prevalence rate ratios (PRRs) and 95% confidence intervals (CIs) of desire for another child among previously and currently pregnant women; PRRs were adjusted for demographic and behavioral factors. RESULTS A total of 4227 sexually active women in Rakai, including 436 HIV+ women, contributed 13,970 observations over 5 survey rounds. Fertility desires increased in the population in the ART/PMTCT rollout [adjusted (adj.) PRR: 1.08, 95% CI: 1.04 to 1.13] and the universal availability periods (adj. PRR: 1.11, 95% CI: 1.08 to 1.14) compared with pre-ART/PMTCT period. A total of 862 woman observations used ART/PMTCT services. Fertility desires were similar among ART/PMTCT service users and nonusers in cross-sectional analysis (adj. PRR: 0.84, 95% CI: 0.62 to 1.14) and 1 year after ART/PMTCT use (adj. PRR: 1.27, 95% CI: 0.83 to 1.94). CONCLUSIONS Availability of ART/PMTCT may increase fertility desires of previously pregnant women in Rakai, Uganda. Use of ART/PMTCT services was not correlated with fertility desires of previously or current pregnant women.
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Gregson S, Dharmayat K, Pereboom M, Takaruza A, Mugurungi O, Schur N, Nyamukapa CA. Do HIV prevalence trends in antenatal clinic surveillance represent trends in the general population in the antiretroviral therapy era? The case of Manicaland, East Zimbabwe. AIDS 2015; 29:1845-53. [PMID: 26372390 PMCID: PMC4880038 DOI: 10.1097/qad.0000000000000754] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE National estimates of HIV trends in generalized epidemics rely on HIV prevalence data from antenatal clinic (ANC) surveillance. We investigate whether HIV prevalence trends in ANC data reflect trends in men and women in the general population during the scale-up of antiretroviral therapy (ART) in Manicaland, Zimbabwe. METHODS Trends in HIV prevalence in local ANC attendees and adults aged 15-49 years in towns, agricultural estates, and villages were compared using five rounds of parallel ANC (N = 1200) and general-population surveys (N = 10 000) and multivariable log-linear regression. Changes in the age pattern of HIV prevalence and the age distribution of ANC attendees were compared with those in the general population. Age-specific pregnancy prevalence rates were compared by HIV infection and ART status. RESULTS Cumulatively, from 1998-2000 to 2009-2011, HIV prevalence fell by 60.0% (95% confidence interval, 51.1-67.3%) in ANC surveillance data and by 34.3% (30.8-37.7%) in the general population. Most of the difference arose following the introduction of ART (2006-2011). The estates and villages reflected this overall pattern but HIV prevalence in the towns was lower at local ANCs than in the general population, largely because of attendance by pregnant women from outlying (lower prevalence) areas. The ageing of people living with HIV in the general population (52.4% aged >35 years, 2009-2011) was under-represented in the ANC data (12.6%) because of lower fertility in older and HIV-infected women. CONCLUSION After the introduction of ART in Manicaland, HIV prevalence declined more steeply in ANC surveillance data than in the general population. Models used for HIV estimates must reflect this change in bias.
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Affiliation(s)
- Simon Gregson
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Kanika Dharmayat
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, United Kingdom
| | - Monique Pereboom
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, United Kingdom
| | - Albert Takaruza
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Owen Mugurungi
- AIDS and TB Unit, Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Nadine Schur
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, United Kingdom
| | - Constance A. Nyamukapa
- Department of Infectious Disease Epidemiology, Imperial College London School of Public Health, London, United Kingdom
- Biomedical Research and Training Institute, Harare, Zimbabwe
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Wanyenze RK, Matovu JKB, Kamya MR, Tumwesigye NM, Nannyonga M, Wagner GJ. Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery. BMC Womens Health 2015; 15:5. [PMID: 25627072 PMCID: PMC4320597 DOI: 10.1186/s12905-014-0158-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 12/11/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Eliminating family planning (FP) unmet need among HIV-infected individuals (PLHIV) is critical to elimination of mother-to-child HIV transmission. We assessed FP unmet need among PLHIV attending two clinics with differing models of FP services. Nsambya Home Care provided only FP information while Mulago HIV clinic provided information and contraceptives onsite. METHODS In a cross-sectional study conducted between February-June 2011, we documented pregnancies, fertility desires, and contraceptive use among 797 HIV-infected men and women (408 in Mulago and 389 in Nsambya). FP unmet need was calculated among women who were married, unmarried but had sex within the past month, did not desire the last or future pregnancy at all or wished to postpone for ≥ two years and were not using contraceptives. Multivariable analyses for correlates of FP unmet need were computed for each clinic. RESULTS Overall, 40% (315) had been pregnant since HIV diagnosis; 58% desired the pregnancies. Of those who were not pregnant, 49% (366) did not desire more children at all; 15.7% wanted children then and 35.3% later. The unmet need for FP in Nsambya (45.1%) was significantly higher than that in Mulago at 30.9% (p = 0.008). Age 40+ compared to 18-29 years (OR = 6.05; 95% CI: 1.69, 21.62 in Mulago and OR = 0.21; 95% CI: 0.05, 0.90 in Nsambya), other Christian denominations (Pentecostal and Seventh Day Adventists) compared to Catholics (OR = 7.18; 95% CI: 2.14, 24.13 in Mulago and OR = 0.23; 95% CI: 0.06, 0.80 in Nsambya), and monthly expenditure > USD 200 compared to < USD40 in Nsambya (OR = 0.17; 95% CI: 0.03, 0.90) were associated with FP unmet need. CONCLUSIONS More than half of the pregnancies in this population were desired. Unmet need for FP was very high at both clinics and especially at the clinic which did not have contraceptives onsite. Lower income and younger women were most affected by the lack of contraceptives onsite. Comprehensive and aggressive FP programs are required for fertility support and elimination of FP unmet need among PLHIV, even with integration of FP information and supplies into HIV clinics.
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Affiliation(s)
| | | | - Moses R Kamya
- Makerere University School of Medicine, Kampala, Uganda.
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Assessing and adjusting for differences between HIV prevalence estimates derived from national population-based surveys and antenatal care surveillance, with applications for Spectrum 2013. AIDS 2014; 28 Suppl 4:S497-505. [PMID: 25203158 PMCID: PMC4247262 DOI: 10.1097/qad.0000000000000453] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective(s): To assess differences between HIV prevalence estimates derived from national population surveys and antenatal care (ANC) surveillance sites and to improve the calibration of ANC-derived estimates in Spectrum 2013 to more appropriately account for differences between these data. Design: Retrospective analysis of national population survey and ANC surveillance data from 25 countries with generalized epidemics in sub-Saharan Africa and 8 countries with concentrated epidemics. Methods: Adult national population survey and ANC surveillance HIV prevalence estimates were compared for all available national population survey data points for the years 1999–2012. For sub-Saharan Africa, a mixed-effects linear regression model determined whether the relationship between national population and ANC estimates was constant across surveys. A new calibration method was developed to incorporate national population survey data directly into the likelihood for HIV prevalence in countries with generalized epidemics. Results were used to develop default rules for adjusting ANC data for countries with no national population surveys. Results: ANC surveillance data typically overestimate population prevalence, although a wide variation, particularly in rural areas, is observed across countries and survey years. The new calibration method yields similar point estimates to previous approaches, but leads to an average 44% increase in the width of 95% uncertainty intervals. Conclusion: Important biases remain in ANC surveillance data for HIV prevalence. The new approach to model-fitting in Spectrum 2013 more appropriately accounts for this bias when producing national estimates in countries with generalized epidemics. In countries with concentrated epidemics, local sex ratios should be used to calibrate ANC surveillance estimates.
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Kastner J, Matthews LT, Flavia N, Bajunirwe F, Erikson S, Berry NS, Kaida A. Antiretroviral Therapy Helps HIV-Positive Women Navigate Social Expectations for and Clinical Recommendations against Childbearing in Uganda. AIDS Res Treat 2014; 2014:626120. [PMID: 25328693 PMCID: PMC4189848 DOI: 10.1155/2014/626120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/30/2014] [Accepted: 09/05/2014] [Indexed: 11/17/2022] Open
Abstract
Understanding factors that influence pregnancy decision-making and experiences among HIV-positive women is important for developing integrated reproductive health and HIV services. Few studies have examined HIV-positive women's navigation through the social and clinical factors that shape experiences of pregnancy in the context of access to antiretroviral therapy (ART). We conducted 25 semistructured interviews with HIV-positive, pregnant women receiving ART in Mbarara, Uganda in 2011 to explore how access to ART shapes pregnancy experiences. Main themes included: (1) clinical counselling about pregnancy is often dissuasive but focuses on the importance of ART adherence once pregnant; (2) accordingly, women demonstrate knowledge about the role of ART adherence in maintaining maternal health and reducing risks of perinatal HIV transmission; (3) this knowledge contributes to personal optimism about pregnancy and childbearing in the context of HIV; and (4) knowledge about and adherence to ART creates opportunities for HIV-positive women to manage normative community and social expectations of childbearing. Access to ART and knowledge of the accompanying lowered risks of mortality, morbidity, and HIV transmission improved experiences of pregnancy and empowered HIV-positive women to discretely manage conflicting social expectations and clinical recommendations regarding childbearing.
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Affiliation(s)
- Jasmine Kastner
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lynn T. Matthews
- Massachusetts General Hospital (MGH), Center for Global Health, Boston, MA 02114, USA
- Division of Infectious Disease, MGH, Boston, MA 02114, USA
| | - Ninsiima Flavia
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Susan Erikson
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Nicole S. Berry
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall Room 10522, 8888 University Drive, Burnaby, BC, Canada V5A 1S6
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Wagner GJ, Wanyenze R. Fertility Desires and Intentions and the Relationship to Consistent Condom Use and Provider Communication Regarding Childbearing Among HIV Clients in Uganda. ACTA ACUST UNITED AC 2013; 2013. [PMID: 25379322 DOI: 10.5402/2013/478192] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES HIV prevention and reproductive health programs emphasize consistent condom use and preventing unplanned pregnancies, but do not account for the childbearing desires of many HIV clients. We examined the correlates of fertility desires and intentions, including condom use, among HIV clients in Uganda. METHODS Baseline data from a prospective cohort study of clients starting antiretroviral therapy were analyzed. All measures were self-report, except abstracted CD4 count. RESULTS The sample included 767 clients; 34% were men and 50% had a primary sex partner. Among those with a desire (31%) or intention (24%) for having a child in the near future, 60% had not discussed this with providers. A majority (61%) had received advise about family planning, and 27% were told by their provider that they should not bear a child because of their HIV status. In regression analysis, male gender, younger age, higher CD4, having fewer children, and having a primary partner were significantly associated with fertility desires and intentions; having been told by one's provider not to have a child was associated with intentions but not desires. Among participants with a primary partner, consistent condom use was greater among those with no fertility intentions, as was receipt of advise about family planning, while HIV disclosure to partner was greater among those with intentions. Partner HIV status was not associated with fertility desires or intentions. CONCLUSIONS These findings highlight the need for HIV care and reproductive health programs to incorporate safer conception counseling and improve provider/patient communication regarding childbearing.
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Affiliation(s)
- Glenn J Wagner
- RAND Corporation; 1776 Main St., Santa Monica, CA 90407, USA
| | - Rhoda Wanyenze
- School of Public Health, Makerere University; Kampala, Uganda
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Wanyenze RK, Wagner GJ, Tumwesigye NM, Nannyonga M, Wabwire-Mangen F, Kamya MR. Fertility and contraceptive decision-making and support for HIV infected individuals: client and provider experiences and perceptions at two HIV clinics in Uganda. BMC Public Health 2013; 13:98. [PMID: 23374175 PMCID: PMC3568663 DOI: 10.1186/1471-2458-13-98] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/31/2013] [Indexed: 11/20/2022] Open
Abstract
Background Some people living with HIV/AIDS (PLHIV) want to have children while others want to prevent pregnancies; this calls for comprehensive services to address both needs. This study explored decisions to have or not to have children and contraceptive preferences among PLHIV at two clinics in Uganda. Methods This was a qualitative cross-sectional study. We conducted seventeen focus group discussions and 14 in-depth interviews with sexually active adult men and women and adolescent girls and boys, and eight key informant interviews with providers. Overall, 106 individuals participated in the interviews; including 84 clients through focus group discussions. Qualitative latent content analysis technique was used, guided by key study questions and objectives. A coding system was developed before the transcripts were examined. Codes were grouped into categories and then themes and subthemes further identified. Results In terms of contraceptive preferences, clients had a wide range of preferences; whereas some did not like condoms, pills and injectables, others preferred these methods. Fears of complications were raised mainly about pills and injectables while cost of the methods was a major issue for the injectables, implants and intrauterine devices. Other than HIV sero-discordance and ill health (which was cited as transient), the decision to have children or not was largely influenced by socio-cultural factors. All adult men, women and adolescents noted the need to have children, preferably more than one. The major reasons for wanting more children for those who already had some were; the sex of the children (wanting to have both girls and boys and especially boys), desire for large families, pressure from family, and getting new partners. Providers were supportive of the decision to have children, especially for those who did not have any child at all, but some clients cited negative experiences with providers and information gaps for those who wanted to have children. Conclusions These findings show the need to expand family planning services for PLHIV to provide more contraceptive options and information as well as expand support for those who want to have children.
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Reproductive decision-making and periconception practices among HIV-positive men and women attending HIV services in Durban, South Africa. AIDS Behav 2013; 17:461-70. [PMID: 22038045 PMCID: PMC3560938 DOI: 10.1007/s10461-011-0068-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Understanding reproductive decisions and periconception behavior among HIV-discordant couples is important for designing risk reduction interventions for couples who choose to conceive. In-depth interviews were conducted to explore reproductive decision-making and periconception practices among HIV-positive women with recent pregnancy (n = 30), and HIV-positive men (n = 20), all reporting partners of negative or unknown HIV-status, and attending HIV services in Durban, South Africa. Transcripts were coded for categories and emergent themes. Participants expressed strong reasons for having children, but rarely knew how to reduce periconception HIV transmission. Pregnancy planning occurred on a spectrum ranging from explicitly intended to explicitly unintended, with many falling in between the two extremes. Male fertility desire and misunderstanding serodiscordance contributed to HIV risk behavior. Participants expressed openness to healthcare worker advice for safer conception and modified risk behavior post-conception, suggesting the feasibility of safer conception interventions which may target both men and women and include serodiscordance counseling and promotion of contraception.
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Hayford SR, Agadjanian V, Luz L. Now or never: perceived HIV status and fertility intentions in rural Mozambique. Stud Fam Plann 2013. [PMID: 23185862 DOI: 10.1111/j.1728-4465.2012.00317.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
As the HIV epidemic evolves, researchers are devoting increased attention to the infection's effect on various life-course activities, including marriage and reproduction. The impact of HIV on decisions about childbearing is particularly important, given the role that vertical transmission plays in the persistence of the epidemic. Previous studies on HIV and fertility intentions have yielded inconsistent results. This article expands on prior research by taking into account preferred timing of childbearing. Using data from a population-based survey in rural Mozambique, we show that higher perceived risk of HIV is associated with greater likelihood of both wanting to speed up childbearing and wanting to stop having children. The "now or never" approach to childbearing is shown to be consistent with the widely held belief that HIV infection is incompatible with childbearing in the long term.
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Affiliation(s)
- Sarah R Hayford
- School of Social and Family Dynamics and Center for Population Dynamics, Arizona State University, Box 873701, Tempe, AZ 85287-3701, USA.
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Reproductive counseling by clinic healthcare workers in Durban, South Africa: perspectives from HIV-infected men and women reporting serodiscordant partners. Infect Dis Obstet Gynecol 2012; 2012:146348. [PMID: 22927713 PMCID: PMC3426202 DOI: 10.1155/2012/146348] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 06/15/2012] [Indexed: 12/03/2022] Open
Abstract
Background. Understanding HIV-infected patient experiences and perceptions of reproductive counseling in the health care context is critical to inform design of effective pharmaco-behavioral interventions that minimize periconception HIV risk and support HIV-affected couples to realize their fertility goals. Methods. We conducted semistructured, in-depth interviews with 30 HIV-infected women (with pregnancy in prior year) and 20 HIV-infected men, all reporting serodiscordant partners and accessing care in Durban, South Africa. We investigated patient-reported experiences with safer conception counseling from health care workers (HCWs). Interview transcripts were reviewed and coded using content analysis for conceptual categories and emergent themes. Results. The study findings indicate that HIV-infected patients recognize HCWs as a resource for periconception-related information and are receptive to speaking to a HCW prior to becoming pregnant, but seldom seek or receive conception advice in the clinic setting. HIV nondisclosure and unplanned pregnancy are important intervening factors. When advice is shared, patients reported receiving a range of information. Male participants showed particular interest in accessing safer conception information. Conclusions. HIV-infected men and women with serodiscordant partners are receptive to the idea of safer conception counseling. HCWs need to be supported to routinely initiate accurate safer conception counseling with HIV-infected patients of reproductive age.
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Oguntibeju OO. Quality of life of people living with HIV and AIDS and antiretroviral therapy. HIV AIDS (Auckl) 2012; 4:117-24. [PMID: 22893751 PMCID: PMC3418767 DOI: 10.2147/hiv.s32321] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The development of antiretroviral drugs has significantly changed the perception of HIV/AIDS from a very fatal to a chronic and potentially manageable disease, and the availability and administration of antiretroviral therapy (ART) has significantly reduced mortality and morbidity associated with HIV and AIDS. There is a relationship between ART and quality of life of people living with HIV and AIDS, and several studies have reported a strong positive association between ART and improved quality of life in different domains among people living with HIV and AIDS in both developed and developing countries. However, a few studies have reported on the negative effects of ART, which directly or indirectly relate to the quality of life and longevity of HIV-infected persons. In this review, the effects and benefits of ART on people living with HIV and AIDS based on studies done in developed and developing countries is examined.
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Affiliation(s)
- Oluwafemi O Oguntibeju
- Oxidative Stress Research Centre, Cape Peninsula University of Technology, Bellville, South Africa
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Hạnh NTT, Rasch V, Chi BK, Gammeltoft T. Prevention of mother-to-child transmission--precarious hopes and childbearing choices among HIV-infected women in a northern province of Vietnam. Women Health 2012; 52:485-502. [PMID: 22747185 DOI: 10.1080/03630242.2012.684372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The world over, increased access to treatment brings reproductive hope to women infected with HIV. Yet, despite the expanding availability of programs for prevention of mother-to-child transmission, HIV-positive women continue to face numerous problems and uncertainties in the realm of reproduction. The results reported here are derived from ethnographic research conducted in a northern province of Vietnam in 2007. The authors interviewed 32 HIV-positive women, exploring the hopes that they invested in prevention of mother-to-child transmission, and examining how this new technology enhanced the women's faith in their futures and childbearing capacities. Based on the findings, the authors discuss the new forms of gendered uncertainty that arise in the era of HIV/AIDS in Vietnam. They conclude that prevention of mother-to-child transmission, including the counseling offered by health providers, plays an important role in building and strengthening reproductive hopes for women living with HIV, while also generating new concerns.
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Affiliation(s)
- Nguyễn Thị Thúy Hạnh
- Department of Population, Institute for Preventive Medicine and Public Health, Hanoi Medical University, No. 1 Ton That Tung Street, Khuong Thuong, Dong Da District, Hanoi, Vietnam.
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Wagner G, Linnemayr S, Kityo C, Mugyenyi P. Factors associated with intention to conceive and its communication to providers among HIV clients in Uganda. Matern Child Health J 2012; 16:510-8. [PMID: 21359828 DOI: 10.1007/s10995-011-0761-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Persons living with HIV/AIDS (PLHA) must discuss their fertility intentions with healthcare providers to receive the support needed to have children safely and limit transmission risks. However, few quantitative studies have examined correlates of fertility intentions, let alone the communication of such intentions with providers. We examined the prevalence and correlates of intentions to have children, and comfort discussing such plans with one's providers, in HIV clients at two HIV clinics in Uganda. Cross-sectional self-report data were collected from 233 patients who had primary partners. Bivariate correlates significant at the P < 0.10 level were included in logistic regression analysis. Of the 233 participants, 103 (44%) reported an intention to conceive a child in the near future. In multivariate analysis, younger age of both the patient and their partner, better physical health functioning and higher internalized HIV stigma were associated with having fertility intentions. One-third (35%) of those with fertility intentions expressed having difficulty discussing these intentions with their providers, which was associated with receiving care at the rural clinic and greater internalized HIV stigma. These findings highlight the need for reproductive health services that help clients accept themselves as PLHA and their fertility rights, thus promoting patient-doctor communication needed to promote safe child conception and delivery outcomes.
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King R, Khana K, Nakayiwa S, Katuntu D, Homsy J, Lindkvist P, Johansson E, Bunnell R. 'Pregnancy comes accidentally--like it did with me': reproductive decisions among women on ART and their partners in rural Uganda. BMC Public Health 2011; 11:530. [PMID: 21726467 PMCID: PMC3223906 DOI: 10.1186/1471-2458-11-530] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 07/05/2011] [Indexed: 11/29/2022] Open
Abstract
Background As highly active antiretroviral therapy (ART) restores health, fertility and sexual activity among HIV-infected adults, understanding how ART influences reproductive desires and decisions could inform interventions to reduce sexual and vertical HIV transmission risk. Methods We performed a qualitative sub-study among a Ugandan cohort of 1,000 adults on ART with four purposively selected categories of participants: pregnant, not pregnant, delivered, and aborted. In-depth interviews examined relationships between HIV, ART and pregnancy, desire for children, perceived risks and benefits of pregnancy, decision-making regarding reproduction and family planning (FP) among 29 women and 16 male partners. Analysis focused on dominant explanations for emerging themes across and within participant groups. Results Among those who had conceived, most couples stated that their pregnancy was unintentional, and often occurred because they believed that they were infertile due to HIV. Perceived reasons for women not getting pregnant included: ill health (included HIV infection and ART), having enough children, financial constraints, fear of mother-to-child HIV transmission or transmission to partner, death of a child, and health education. Most women reported FP experiences with condoms and hormonal injections only. Men had limited FP information apart from condoms. Conclusions Counselling at ART initiation may not be sufficient to enable women who do not desire children to adopt relevant family planning practices. On-going reproductive health education and FP services, with emphasis on the restoration of fertility after ART initiation, should be integrated into ART programs for men and women.
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Affiliation(s)
- Rachel King
- Global Health Sciences, University of California, San Francisco, 50 Beale St, San Francisco, CA 94105, USA.
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Estimating the impact of expanded access to antiretroviral therapy on maternal, paternal and double orphans in sub-Saharan Africa, 2009-2020. AIDS Res Ther 2011; 8:13. [PMID: 21385370 PMCID: PMC3063201 DOI: 10.1186/1742-6405-8-13] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 03/07/2011] [Indexed: 11/17/2022] Open
Abstract
Background HIV/AIDS has orphaned 11.6 million children in sub-Saharan Africa. Expanded antiretroviral therapy (ART) use may reduce AIDS orphanhood by decreasing adult mortality and population-level HIV transmission. Methods We modeled two scenarios to measure the impact of adult ART use on the incidence of orphanhood in 10 sub-Saharan African countries, from 2009 to 2020. Demographic model data inputs were obtained from cohort studies, UNAIDS, UN Population Division, WHO and the US Census Bureau. Results Compared to current rates of ART uptake, universal ART access averted 4.37 million more AIDS orphans by year 2020, including 3.15 million maternal, 1.89 million paternal and 0.75 million double orphans. The number of AIDS orphans averted was highest in South Africa (901.71 thousand) and Nigeria (839.01 thousand), and lowest in Zimbabwe (86.96 thousand) and Côte d'Ivoire (109.12 thousand). Conclusion Universal ART use may significantly reduce orphanhood in sub-Saharan Africa.
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Associations between HIV Antiretroviral Therapy and the Prevalence and Incidence of Pregnancy in Rakai, Uganda. AIDS Res Treat 2011; 2011:519492. [PMID: 21490780 PMCID: PMC3066572 DOI: 10.1155/2011/519492] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/26/2010] [Accepted: 12/12/2010] [Indexed: 11/21/2022] Open
Abstract
Background. Use of antiretroviral therapy (ART) may be associated with higher pregnancy rates.
Methods. The prevalence and incidence of pregnancy was assessed in 712 HIV+ pre-ART women of reproductive age (WRA) (15–45) and 244 HIV+ WRA initiating ART. Prevalence rate ratios (PRR), incidence rate ratios (IRR), and 95% confidence interval (CI) were assessed.
Results. The incidence of pregnancy was 13.1/100 py among women in pre-ART care compared to 24.6/100 py among women on ART (IRR = 0.54; 95% CI 0.37, 0.81, p < 0.0017). The prevalence of pregnancy at ART initiation was 12.0% with CD4 counts 100–250 compared with 3.2% with CD4 <100 (PRR = 3.24, CI 1.51–6.93), and the incidence of pregnancy while on ART was highest in women with a good immunologic response. Desire for more children was a very important factor in fertility.
Conclusion. ART was associated with increased pregnancy rates in HIV+ women, particularly those with higher CD4 counts and good immunologic response to therapy, suggesting a need to strengthen reproductive health services for both women and their partners that could address their fertility decisions/intentions particularly after ART initiation.
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Raboud J, Li M, Blitz S, D'Aquila A, Sterling S, Walmsley S. Factors associated with HIV-positive women carrying pregnancies to term. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:756-62. [PMID: 21050507 DOI: 10.1016/s1701-2163(16)34616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To determine predictors of HIV-positive women who choose to carry a pregnancy to term. METHODS We collected pregnancy data up to December 2008 on women who had attended the University Health Network Immunodeficiency Clinic in Toronto since 2000 and were < 50 years of age at the time of their first HIV-positive test. Data were included on all pregnancies, including those that occurred before the woman was known to be HIV positive or first attended the clinic. RESULTS Data were collected from a total of 341 women who were < 50 years of age at their first HIV-positive test. Of these women, 179 (52%) had a total of 484 pregnancies, and 110 of these pregnancies (23%) in 74 women were known to occur after the woman tested HIV positive. An additional 52 women (11%) were found to be HIV positive during the pregnancy. Predictors of a woman's carrying a pregnancy to term when HIV positive were age, region of maternal birth, number of previous live births, and pregnancy during the highly active antiretroviral therapy (HAART) era. CONCLUSION HIV-positive women are more likely to carry a pregnancy to term during the new HAART era than they were before this era. Younger African-born HIV-positive women who already have children are more likely than other HIV-positive women to choose to carry a pregnancy to term.
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Affiliation(s)
- Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto ON; University Health Network, Toronto ON, Canada
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Kaida A, Laher F, Strathdee SA, Money D, Janssen PA, Hogg RS, Gray G. Contraceptive use and method preference among women in Soweto, South Africa: the influence of expanding access to HIV care and treatment services. PLoS One 2010; 5:e13868. [PMID: 21079770 PMCID: PMC2974641 DOI: 10.1371/journal.pone.0013868] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 10/13/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. METHODS We used survey data from 563 sexually active, non-pregnant women (18-44 years) recruited from the Perinatal HIV Research Unit in Soweto (May-December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use. RESULTS Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIV-negative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIV-positive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods. CONCLUSION Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health.
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Affiliation(s)
- Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.
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Matthews LT, Baeten JM, Celum C, Bangsberg DR. Periconception pre-exposure prophylaxis to prevent HIV transmission: benefits, risks, and challenges to implementation. AIDS 2010; 24:1975-82. [PMID: 20679759 PMCID: PMC3773599 DOI: 10.1097/qad.0b013e32833bedeb] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HIV-serodiscordant couples face complicated choices between fulfilling reproductive desire and risking HIV transmission to their partners and children. Sexual HIV transmission can be dramatically reduced through artificial insemination and sperm washing; however, most couples cannot access these resources. We propose that periconception pre-exposure prophylaxis (PrEP) could offer an important, complementary therapy to harm reduction counseling programs that aim to decrease HIV transmission for couples who choose to conceive. In this paper, we describe the potential benefits of periconception PrEP and define critical points of clarification prior to implementation of PrEP as part of a reproductive health program. We consider sexual transmission risk, current risk reduction options, PrEP efficacy, cost, adherence, resistance, fetal toxicity, and impact of PrEP counseling on entry into health services. We address PrEP in the context of other periconception HIV-prevention strategies, including antiretroviral treatment of the HIV-infected partner. We conclude that, should PrEP prove safe and efficacious in ongoing trials, periconception PrEP may offer a useful approach to minimize risk of HIV transmission for individuals of reproductive age in HIV-endemic countries.
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Affiliation(s)
- Lynn T Matthews
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center
| | - Jared M Baeten
- Departments of Global Health and Medicine, University of Washington
| | - Connie Celum
- Departments of Global Health and Medicine, University of Washington
| | - David R Bangsberg
- Ragon Institute, Massachusetts General Hospital Center for Global Health, Harvard Medical School
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Kaida A, Laher F, Strathdee SA, Janssen PA, Money D, Hogg RS, Gray G. Childbearing intentions of HIV-positive women of reproductive age in Soweto, South Africa: the influence of expanding access to HAART in an HIV hyperendemic setting. Am J Public Health 2010; 101:350-8. [PMID: 20403884 DOI: 10.2105/ajph.2009.177469] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. METHODS We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART-naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children. RESULTS Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART. CONCLUSIONS Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.
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Affiliation(s)
- Angela Kaida
- BC Centre for Excellence in HIV/AIDS and the School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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Myer L, Carter RJ, Katyal M, Toro P, El-Sadr WM, Abrams EJ. Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study. PLoS Med 2010; 7:e1000229. [PMID: 20161723 PMCID: PMC2817715 DOI: 10.1371/journal.pmed.1000229] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 12/30/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates. METHODS AND FINDINGS We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19-2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts. CONCLUSIONS ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Landon Myer
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
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The use of routine monitoring and evaluation systems to assess a referral model of family planning and HIV service integration in Nigeria. AIDS 2009; 23 Suppl 1:S97-S103. [PMID: 20081394 DOI: 10.1097/01.aids.0000363782.50580.d8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To measure changes in service utilization of a model integrating family planning with HIV counselling and testing (HCT), antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in the Nigerian public health facilities. DESIGN It is a retrospective survey of attendance and family planning commodity uptake in 71 health facilities in Nigeria that analyzes the preintegration and postintegration periods between March 2007 and January 2009. METHODS A prepost retrospective comparison of mean attendance at family planning clinics and couple-years of protection (CYP) compared 6 months preintegration with 9 months postintegration period. An analysis of service ratios was conducted, relating completed referrals at family planning clinics to service utilization at the referring HIV clinics. RESULTS Mean attendance at family planning clinics increased significantly from 67.6 in preintegration to 87.0 in postintegration. The mean CYP increased significantly from 32.3 preintegration to 38.2 postintegration. Service ratio of referrals from each of the HIV clinics was low but increased in the postintegration period by 4, 34 and 42 per 1000 clients from HCT, ART and PMTCT clinics, respectively. Service ratios were higher in primary healthcare settings than in secondary or tertiary hospitals. Attendance by men at family planning clinics was significantly higher among clients referred from HIV clinics. CONCLUSION Family planning-HIV integration using the referral model improved family planning service utilization by clients accessing HIV services, but further improvement is possible. Male utilization of family planning services also improved. The government of Nigeria should review the family planning user fee policy and scale up the integration in primary healthcare facilities.
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Laher F, Todd CS, Stibich MA, Phofa R, Behane X, Mohapi L, Gray G. A qualitative assessment of decisions affecting contraceptive utilization and fertility intentions among HIV-positive women in Soweto, South Africa. AIDS Behav 2009; 13 Suppl 1:47-54. [PMID: 19308719 DOI: 10.1007/s10461-009-9544-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 03/09/2009] [Indexed: 11/29/2022]
Abstract
The HIV epidemic in sub-Saharan Africa disproportionately affects women of reproductive age. The increasing provision of Highly Active Anti-Retroviral Therapy (HAART) with improved prognosis and maternal-fetal outcomes calls for an understanding of fertility planning for HIV-positive women. We describe the effect of HIV and HAART on pregnancy desires and contraceptive use among HIV-positive women in Soweto, South Africa. Focus group discussions and in-depth interviews were conducted with 42 HIV-positive women of reproductive age. Analysis was performed using ATLAS-ti (ATLAS-ti Center, Berlin). Emergent themes were impact of HIV diagnosis on pregnancy intentions; factors affecting contraceptive uptake including real and normative side effects, body image, and perceived vaginal wetness; and the mitigating influence of partnership on both pregnancy intentions and contraceptive use. Routine counseling about pregnancy desires and contraception should be offered to HIV-positive women.
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Affiliation(s)
- Fatima Laher
- Perinatal HIV Research Unit, University of the Witwatersrand, Diepkloof, P.O. Box 114, Johannesburg, Soweto, 1864, South Africa.
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Cooper D, Moodley J, Zweigenthal V, Bekker LG, Shah I, Myer L. Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services. AIDS Behav 2009; 13 Suppl 1:38-46. [PMID: 19343492 DOI: 10.1007/s10461-009-9550-1] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 03/16/2009] [Indexed: 11/29/2022]
Abstract
Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women's fertility intentions. Gender differences were also apparent in participants' key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.
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Affiliation(s)
- Diane Cooper
- Women's Health Research Unit, School of Public Health & Family Medicine, University of Cape Town, Anzio Road Observatory, 7925, Cape Town, South Africa.
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Antiretroviral therapy is associated with increased fertility desire, but not pregnancy or live birth, among HIV+ women in an early HIV treatment program in rural Uganda. AIDS Behav 2009; 13 Suppl 1:28-37. [PMID: 18389364 DOI: 10.1007/s10461-008-9371-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
Abstract
To assess the association between antiretroviral therapy (ART) and fertility history and desire among HIV-positive Ugandan women, we conducted a cross-sectional study among HIV-positive Ugandan women aged 18-50 years who attended an HIV clinic at Mbarara University in western Uganda between November 1, 2005 and June 6, 2006. Of 538 women approached, 501 were enrolled. ART use was associated with increased odds of fertility desire (AOR 2.99, 95% CI 1.38-6.28), and decreased odds of pregnancy (AOR 0.56, 95% CI 0.33-0.95) and live birth (AOR 0.30, 95% CI 0.13-0.66). ART was associated with an increase in fertility desire, but was not associated with an increase in fertility. Additional studies will be needed to determine if this greater fertility desire among ART-treated women leads to an increase in fertility as ART use expands.
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Agadjanian V, Hayford SR. PMTCT, HAART, and childbearing in Mozambique: an institutional perspective. AIDS Behav 2009; 13 Suppl 1:103-12. [PMID: 19326206 DOI: 10.1007/s10461-009-9535-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 02/16/2009] [Indexed: 11/24/2022]
Abstract
Maternal and Child Health (MCH) units, where VCT/PMTCT/HAART have been integrated with traditional services, play a critical role in the connection between the massive HAART rollout and reproductive behavior. In this article, we use data from semi-structured interviews with MCH workers and ethnographic observations carried out in southern Mozambique to explore this role from the institutional perspective. We find that, along with logistical and workload problems, the de facto segregation of PMTCT/HAART clients within the "integrated" MCH system and the simplistic and uncompromising message discouraging further fertility and stressing condom-based contraception may pose serious challenges to a successful formulation and implementation of reproductive goals among seropositive clients. Although the recency of PMTCT/HAART services may partly explain these challenges, we argue that they are due largely to cultural miscommunication between providers and clients. We show how the cultural gap between the two is bridged by community activists and peer interactions among clients.
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Affiliation(s)
- Victor Agadjanian
- Center for Population Dynamics, School of Social and Family Dynamics, Arizona State University, Tempe, AZ 85287-3701, USA.
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Forrest JI, Kaida A, Dietrich J, Miller CL, Hogg RS, Gray G. Perceptions of HIV and fertility among adolescents in Soweto, South Africa: stigma and social barriers continue to hinder progress. AIDS Behav 2009; 13 Suppl 1:55-61. [PMID: 19343491 DOI: 10.1007/s10461-009-9552-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 03/16/2009] [Indexed: 11/28/2022]
Abstract
The scale up of highly active antiretroviral therapy (HAART) for the treatment of HIV has raised new concerns relating to fertility desires and outcomes. Among these concerns is social stigma surrounding HIV and childbearing. High rates of infection and patterns of high fertility make adolescents a crucial demographic to qualify perceptions of HIV and fertility. We conducted two focus groups (n = 11 males, n = 8 females) with participants ascertained from an HIV adolescent community advisory board in Soweto, South Africa. Adolescents raised concern over re-infection by HIV positive couples attempting to conceive. They also used this concern to justify their attitudes that HIV positive couples should adopt when faced with the desire to have children. Lastly, participants spoke of a need to revise adolescent sexual and reproductive health services to make them more youth-friendly where users could avoid stigma generated by community healthcare workers. This study adds to the growing literature that calls for an evaluation of adolescent HIV educational programs and a healthcare worker intervention that specifically targets stigma surrounding HIV and childbearing.
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Affiliation(s)
- Jamie I Forrest
- Faculty of Health Sciences, Simon Fraser University, 8888 University Avenue, Burnaby, BC, Canada.
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Thanh DC, Moland KM, Fylkesnes K. The context of HIV risk behaviours among HIV-positive injection drug users in Viet Nam: moving toward effective harm reduction. BMC Public Health 2009; 9:98. [PMID: 19348681 PMCID: PMC2676271 DOI: 10.1186/1471-2458-9-98] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 04/06/2009] [Indexed: 12/01/2022] Open
Abstract
Background Injection drug users represent the largest proportion of all HIV reported cases in Viet Nam. This study aimed to explore the perceptions of risk and risk behaviours among HIV-positive injection drug users, and their experiences related to safe injection and safe sex practices. Methods This study used multiple qualitative methods in data collection including in-depth interviews, focus group discussions and participant observation with HIV-positive injection drug users. Results The informants described a change in the sharing practices among injection drug users towards more precautions and what was considered 'low risk sharing', like sharing among seroconcordant partners and borrowing rather than lending. However risky practices like re-use of injection equipment and 'syringe pulling' i.e. the use of left-over drugs in particular, were frequently described and observed. Needle and syringe distribution programmes were in place but carrying needles and syringes and particularly drugs could result in being arrested and fined. Fear of rejection and of loss of intimacy made disclosure difficult and was perceived as a major obstacle for condom use among recently diagnosed HIV infected individuals. Conclusion HIV-positive injection drug users continue to practice HIV risk behaviours. The anti-drug law and the police crack-down policy appeared as critical factors hampering ongoing prevention efforts with needle and syringe distribution programmes in Viet Nam. Drastic policy measures are needed to reduce the very high HIV prevalence among injection drug users.
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Affiliation(s)
- Duong Cong Thanh
- Centre for International Health, University of Bergen, Bergen, Norway.
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Homsy J, Bunnell R, Moore D, King R, Malamba S, Nakityo R, Glidden D, Tappero J, Mermin J. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a prospective cohort study. PLoS One 2009; 4:e4149. [PMID: 19129911 PMCID: PMC2612743 DOI: 10.1371/journal.pone.0004149] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 12/01/2008] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa. METHODOLOGY /PRINCIPAL FINDINGS: Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women's desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p<0.0001). This was paralleled by an increase in the proportion of women reporting sexual activity in the past 3 months, from 24.4% at baseline to 32.5% over 24 months of follow-up (p = 0.001). Only 14% of women used permanent or semi-permanent family planning methods by their second year on ART. In the multivariate model, younger age (HR = 2.71 per 10-year decrease, 95% CI: 2.95-3.78), having a BMI>18.5 (HR = 1.09, CI: 1.01-1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02-3.13) were independently associated with pregnancy. CONCLUSION/SIGNIFICANCE Women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.
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Affiliation(s)
- Jaco Homsy
- Centers for Disease Control and Prevention, Global AIDS Program, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Entebbe, Uganda.
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Andia I, Kaida A, Maier M, Guzman D, Emenyonu N, Pepper L, Bangsberg DR, Hogg RS. Highly active antiretroviral therapy and increased use of contraceptives among HIV-positive women during expanding access to antiretroviral therapy in Mbarara, Uganda. Am J Public Health 2008; 99:340-7. [PMID: 19059862 DOI: 10.2105/ajph.2007.129528] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We investigated whether the prevalence of contraceptive use among women who are HIV positive varied according to use of highly active antiretroviral therapy (HAART) in Mbarara, Uganda. METHODS We used data from a cross-sectional survey of 484 women who were HIV positive (18-50 years) and were attending Mbarara University's HIV clinic, 45% of whom were receiving HAART. Multivariate logistic regression was used to investigate the association between HAART use and contraceptive use. Data were collected between November 2005 and June 2006. RESULTS Overall, 45% of the women were sexually active in the previous 3 months. Of these, 85% reported using contraceptive methods, with 84% reporting use of barrier contraceptive methods. Women receiving HAART were more than twice as likely to use contraceptive methods (adjusted odds ratio [AOR] = 2.64; 95% confidence interval [CI] = 1.07, 6.49) and more than 3 times as likely to use barrier contraceptive methods (AOR = 3.62; 95% CI = 1.54, 8.55) than were women not receiving HAART. CONCLUSIONS Our findings support the need for increased attention to better integration of reproductive health and HIV and AIDS services for women who are HIV positive.
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Affiliation(s)
- Irene Andia
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.
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Reconsidering the impact of conflict on HIV infection among women in the era of antiretroviral treatment scale-up in sub-Saharan Africa: a gender lens. AIDS 2008; 22:1705-7. [PMID: 18753938 DOI: 10.1097/qad.0b013e328308de0e] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaida A, Gray G, Bastos FI, Andia I, Maier M, McIntyre J, Grinsztejn B, Strathdee SA, Bangsberg DR, Hogg R. The relationship between HAART use and sexual activity among HIV-positive women of reproductive age in Brazil, South Africa, and Uganda. AIDS Care 2008; 20:21-5. [PMID: 18278611 DOI: 10.1080/09540120701426540] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to determine whether current HAART use is associated with recent sexual intercourse among HIV-infected women (18-49 years) from Brazil, South Africa and Uganda. We conducted an analysis of survey data from a cross-sectional study, which enrolled 179 HIV-infected women receiving regular care from the Mbarara Hospital HIV Clinic in Uganda (n=85); the Perinatal HIV Research Unit in Soweto, South Africa (n=50); and the IPEC-Fiocruz cohort in Rio de Janeiro, Brazil (n=44). The primary outcome was sexual intercourse in the previous month. Secondary outcomes were protected sex and contraceptive use. We found that overall, 46% reported recent sexual intercourse. After adjusting for covariates, recent sexual intercourse was not associated with HAART use (AOR: 0.76; 95%CI: 0.34-1.72); however, it was significantly associated with being currently married, wanting to have more children and having higher HAART optimism. Among women reporting recent sexual intercourse (n=83), HAART users were significantly more likely to practice protected sex (crude OR: 3.64; 95%CI: 1.41-9.38) and non-significantly more likely to use contraceptive methods (crude OR: 2.15; 95%CI: 0.77-5.99). In summary, self-reported recent sexual intercourse is not more likely among women on HAART. Moreover, sexually active HAART users may be more likely to practice protected sex and use contraceptives.
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Affiliation(s)
- A Kaida
- Department of Healthcare and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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