'Pregnancy comes accidentally--like it did with me': reproductive decisions among women on ART and their partners in rural Uganda

Scoping review of qualitative studies on family planning in Uganda

Family planning (FP) is an essential component of public health programs and significantly impacts maternal and child health outcomes. In Uganda, there is a need for a comprehensive review of the existing literature on FP to inform future research and programmatic efforts. This scoping review aims to identify factors shaping the use of FP in Uganda. We conducted a systematic search of eight scholarly databases, for qualitative studies on FP in Uganda. We screened the titles and abstracts of identified articles published between 2002-2023 and assessed their eligibility based on predefined criteria. We extracted data from the 71 eligible studies and synthesized the findings using thematic analysis and the Ecological Systems Theory (EST) individual, interpersonal, community, institutional, and policy-level determinants. Findings reveal the interplay of factors at different socio-ecological levels influencing family planning decisions. At the individual level, the most common determinants related to the EST were knowledge and attitudes of FP. Interpersonal dynamics, including partner communication and social support networks, played pivotal roles. Community-level factors, such as cultural norms and accessibility of services, significantly influenced family planning practices. Institutional and policy-level factors, particularly a healthcare system's quality and policies, also shaped use. Other themes included the intersection of HIV/AIDS on FP practice and Ugandan views of comprehensive abortion care. This scoping review underscores the intricate socio-ecological fabric shaping FP in Uganda. The findings highlight the need for targeted interventions to increase knowledge and awareness of FP, improve access to services, and address social and cultural norms that discourage contraceptive use. Policymakers and program implementers should also consider gender dynamics and power imbalances in FP programs to ensure they are equitable and effective.

Predictors of Current CD4+ T-Cell Count Among Women of Reproductive Age on Antiretroviral Therapy in Public Hospitals, Southwest Ethiopia

Background

HIV/AIDS is one of the major global public health problems. CD4 is a glycoprotein found on the surface of different immune cells. CD4 cell counts determine the need for screening and prophylactic interventions against common opportunistic infections in those with advanced HIV disease. Thus, this study aimed to assess the predictors of current CD4⁺ T-cell count among women of reproductive age on antiretroviral therapy in public hospitals, southwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2018. A total of 422 participants in the three public hospitals were selected using a systematic random sampling method. Linear regression analyses were used to determine the important predictors of current CD4⁺ T-cell count at p-values of <0.05.

Results

A total of 422 women with a median age of 37.00 years participated in this study. More than one in ten (12.8%) respondents experienced immunological failure. An increased current CD4⁺ T-cell count was observed among patients with a tertiary level of education [β = 56.45, 95% CI (3.5, 109.4)], baseline WHO clinical stage II [β = 44.06, 95% CI (5.3, 82.9)], initial regimen of AZT+3TC+EFV [β = 167.23, 95% CI (100.4, 234.1)], with increased baseline CD4⁺ T-cell count [β = 0.35, 95% CI (0.2, 0.5)], and with increased time duration on ART [β = 14.36, 95% CI (6.304, 22.4)]. On the other hand, the current CD4⁺ T-cell count was lowered among patients with poor baseline adherence, opportunistic infection, and viral load of ≥1000 by 181.06 cells/mm³, 101.62 cells/mm³, and 137.53 cells/mm³ compared to good baseline adherence, no opportunistic infection and undetectable viral load, respectively.

Conclusion

The immunological failure was relatively low. Maintaining adherence, early identification and treatment of opportunistic infections, and minimizing viral load to undetectable levels may further decrease immunological failure.

The role of unintended pregnancy in internalized stigma among women living with HIV in Kenya

BACKGROUND

Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV.

METHODS

Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored.

RESULTS

About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination.

CONCLUSIONS

Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.

Dual Contraceptive Utilization and Associated Factors Among Reproductive-Age Women on Anti-Retroviral Therapy at Hospitals in Central Ethiopia

Background

Ethiopia is one of the Sub-Saharan African countries with an increasingly risky sexual practice and mostly affected by the Human Immunodeficiency Virus (HIV) epidemic. Dual protection is an important preventive approach which can prevent both unwanted pregnancy and sexually transmitted infections including HIV/AIDS. Therefore, this study aimed to assess the dual contraceptive utilization and associated factors among reproductive-age women on Anti-Retroviral Therapy (ART) in central Ethiopia.

Methods

An-institution based cross-sectional study was conducted among 311 women on ART at public hospitals of West Shewa Zone from June to September 2019. A systematic random sampling technique was used to select the study participants. A pretested structured interviewer-administered questionnaire was used for data collection. The data were entered into Epi data version 3.1 and exported to IBM SPSS statistical software version 25 for analysis. Bivariate and multivariable logistic regression analysis were computed. Odds ratio along with 95% confidence interval was computed to ascertain the association.

Results

The prevalence of dual contraceptive utilization among women on ART was 21.4% (95% CI: 16.8-25.9). Age of respondents between 15 and 24 years [AOR=8.35, (95% CI: 3.12-17.78)], living in urban [AOR=2.59, 95% CI: 1.15-4.22], separated women [AOR=2.28, 95% CI (1.26-5.04)], had post-diagnosis counselling on family planning [AOR=5.33, 95% CI: 1.52-18.68], disclosed HIV status [AOR=5.98, 95% CI: 1.63-21.93], freely discuss with their husband [AOR=4.22, 95% CI, 1.84-12.36], have no fertility desire [AOR=2.46, (95% CI: 1.34-6.44)] were significantly associated with dual contraceptive utilization.

Conclusion and Recommendation

The overall magnitude of dual contraceptive utilization among women on ART was found to be low. Factors like age, residence, marital status, post-diagnosis counselling, disclosure of HIV status, and free discussion with husband were significantly associated with dual contraceptive method utilization. Therefore, it is necessary to expand the range of strategies and tools available to married and single women's for protecting themselves from being infected with other strains and pregnancy. The concerned stakeholders also should emphatically consider those identified factors for intervention.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

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.

Men's and women's roles in decision making about abortion in the context of HIV

OBJECTIVE

Mother-to-child transmission of HIV is a matter of global concern but is particularly serious in Zimbabwe. A number of strategies have been identified to limit the risk of mother-to-child transmission, including abortion. The aim of the current study was to assess men's and women's roles in decision making about abortion in a setting with a high prevalence of HIV.

METHODS

Qualitative research based on eight focus group discussions was conducted among adult men and women in Gokwe North District, Zimbabwe.

RESULTS

Both men and women expressed strong, negative attitudes towards abortion. Often, HIV-infected women considered carrying their pregnancy to term so as to fulfil societal and cultural expectations of childbirth after marriage. Termination of pregnancy by HIV-infected women was discouraged due to the availability of highly active antiretroviral drugs. Fear of giving birth to a sick and HIV-infected child, however, remained high. Also, the restricted legal environment appeared to complicate HIV-positive women's decisions to abort. Male involvement in decision making about abortion was relatively limited; if women opted for termination of pregnancy they were likely to do so secretly without obtaining their partner's consent.

CONCLUSIONS

In the context of HIV, it is important for prevention programmes to target both men and women in order to reduce the risk of mother-to-child transmission.

Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique - a qualitative study

Background

In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province.

Methods

In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu’s practice theory.

Results

The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors.

Conclusion

Women’s experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women’s perceptions and the cultural context of maternity when providing information about sexual and reproductive health.

Prevalence and factors influencing modern contraceptive use among HIV-positive women in Kilimanjaro region, northern Tanzania

Background

Mother-to-Child-Transmission (MTCT) of HIV is still a public health problem in sub-Saharan Africa. The region has a high unmet need for family planning and high unplanned pregnancy rates among HIV-positive women. Most efforts to prevent MTCT of HIV have focused on the third prong, a strategy which offers antiretroviral (ARV) drugs to HIV-infected pregnant women and their exposed infants. However, the effective use of contraceptives to prevent unplanned pregnancies among women living with HIV is more effective in reducing HIV MTCT. This study aimed at determining the prevalence and factors influencing modern contraceptive use among HIV-positive women in northern Tanzania.

Methods

This was a cross-sectional study conducted between January and June 2014 in three selected districts of Kilimanjaro region, Tanzania. Data were collected during face-to-face interviews with HIV-positive women attending Care and Treatment Clinics (CTC) in the selected districts. Multivariate logistic regression analysis was used to determine independent predictors of modern contraceptive use.

Results

In total 672 HIV-positive women were enrolled. Their mean age was 36.4 years (±7.7). Fifty four percent (362) were currently using modern contraceptives, and the most common method used was male condoms 76% (275) followed by Depo-Provera 28% (101). A total of 33% (121) of the users reported dual contraceptive use. Women with primary education [Adjusted Odds Ratio (AOR) = 7.54, 95% Confidence Interval (CI): 1.51–17.48, P = 0.014]; post-secondary [AOR = 6.23, 95% CI: 1.14–14.07, P = 0.035]; not currently on ARVs [AOR = 11.29, 95% CI: 2.60–19.94, P = 0.001]; currently sexually active [AOR = 8.40, 95% CI: 4.47–15.78, P < 0.001]; ever discussed contraceptive use with partner [AOR = 3.68, 95% CI: 1.67–8.11, P = 0.001]; and being counseled on dual contraceptive use at CTC [AOR = 2.94, 95% CI: 1.66–5.23, P < 0.001]; had significantly higher odds of currently using modern contraceptive methods.

Conclusions

Given the population studied, the prevalence of modern contraceptive use was low. Strategies are required to increase the use of dual and long-term contraceptive methods among women who do not want more children in order to reduce MTCT, and to improve maternal and child health in the region. Programme managers and health care providers need to identify counseling strategies that are specific to HIV-positive women that not only impart knowledge on contraceptives, but also address the issue of responsibility for influencing HIV transmission in the community.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

Couple perspectives on unintended pregnancy in an area with high HIV prevalence: A qualitative analysis in Rakai, Uganda

Understanding how couples perceive a recent unintended pregnancy in the context of HIV infection and high levels of gender inequality may provide insights for prevention of undesired pregnancy. We used data from 24 in-depth interviews with 8 HIV-serodiscordant and 4 seroconcordant couples living in rural Uganda and interviewed separately; between 15 and 49 years and one or both identified the pregnancy as unintended. A dyadic analysis was performed to understand each partner's perspectives on experiences of a specific pregnancy. We used the social-ecological model to guide the analysis. Issues of agency were commonly invoked in describing pregnancy. Women often cited factors that demonstrated a lack of control when making decisions about continuing the pregnancy. Men often expressed a lack of agency or control over preventing their female partner from becoming pregnant. There was much disagreement between partners about intentions regarding the specific pregnancy. Likewise, lack of communication about child spacing and pregnancy intentions was common among couples. HIV serostatus played a role in some discussions of pregnancy intention among serodiscordant couples. This qualitative analysis supports prior quantitative research on the complexity of pregnancy intentions. A lack of agency at the individual level was compounded by a lack of communication between partners.

High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa

BACKGROUND

Integration of family planning services into HIV care was implemented in South Africa as a core strategy aimed at reducing unintended pregnancies among childbearing women living with HIV. However, it is unclear whether this strategy has made any significant impact at the population level. This paper describes the prevalence and correlates of self-reported unplanned pregnancy among HIV-infected parturient women attending three large maternity centres in the Eastern Cape, South Africa. We also compare unplanned pregnancy rates between HIV-infected parturient women already in care (who have benefitted from services' integration) and newly diagnosed parturient women (who have not benefitted from services' integration).

METHODS

Drawing from the baseline data of the East London Prospective Cohort Study (ELPCS), data of 594 parturient women living with HIV in the Eastern Cape were included. Chi-square statistics and binary logistics regression were employed to determine the correlates of unplanned pregnancy among the cohort.

RESULTS

The prevalence of unplanned pregnancy was 71% (n = 422) with a higher rate among parturient women newly diagnosed during the index pregnancy (87%). Unplanned pregnancy was significantly associated with younger age, single status, HIV diagnosis at booking, high parity and previous abortion. Women who reported unplanned pregnancy were more likely to book late and have lower CD4 counts. After adjusting for confounding variables, having one child and five to seven children (AOR = 2.2; CI = 1.3-3.1), age less than 21 years (AOR = 3.3; CI = 1.1-9.8), late booking after 27 weeks (AOR = 2.7; CI = 1.5-5.0), not married (AOR = 4.3; CI = 2.7-6.8) and HIV diagnosis at booking (AOR = 3.0; CI = 1.6-5.8) were the significant correlates of unplanned pregnancy in the cohort.

CONCLUSION

Unplanned pregnancy remains high overall among parturient women living with HIV in the region, however, with significant reduction among those who were exposed to integrated services. The study confirms that integration of HIV care and family planning services is an important strategy to reduce unplanned pregnancy among women living with HIV. The study's findings have significant implications for the elimination of mother-to-child transmission of HIV in South Africa. Innovative interventions are needed to further consolidate and maximise the benefit of the integration of family planning services with HIV care.

Facing HIV infection and unintended pregnancy: Rakai, Uganda, 2001-2013

Background

Unintended pregnancy is a persistent and global issue with consequences for the health and well-being of mothers and babies. The aim of this paper is to examine unintended pregnancy over time in the context of substantial human immunodeficiency virus (HIV) prevalence and increasing access to anti-retro viral therapy (ART).

Method

Data are from the Rakai Community Cohort Study (RCCS) – a cohort of communities with 10,000–12,000 adults, ages 15–49, in Rakai District, Uganda. We examined prevalence of current pregnancies over time, intended pregnancy, and unintended pregnancies (unwanted, mistimed, ambivalent). We then examined risk factors for the different categories of unintended pregnancy among women who were currently pregnant. The full sample included 32,205 observations over 13 years.

Results

The prevalence of mistimed pregnancy and unwanted pregnancy both decreased significantly over time (p < .001). The prevalence of current pregnancies and intended pregnancy showed no significant changes over the thirteen year period. The same overall pattern was found when only examining HIV positive women in the sample; however, the trends were not significant. Out of the 2820 current pregnancies reported, 54.4% were intended, 29.8% were mistimed, 13.2% were unwanted, and 2.5% were ambivalent. After controlling for other predictors, HIV status had no independent effect on mistimed pregnancy but had a significant effect on unwanted pregnancy (RRR = 2.44, 95% CI = 1.65–3.61, p < .001] and ambivalent pregnancy [RRR = 2.07; CI: 1.03 to 4.18, p = 0.041]. In 2004, after the introduction of ART, there was a decreased risk in unintended pregnancy [RR = 0.75; CI: 0.66 to 0.84, p < .001]. Women with a secondary education or higher also had a decreased risk in unintended pregnancy [RR = 0.70; CI: 0.70 to 0.92, p = 0.002].

Discussion

HIV was an important predictor of unwanted pregnancy. Unintended pregnancy decreased in the sample over time which may be due to an increase in ART availability and rising levels of education.

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.

Greater involvement of HIV-infected peer-mothers in provision of reproductive health services as "family planning champions" increases referrals and uptake of family planning among HIV-infected mothers

Background

In 2012, Makerere University Johns - Hopkins University, and Mulago National Referral Hospital, with support from the National Institute of Health (under Grant number: NOT AI-01-023) undertook operational research at Mulago National Hospital PMTCT/PNC clinics. The study employed Peer Family Planning Champions to offer health education, counselling, and triage aimed at increasing the identification, referral and family planning (FP) uptake among HIV positive mothers attending the clinic.

Methods

The Peer Champion Intervention to improve FP uptake was introduced into Mulago Hospital PMTCT/PNC clinic, Kampala Uganda. During the intervention period, peers provided additional FP counselling and education; assisted in identification and referral of HIV Positive mothers in need of FP services; and accompanied referred mothers to FP clinics. We compiled and compared the average proportions of mothers in need that were referred and took up FP in the pre-intervention (3 months), intervention (6 months), and post-intervention(3 months) periods using interrupted time series with segmented regression models with an autoregressive term of one.

Results

Overall, during the intervention, the proportion of referred mothers in need of FP increased by 30.4 percentage points (P < 0.001), from 52.7 to 83.2 percentage points. FP uptake among mothers in need increased by over 31 percentage points (P < 0.001) from 47.2 to 78.5 percentage points during the intervention. There was a positive non-significant change in the weekly trend of referral β₃ = 2.9 percentage points (P = 0.077) and uptake β₃ = 1.9 percentage points (P = 0.176) during the intervention as compared to the pre-intervention but this was reversed during the post intervention. Over 57% (2494) mothers took up Depo-Provera injectable-FP method during the study.

Conclusions

To support overstrained health care work force in post-natal clinics, peers in trained effective family planning can be a valuable addition to clinic staff in limited-resource settings. The study provides additional evidence on the utilization of peer mothers in HIV care, improves health services uptake including family planning which is a common practice in many donor supported programs. It also provides evidence that may be used to advocate for policy revisions in low-income countries to include peers as support staff especially in busy clinic settings with poor services uptake.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2386-x) contains supplementary material, which is available to authorized users.

Psychosocial challenges facing women living with HIV during the perinatal period in rural Uganda

The complexities of navigating pregnancy while living with HIV predispose women to additional stress. Finding ways to minimize psychosocial challenges during the perinatal period may maximize the well-being of mothers living with HIV and their children. The goal of this study was to explore psychosocial challenges experienced by women living with HIV (WLWH) during pregnancy and the postpartum. We conducted individual in-depth interviews with 20 WLWH recruited from an HIV treatment cohort study in Mbarara, Uganda as part of a larger study exploring perinatal depression. We conducted content analyses to identify themes related to challenges of WLWH during pregnancy and the postpartum. Participants had a median age of 33 years [IQR: 28-35], a median of 3 living children [IQR: 2-5], and 95% had achieved HIV-RNA suppression. Challenges were organized around the following themes: HIV -related stigma from health professionals, HIV status disclosure dilemma, unintended pregnancy and intimate partner violence, HIV and environmental structural barriers and distress and fear related to maternal and child health. Stigma centered on discrimination by health care professionals and personal shame associated with being pregnant as a WLWH. This led to difficulty engaging in HIV care, particularly when coupled with structural barriers, such as lack of transportation to clinic. Participants experienced intimate partner violence and lacked support from their partners and family members. Distress and fear about the health and uncertainty about the future of the unborn baby due to maternal deteriorating physical health was common. The perinatal period is a time of stress for WLWH. Challenges experienced by WLWH may compromise successful engagement in HIV care and may reduce quality of life for women and their children. Strategies aimed at alleviating the challenges of WLWH should involve the larger structural environment including partners, family and community member as well as policy makers, funders and program implementers to work together for the common cause. These consolidated efforts may not only lower the risk of psychological distress but has potential to create long lasting solutions to benefit the wider community.

Pregnancy and HIV Disease Progression in an Early Infection Cohort from Five African Countries

BACKGROUND

Understanding associations between pregnancy and HIV disease progression is critical to provide appropriate counseling and care to HIV-positive women.

METHODS

From 2006 to 2011, women less than age 40 with incident HIV infection were enrolled in an early HIV infection cohort in Kenya, Rwanda, South Africa, Uganda, and Zambia. Time-dependent Cox models evaluated associations between pregnancy and HIV disease progression. Clinical progression was defined as a single CD4 measurement <200 cells/μl, percent CD4 <14%, or category C event, with censoring at antiretroviral (ART) initiation for reasons other than prevention of mother-to-child transmission (PMTCT). Immunologic progression was defined as two consecutive CD4s ≤350 cells/μl or a single CD4 ≤350 cells/μl followed by non-PMTCT ART initiation. Generalized estimating equations assessed changes in CD4 before and after pregnancy.

RESULTS

Among 222 women, 63 experienced clinical progression during 783.5 person-years at risk (8.0/100). Among 205 women, 87 experienced immunologic progression during 680.1 person-years at risk (12.8/100). The association between pregnancy and clinical progression was adjusted hazard ratio [aHR] = 0.7; 95% confidence interval (CI): 0.2, 1.8. The association between pregnancy and immunologic progression was aHR = 1.7; 95% CI: 0.9, 3.3. Models controlled for age; human leukocyte antigen alleles A*03:01, B*45, B*57; CD4 set point; and HIV-1 subtype. CD4 measurements before versus after pregnancies were not different.

CONCLUSIONS

In this cohort, pregnancy was not associated with increased clinical or immunologic HIV progression. Similarly, we did not observe meaningful deleterious associations of pregnancy with CD4s. Our findings suggest that HIV-positive women may become pregnant without harmful health effects occurring during the pregnancy. Evaluation of longer-term impact of pregnancy on progression is warranted.

HIV/AIDS and contraceptive use: factors associated with contraceptive use among sexually active HIV-positive women in Kenya

OBJECTIVES

With increased availability of antiretroviral therapy and improved survival for people living with HIV, more HIV-positive women are leading full reproductive lives. However, HIV-positive women have special contraceptive needs/concerns. This paper examines the individual and community-level HIV/AIDS factors associated with contraceptive use and compares predictors of contraceptive uptake between HIV-positive and HIV-negative women in Kenya.

STUDY DESIGN

The study is based on secondary analysis of cross-sectional data of a sample of 9132 sexually active women of reproductive age from the Kenya Demographic and Health Surveys collected in 2003 and 2008. Multilevel logistic regression models are used to examine individual and contextual community-level factors associated with current contraceptive use.

RESULTS

The study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities. It further reveals striking differences in factors associated with contraceptive uptake between HIV-positive and HIV-negative women. Education and the desire to stop childbearing are strongly associated with contraceptive uptake among uninfected women, but both factors are not significant among HIV-positive women for whom wealth is the most important factor. While HIV-negative women in the richest wealth quintile are about twice as likely to use contraceptives as their counterparts of similar characteristics in the poorest quintile, this gap is about sevenfold among HIV-positive women.

CONCLUSION

These findings suggest that having the desire and relevant knowledge to use contraceptives does not necessarily translate into expected contraceptive behavior for HIV-positive women in Kenya and that poor HIV-positive women may be particularly in need of increased access to contraceptive services.

IMPLICATIONS

• Study provides evidence of lower contraceptive uptake among women living in high HIV-prevalence communities in Kenya. • Results reveal striking differences in factors associated with contraceptive use between HIV-positive and HIV-negative women. • Poverty may be an impediment to contraceptive uptake among HIV-positive women in Kenya.

Getting pregnant in HIV clinical trials: women's choice and safety needs. The experience from the ANRS12169-2LADY and ANRS12286-MOBIDIP trials

INTRODUCTION

Pregnancy is an exclusion criteria in most clinical trials involving antiretroviral therapy (ART) and modern contraception methods are systematically proposed to women of childbearing age. Nevertheless pregnancies are often observed. Reproductive choices during clinical trials should be understood to adapt interventions to the level of risk for mother and baby safety. Our goal was to describe the reproductive behavior and pregnancy outcomes among HIV-infected women on second-line antiretroviral treatment enrolled in two clinical trials and to compare them with those of HIV-positive women in non-research settings.

METHODS

The number and outcomes of pregnancies were recorded among 281 non menopausal women enrolled in the ANRS 12169-2LADY and ANRS 12286-MOBIDIP clinical trials in Cameroon, Senegal and Burkina Faso. All participants had agreed to use a least one contraceptive method (barrier or non-barrier) which was provided for free during the study. Data were collected through revision of pregnancy notification forms and by data extraction from the study database, regularly updated and checked during the study.

RESULTS

Sixty-six women had 84 pregnancies between January 2010 and July 2015 resulting in a pregnancy rate of 8.0 per 100 women-years (WY) (95% CI 6.5-9.9) which is similar to the ones observed in cohort studies in Sub-Saharan Africa (varying from 2.5 to 9.4 pregnancies per 100 WY). Among 60 live births, 10 (16.6%) were born prematurely and 9 (15%) had a low birth weight. Sixteen miscarriages/stillbirths occurred (19.5%). This percentage is comparable to the one expected in the seronegative population which is reassuring for HIV-positive women considering pregnancy on ART. Only one minor birth defect was diagnosed. In univariate and multivariate analysis, miscarriages/stillbirths were not associated either with age, nadir of CD4 count, duration of ART, CD4 count, or viral load at the beginning of pregnancy.

CONCLUSION

HIV-positive women participating in clinical trials conducted in Sub-Saharan Africa tend to get pregnant as often as seropositive women who received medical care in non-research settings. It is therefore essential to adopt a pragmatic approach by re-evaluating the relevance of the criteria for exclusion of pregnant women according to the risk associated with exposure and to seek more effective and innovating contraceptive strategies when using potentially teratogenic molecules.

Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania

AIM

To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa.

DESIGN

Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression.

RESULTS

Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use.

CONCLUSIONS

There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.

Contraceptive use among HIV-infected women and men receiving antiretroviral therapy in Lusaka, Zambia: a cross-sectional survey

Background

Family planning (FP) is an essential health service and an important part of comprehensive HIV care. However, there is limited information about the contraceptive needs of people living with HIV in sub-Saharan Africa, which in turn has hampered efforts to expand and integrate FP services into existing HIV programs.

Methods

We performed a cross-sectional survey to determine FP prevalence and predictors among HIV-positive women and men attending 18 public antiretroviral therapy (ART) clinics in Lusaka, Zambia. Trained peer counselors administered the 10-question survey to those seeking care for five days at each of the target sites.

Results

From February to April 2014, we surveyed 7,046 HIV-infected patients receiving routine HIV services. Use of modern contraception was reported by 69 % of female ART patients and 79 % of male ART patients. However, highly effective contraceptive use and dual method use were low among women (38 and 25 %, respectively) and men (19 and 14 %, respectively). HIV disclosure status (adjusted odds ratio (AOR) = 4.91, 95 % confidence interval (CI) = 3.32–7.24 for women, AOR = 3.58, 95 % CI = 2.39–5.38 for men) and sexual activity in the last 6 months (AOR = 5.80, 95 % CI = 4.51–7.47 for women, AOR = 6.24, 95 % CI = 3.51–11.08 for men) were associated with modern contraceptive use in multivariable regression. Most respondents said they would access FP services if made available within ART clinic.

Conclusions

While FP-ART integration may be a promising strategy for increasing FP service uptake, such services must focus on assessing sexual activity and advocating for dual method use to increase effective contraceptive use and prevent unintended pregnancies.

Effect of subsequent pregnancies on HIV disease progression among women in the Mulago Hospital MTCT-Plus program in Uganda

OBJECTIVE

To investigate the effect of subsequent pregnancies on HIV disease progression among HIV-infected women at Mulago Hospital, Uganda.

METHODS

In a retrospective cohort study, data were analyzed from women enrolled in the Mother-To-Child Transmission Plus program from March 2003 to December 2011. The CD4 cell count, the development of new AIDS-defining opportunistic infections, and the AIDS-related mortality were compared between women with and without subsequent pregnancies.

RESULTS

Overall, 409 women were enrolled and 195 (47.7%) had subsequent pregnancies. Antiretroviral therapy (ART) was initiated in 143 (73.3%) women with and 155 (72.4%) women without subsequent pregnancies. Kaplan-Meier analysis for women receiving ART showed no differences between women with and without subsequent pregnancies in the median times to clinical failure (62.7 vs 64.7 months; P=0.31), immunological failure (68.8 vs 75.5 months; P=0.10), and death (68.8 vs 75.5 months; P=0.53). In a Cox regression analysis, subsequent pregnancies were not associated with immunological failure during follow-up (adjusted hazard ratio 1.13, 95% confidence interval 0.06-2.09).

CONCLUSION

Subsequent pregnancies could have no detrimental effect on HIV disease progression among HIV-infected women whose treatment is well managed.

Unintended pregnancy among HIV-positive pregnant women in Enugu, southeast Nigeria

OBJECTIVE

To determine the prevalence and factors associated with unintended pregnancy among HIV-positive pregnant women in Enugu, southeast Nigeria.

METHODS

A questionnaire-based cross-sectional study was performed of HIV-positive pregnant women receiving prenatal care at two tertiary health institutions in Enugu between March 1 and August 31, 2012. The women were interviewed with a pretested questionnaire.

RESULTS

Overall, 180 HIV-positive pregnant women were recruited, 67 (37.2%) of whom declared that their pregnancy was unintended. Overall, 174 (96.7%) patients were receiving antiretroviral therapy and 99 (55.0%) had future fertility intensions. Participants with regular partners (married or cohabiting) had a significantly higher rate of unintended pregnancy than those with unstable partners (40.3%, n=64/159 vs 14.3%, n=3/21 P=0.029). Age, parity, educational level, and current treatment with antiretroviral therapy did not significantly affect the prevalence of unintended pregnancy.

CONCLUSION

A substantial number of HIV-positive pregnant women declared their pregnancies to be unintended. Modern contraceptives should be made readily available and accessible to HIV-positive women to help eliminate mother-to-child transmission of HIV and subsequent new pediatric HIV infections.

Application of an ecological framework to examine barriers to the adoption of safer conception strategies by HIV-affected couples

Safer conception interventions can significantly reduce the risk of horizontal HIV transmission between HIV-serodiscordant partners. However, prior to implementing safer conception interventions, it is essential to understand potential barriers to their adoption so that strategies can be developed to overcome these barriers. This paper examines potential barriers to the adoption of safer conception strategies by HIV-affected couples in Iringa, Tanzania using an ecological framework. We interviewed 30 HIV-positive women, 30 HIV-positive men and 30 health providers engaged in delivering HIV-related services. We also conducted direct observations at five health facilities. Findings suggest that there are multiple barriers to safer conception that operate at the individual, relational, environmental, structural, and super-structural levels. The barriers to safer conception identified are complex and interact across these levels. Barriers at the individual level included antiretroviral adherence, knowledge of HIV status, knowledge and acceptability of safer conception strategies, and poor nutrition. At the relational level, unplanned pregnancies, non-disclosure of status, gendered power dynamics within relationships, and patient-provider interactions posed a threat to safer conception. HIV stigma and distance to health facilities were environmental barriers to safer conception. At the structural level there were multiple barriers to safer conception, including limited safer conception policy guidelines for people living with HIV (PLHIV), lack of health provider training in safer conception strategies and preconception counseling for PLHIV, limited resources, and lack of integration of HIV and sexual and reproductive health services. Poverty and gender norms were super-structural factors that influenced and reinforced barriers to safer conception, which influenced and operated across different levels of the framework. Multi-level interventions are needed to ensure adoption of safer conception strategies and reduce the risk of HIV transmission between partners within HIV-serodiscordant couples.

Family planning use among women living with HIV: knowing HIV positive status helps - results from a national survey

Background

Women living with HIV continues to encounter unintended pregnancies with a concomitant risk of mother-to-child transmission of HIV infection. Preventing unintended pregnancy among HIV-infected women is one of the strategies in the prevention of new HIV infections among children. The aim of this analysis was to assess the practice of family planning (FP) among HIV-infected women and the influence of women’s awareness of HIV positive status in the practice of FP.

Methods

The analysis was made in the Malawi Demographic and Health Survey (DHS) data among 489 non-pregnant, sexually active, fecund women living with HIV. Multiple logistic regression analysis was performed using SPSS software to identify the factors associated with FP use. Adjusted odds ratios (AOR) with 95 % confidence intervals were computed to assess the association of different factors with the practice of family planning.

Result

Of the 489 confirmed HIV positive women, 184 (37.6 %) reported that they knew that they were HIV positive. The number of women who reported that they were currently using FP method(s) were 251 (51.2 %). The number of women who reported unmet need for FP method(s) were 107 (21.9 %). In the multiple logistic regression analysis, women’s knowledge of HIV positive status [AOR: 2.32(1.54, 3.50)], secondary and above education [AOR: 2.36(1.16, 4.78)], presence of 3–4 alive children [AOR: 2.60(1.08, 6.28)] and more than 4 alive children [AOR: 3.03(1.18, 7.82)] were significantly associated with current use of FP.

Conclusion

Women’s knowledge of their HIV-positive status was found to be a significant predictor of their FP practice. Health managers and clinicians need to improve HIV counselling and testing coverage among women of child-bearing age and address the FP needs of HIV-infected women.

Increasing incidence of pregnancy among women receiving HIV care and treatment at a large urban facility in western Uganda

Background

Antiretroviral treatment restores physical functioning and may have an impact on fertility desires. Counseling is given to HIV positive women to create awareness and to provide information on pregnancy and delivery. The purpose of this study was to determine the incidence of pregnancy and factors that predict pregnancy among women of reproductive age receiving HIV care and treatment at a large urban center in western Uganda.

Methods

We conducted a retrospective cohort study using routinely collected data at the Immune Suppression (ISS) Clinic of Mbarara Regional Referral Hospital located in Mbarara District, western Uganda collected between January 2006 and June 2010. Women aged 15 to 50 years were eligible for analysis. The primary outcome was incidence of pregnancy calculated as number of pregnancies per 1000 person years (PY). Data was analyzed by calendar year and year of enrolment and used survival analysis to determine the predictors of pregnancy.

Results

A total of 3144 women were included with a median follow up of 12.5 months. The overall incidence rate was 90.7 pregnancies per 1000 person years. Incidence increased from 29.8 pregnancies per 1000 PY in 2006 to 122 pregnancies per 1000 PY in 2010 (p < 0.001). Significant predictors for pregnancy were younger age (HR 10.96 95% CI 3.22-37.2), married (HR 2.09 95% CI 1.69-2.64) and single (HR 1.95 95% CI 1.34-2.84) compared to widowed or separated, primary education (HR 1.65 95% CI 1.02-2.66), not knowing the HIV status of the spouse (HR 1.46, 95%CI 1.13-1.93) compared to knowing. The use of family planning (HR 0.23 95% CI 0.18- 0.30) and an increase in CD4 count between baseline and most recent count were protective against pregnancy. ART use was not a significant predictor.

Conclusion

Incidence of pregnancy among women receiving routine HIV care and treatment has increased and is almost comparable to that in the general population. Thus routine HIV care should integrate reproductive health needs for these women.

Electronic supplementary material

The online version of this article (doi:10.1186/1742-4755-11-81) contains supplementary material, which is available to authorized users.

Fertility desire among HIV-positive women in Tigray region, Ethiopia: implications for the provision of reproductive health and prevention of mother-to-child HIV transmission services

Background

There is growing recognition of the difficult reproductive decisions faced by HIV-positive women. Studies in both resource-constrained and developed countries have suggested that many HIV-positive women continue to desire children in spite of their understanding of the possible risks that HIV poses. This study investigates the factors associated with fertility desire among HIV-positive women in Tigray region, Ethiopia.

Methods

A cross-sectional survey was conducted among 964 HIV-positive women receiving HIV care in 12 health centers of Tigray region. In each health center, the number of study participants was allocated proportionally to the load of HIV-positive women in the chronic care clinics. A descriptive summary of the data and a logistic regression model were used to identify factors associated with fertility desire using odds ratios with a 95% confidence interval and P-value of 0.05.

Results

Four hundred and thirty nine (45.5%) of the participants reported a desire to have children in the future. Eighty six percent of the women had given birth to at least one live baby at the time of study, with the median number of live births being 2 (Inter quartile range = 1,3). Women in the age group of 15–24 years [AOR = 2.64(95% CI: 1.44, 4.83)] and 25–34 years [AOR = 2.37 (95% CI: 1.60, 2.4 3.50)] had higher fertility desire as compared to women in the age group of 35–49 years. Having no children [AOR = 25.76 (95% CI: 13.66, 48.56)], having one to two children [AOR = 5.14 (95% CI: 3.37, 7.84)] and disclosing HIV status to husband/sexual partner [AOR = 1.74 (95% CI: 1.11, 2.72)] were all independently associated with fertility desire.

Conclusions

Age, HIV disclosure status to husband/sexual partner, and relatively few live children were all found to influence HIV-positive women’s fertility desire. Programmers and policy makers should consider the effects of these factors for HIV-positive women as they develop HIV/AIDS interventions.

Effect of HIV status on fertility intention and contraceptive use among women in nine sub-Saharan African countries: evidence from Demographic and Health Surveys

BACKGROUND

Expanding access to antiretroviral therapy (ART) means that HIV is no longer a death sentence. This change has implications for reproductive decisions and behaviors of HIV-infected individuals.

DESIGN

Using multiple rounds of biomarker data from Demographic and Health Surveys (2004-2012) in nine sub-Saharan African countries, we compare patterns of associations between HIV status and fertility intention and between current use of modern contraception and HIV status in the context of expanding ART coverage.

RESULTS

Generally, results show that knowledge of HIV status and proportion of women ever tested for HIV increased substantially between the two surveys for almost all countries. Whereas modern contraceptive use slightly increased, fertility intentions remained relatively stable, except for Rwanda, where they decreased. RESULTS from the two surveys for the nine countries do however indicate that there is no clear consistent pattern of fertility intention and modern contraceptive use behavior by HIV status, with variations observed across countries. However, multivariate analyses show that for Rwanda and Zimbabwe women who were HIV positive, with knowledge of their status, had lower odds of wanting more children. Similarly only in Rwanda (both surveys) were HIV-positive women who knew their status more likely to be current users of contraception compared with women who were HIV negative. The reverse was observed for Zimbabwe.

CONCLUSIONS

Generally, the results point to the fact that the assumption that reproductive intention and behavior of HIV-positive women will differ compared with that of HIV-negative women may only hold true to the extent that women know their HIV status. Continuous expansion of voluntary counseling and testing services and integration of HIV treatment and care services with reproductive health services are thus warranted.

Contraceptive use and unmet need for family planning among HIV positive women on antiretroviral therapy in Kumasi, Ghana

BACKGROUND

A key strategy for minimizing HIV infection rates especially via reduction of Mother- to-Child transmission is by reducing the unmet need for family planning. In Ghana, the integration of family planning services into Antiretroviral Therapy services for persons living with HIV/AIDS has largely been ignored. We set out to measure the prevalence of modern methods of contraception, the unmet need for family planning and to identify factors associated with the use of modern methods of contraception among HIV positive women on anti retroviral therapy.

METHODS

This was a descriptive cross sectional study of HIV positive women in their reproductive ages accessing care at an adult Antiretroviral Therapy Clinic in Kumasi, Ghana. Data was collected using a structured questionnaire. Data analysis was conducted using Epi Info version 7.1.2.0.

RESULTS

A total of 230 women were included in the study. Fifty six percent were in the 30-39 year age group. The mean age (SD) was 36.3 (5.4) years. While 53.5% of respondents desired to have children, partner desire for children was reported by 54.6% of respondents with partners. About 74% had received information on contraception from their provider. 42.6% of participants and/or their partners were using a contraception method at the time of study; the male condom (79.6%) being the most commonly used method. The estimated unmet need for contraception was 27.8%. Contraceptive use was strongly associated with partner knowledge of HIV status (AOR = 3.64; 95% CI 1.36-9.72; p = 0.01) and use of a contraceptive method prior to diagnosis of HIV (AOR = 6.1; 2.65-14.23; p < 0.001).

CONCLUSION

Contraceptive Prevalence is high among HIV positive women in Kumasi compared with the general Ghanaian population. Despite this, there still is a high unmet need for family planning in this population. We recommend continuous education on contraceptives use to HIV patients accessing HAART services to further increase contraceptive uptake.

Antiretroviral Therapy Helps HIV-Positive Women Navigate Social Expectations for and Clinical Recommendations against Childbearing in Uganda

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.

"We have to try and have this child before it is too late": missed opportunities in client-provider communication on reproductive intentions of people living with HIV

Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception.

Reproductive desire in women with HIV infection in Spain, associated factors and motivations: a mixed-method study

Background

Antiretroviral therapy has created new expectations in the possibilities of procreation for persons living with HIV. Our objectives were to evaluate reproductive desire and to analyze the associated sociodemographic and clinical factors in HIV-infected women in the Spanish AIDS Research Network Cohort (CoRIS).

Methods

A mixed qualitative-quantitative approach was designed. Women of reproductive age (18–45) included in CoRIS were interviewed by phone, and data were collected between November 2010 and June 2012 using a specifically designed questionnaire. Reproductive desire was defined as having a desire to be pregnant at present or having unprotected sex with the purpose of having children or wanting to have children in the near future.

Results

Overall, 134 women were interviewed. Median age was 36 years (IQR 31–41), 55% were Spanish, and 35% were unemployed. 84% had been infected with HIV through unprotected sex, with a median time since diagnosis of 4.5 years (IQR 2.9-6.9). Reproductive desire was found in 49% of women and was associated with: 1) Age (women under 30 had higher reproductive desire than those aged 30–39; OR = 4.5, 95% CI 1.4-14.3); 2) having no children vs. already having children (OR = 3.2; 1.3-7.7 3); Being an immigrant (OR = 2.2; 1.0-5.0); and 4) Not receiving antiretroviral treatment (OR = 3.6; 1.1-12.1). The main reasons for wanting children were related to liking children and wanting to form a family. Reasons for not having children were HIV infection, older age and having children already. Half of the women had sought or received information about how to have a safe pregnancy, 87% had disclosed their serostatus to their family circle, and 39% reported having experienced discrimination due to HIV infection.

Conclusions

The HIV-infected women interviewed in CoRIS have a high desire for children, and the factors associated with this desire are not fundamentally different from those of women in the general population. Maternity may even help them face a situation they still consider stigmatized and prefer not to disclose. Health-care protocols for handling HIV-positive women should incorporate specific interventions on sexual and reproductive health to help them fulfill their procreation desire and experience safe pregnancies.

Contraceptive utilization and associated factors among HIV positive women on chronic follow up care in Tigray Region, Northern Ethiopia: a cross sectional study

BACKGROUND

In sub-Sahara Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Maternal to child transmission is responsible for 90% of childhood HIV infection. Preventing unwanted pregnancy among HIV positive women is imperative to reduce maternal and infant morbidity and mortality.

METHODS

A cross-sectional survey was conducted among 964 HIV positive women in selected 12 health centers of Tigray region. In this paper, analysis was restricted only for 847 women who were sexually active and non-pregnant. In each health center the number of study participants was allocated proportionally to the load of HIV positive women in chronic care clinics. The data were entered into EpiData version 3.1, and cleaned and analyzed using Stata version 11.1. Descriptive summary of data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05.

FINDINGS

Three hundred ninety four (46.5%) of all HIV positive women had intension to have more children. Three hundred seventy five (44.3%) were using contraceptive methods at time of survey. Injectable (70.7%) and male condom (47.6%) were most commonly used type of contraceptives. In the multivariable analysis, women who were urban dwellers (AOR = 2.55; 95% CI: 1.27, 5.02), completed primary education (AOR = 2.27; 95% CI: 1.12, 2.86) and those openly discussed about contraceptive methods with their husbands or sexual partners (AOR = 6.3; 95% CI: 3.42, 11.76) were more likely to use contraceptive. Women who have one or more living children were also more likely to use contraceptive compared with women with no child.

CONCLUSION

Less than half of women used contraceptive methods. The use of condoms could impact unintended pregnancies and reduced risks of vertical and sexual transmission. Efforts to increase contraceptive utilization focusing on the barrier methods should be strengthen in HIV/AIDS chronic care units.

Modern contraceptive utilization among female ART attendees in health facilities of Gimbie town, West Ethiopia

BACKGROUND

In many areas of the world where HIV prevalence is high, rates of unintended pregnancy have also been shown to be high. Of all pregnancies worldwide in 2008, 41% were reported as unintended and approximately 50% of these ended in abortion. To address these problems family planning is the best solution. Therefore, the purpose of the study was to assess modern contraceptive use among females on ART in health facilities of Gimbie town, Western Ethiopia.

METHODS

A facility based cross-sectional study was conducted in Gimbie town, western Ethiopia from December 2012 to January 2013. HIV infected women of reproductive age group (15-49 years) who came for ART care follow up during the data collection period were included in the study. Data was collected using an interviewer administered questionnaire. Binary logistic regression and multivariate analysis were employed using SPSS version 17.

RESULTS

Three hundred ninety five women on ART have participated in the study. More than half, 224 (56.7%), of the respondents were using modern contraceptive, of whom 67 (30%) use dual contraceptive method. Having information on modern contraception is positively associated with modern contraceptive use with (AOR=6.3, 95% CI (1.67, 24.1)) and respondents who have family size ≤4 were 50% less contraceptive users than those who have family size >4 (AOR=0.51, 95% CI (0.27, 0.96)).

CONCLUSION

In this study contraceptive use among HIV positive women is better than the general population. However, use of dual methods, long acting and permanent method of contraceptives were found to be low. Continuous and targeted information provision on modern contraceptive should be done.

The role of family planning in elimination of new pediatric HIV infection

PURPOSE OF REVIEW

We reviewed recent literature on the role of family planning in eliminating new pediatric HIV infections.

RECENT FINDINGS

Global commitments to eliminate new pediatric HIV infections recognize that preventing unintended pregnancies among women with HIV is essential to achieving this goal. However, substantial shortcomings exist in translating this policy support into widespread practice. Programs to prevent mother-to-child transmission of HIV continue to be implemented and evaluated as a narrow set of interventions that typically begins in antenatal care, after a woman is already pregnant. In addition, data suggest that women living with HIV experience high rates of unmet need for family planning and unintended pregnancies. Evidence is growing that integrating family planning and HIV services is an effective strategy for increasing access to contraception among women with HIV who do not wish to become pregnant. A number of health system obstacles must be resolved to achieve effective, sustained delivery of integrated services at scale.

SUMMARY

Prevention of unintended pregnancies among women with HIV must be elevated as a programmatic priority. By strengthening family planning programs for all women, and better integrating family planning and HIV services, progress toward ending new pediatric HIV infections will be accelerated.

Family planning practice and predictors of risk of inconsistent condom use among HIV-positive women on anti-retroviral therapy in Cambodia

Background

In Cambodia, while anti-retroviral therapy (ART) services are increasingly available, the unmet needs of family planning among general population are high. These facts raise concern on possible exposure of many HIV-positive women on ART to the potential risk of unintended pregnancy. This study aimed to clarify family planning practices in Cambodia and determine predictors of risk of inconsistent condom use among women on ART.

Methods

A cross-sectional survey with a structured questionnaire was conducted at five government-run health centers in Phnom Penh, Cambodia, from June to September, 2012. Multiple logistic regression analysis was used to identify predictors of risk of inconsistent condom use among regular users of contraceptive methods.

Results

Of 408 respondents, 40, 17 and 10 used the pill, IUD, and injection, respectively, while 193 used condoms. 374 were not planning to have a child. Among 238 sexually active women who were not planning to have a baby, 59 were exposed to the risk of unintended pregnancy. Multivariate logistic regression analysis that did not include variables related to partners identified "seeking family planning information" (adjusted odds ratio (AOR): 2.6, 95% confidence intervals (95% CI): 1.1-6.2), awareness of mother-to-child transmission (MTCT) (AOR: 4.7, 95% CI: 1.9-11.6) and "having a son" (AOR: 2.0, 95% CI: 1.1-3.9) were significant predictors of inconsistent condom use. Another model that included all variables identified “able to ask a partner to use condom at every sexual intercourse” was the only predictor (AOR: 23.7, 95% CI: 5.8-97.6).

Conclusions

About one-quarter of women on ART are at risk to unintended pregnancy although most do not plan to get pregnant. Furthermore, women on ART could be more empowered through improvement of communication and negotiation skills with partners to demand the use of condom during sexual intercourse. The use of other contraceptive methods that do not need partner involvement should be promoted.

Adherence to antiretroviral therapy in Jinja, Uganda: a six-year follow-up study

Introduction

We report on the adherence experience of a group of people living with HIV on ART over six years in Uganda.

Methods

Between 2005 and 2009, we followed up 41 participants who were also part of a clinical trial comparing home and facility based delivery of ART in Jinja, eastern Uganda. We conducted qualitative in-depth interviews at enrolment, 3, 6, 18 and 30 months to capture experiences with adherence over time. In 2011 we returned to these participants to find out how they were fairing with long term adherence. We managed to retrace 24 participants and interviewed them about their experience. We thematically analysed the data and compared findings over time.

Results

Initially there were few barriers to adherence and many followed the adherence guidance closely. By year six, relaxation of these rules was noticeable although self-reported adherence continued to be high. Alcohol consumption was more common than before. Some relatives of the participants who had died claimed that some deaths were a result of alcohol. While participants reported that ART had allowed them to reclaim independence and return to work the changes in work and social routines created new challenges for adherence. Side effects like lipodystrophy were not only causing some stigma but for some tested their faith in the drugs. Many participants reported resumption of sexual lives but apart from those who selected same status partners, disclosure to new partners was minimal.

Conclusion

Good adherence practice to ART wanes over the long-term, and people who may have disclosed at initiation find it difficult to do so to new partners once they are healthy. Further adherence interventions and support with disclosure over the course of therapy may need to be considered. (Words: 283)

Attitudes toward family planning among HIV-positive pregnant women enrolled in a prevention of mother-to-child transmission study in Kisumu, Kenya

Background

Preventing unintended pregnancies among HIV-positive women through family planning (FP) reduces pregnancy-related morbidity and mortality, decreases the number of pediatric HIV infections, and has also proven to be a cost-effective way to prevent mother-to-child HIV transmission. A key element of a comprehensive HIV prevention agenda, aimed at avoiding unintended pregnancies, is recognizing the attitudes towards FP among HIV-positive women and their spouse or partner. In this study, we analyze FP attitudes among HIV-infected pregnant women enrolled in a PMTCT clinical trial in Western Kenya.

Methods and Findings

Baseline data were collected on 522 HIV-positive pregnant women using structured questionnaires. Associations between demographic variables and the future intention to use FP were examined using Fisher's exact tests and permutation tests. Most participants (87%) indicated that they intended to use FP. However, only 8% indicated condoms as a preferred FP method, and 59% of current pregnancies were unintended. Factors associated with positive intentions to use FP were: marital status (p = 0.04), having talked to their spouse or partner about FP (p<0.001), perceived spouse or partner approval of FP (p<0.001), previous use of a FP method (p = 0.006), attitude toward the current pregnancy (p = 0.02), disclosure of a sexually transmitted infection (STI) diagnosis (p = 0.03) and ethnic group (p = 0.03).

Conclusion

A significant gap exists between future FP intentions and current FP practices. Support and approval by the spouse or partner are key elements of FP intentions. Counseling services should be offered to both members of a couple to increase FP use, especially given the high number of unplanned pregnancies among HIV-positive women. Condoms should be promoted as part of a dual use method for HIV and STI prevention and for contraception. Integration of individual and couple FP services into routine HIV care, treatment and support services is needed in order to avoid unintended pregnancies and to prevent mother-to-child HIV transmission.

Incidence and predictors of pregnancy among a cohort of HIV-positive women initiating antiretroviral therapy in Mbarara, Uganda

Objective

Many people living with HIV in sub-Saharan Africa desire biological children. Implementation of HIV prevention strategies that support the reproductive goals of people living with HIV while minimizing HIV transmission risk to sexual partners and future children requires a comprehensive understanding of pregnancy in this population. We analyzed prospective cohort data to determine pregnancy incidence and predictors among HIV-positive women initiating antiretroviral therapy (ART) in a setting with high HIV prevalence and fertility.

Methods

Participants were enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort of HIV-positive individuals initiating ART in Mbarara. Bloodwork (including CD4 cells/mm³, HIV viral load) and questionnaires (including socio-demographics, health status, sexual behavior, partner dynamics, HIV history, and self-reported pregnancy) were completed at baseline and quarterly. Our analysis includes 351 HIV-positive women (18–49 years) who enrolled between 2005–2011. We measured pregnancy incidence by proximal and distal time relative to ART initiation and used multivariable Cox proportional hazards regression analysis (with repeated events) to identify baseline and time-dependent predictors of pregnancy post-ART initiation.

Results

At baseline (pre-ART initiation), median age was 33 years [IQR: 27–37] and median prior livebirths was four [IQR: 2–6]. 38% were married with 61% reporting HIV-positive spouses. 73% of women had disclosed HIV status to a primary sexual partner. Median baseline CD4 was 137 cells/mm³ [IQR: 81–207]. At enrolment, 9.1% (31/342) reported current pregnancy. After ART initiation, 84 women experienced 105 pregnancies over 3.8 median years of follow-up, yielding a pregnancy incidence of 9.40 per 100 WYs. Three years post-ART initiation, cumulative probability of at least one pregnancy was 28% and independently associated with younger age (Adjusted Hazard Ratio (AHR): 0.89/year increase; 95%CI: 0.86–0.92) and HIV serostatus disclosure to primary sexual partner (AHR: 2.45; 95%CI: 1.29–4.63).

Conclusions

Nearly one-third of women became pregnant within three years of initiating ART, highlighting the need for integrated services to prevent unintended pregnancies and reduce periconception-related risks for HIV-infected women choosing to conceive. Association with younger age and disclosure suggests a role for early and couples-based safer conception counselling.

Impact of long-term contraceptive promotion on incident pregnancy: a randomized controlled trial among HIV-positive couples in Lusaka, Zambia

OBJECTIVES

To evaluate the impact of family planning promotion on incident pregnancy in a combined effort to address Prongs 1 and 2 of prevention of mother-to-child transmission of HIV.

DESIGN

We conducted a factorial randomized controlled trial of 2 video-based interventions.

METHODS

"Methods" and "Motivational" messages promoted long-term contraceptive use among 1060 couples with HIV in Lusaka, Zambia.

RESULTS

Among couples not using contraception before randomization (n = 782), the video interventions had no impact on incident pregnancy. Among baseline contraceptive users, viewing the "Methods video" which focused on the intrauterine device and contraceptive implant was associated with a significantly lower pregnancy incidence [hazard ratio (HR) = 0.38; 95% confidence interval (CI): 0.19 to 0.75] relative to those viewing control and/or motivational videos. The effect was strongest in concordant positive couples (HR = 0.22; 95% CI: 0.08 to 0.58) and couples with HIV-positive women (HR = 0.23; 95% CI: 0.09 to 0.55).

CONCLUSIONS

The "Methods video" intervention was previously shown to increase uptake of long-acting contraception and to prompt a shift from daily oral contraceptives to quarterly injectables and long-acting methods such as the intrauterine device and implant. Follow-up confirms sustained intervention impact on pregnancy incidence among baseline contraceptive users, in particular couples with HIV-positive women. Further work is needed to identify effective interventions to promote long-acting contraception among couples who have not yet adopted modern methods.

Contraceptive use and associated factors among women enrolling into HIV care in southwestern Uganda

BACKGROUND

Preventing unintended pregnancies among women living with HIV is an important component of prevention of mother-to-child HIV transmission (PMTCT), yet few data exist on contraceptive use among women entering HIV care.

METHODS

This was a retrospective study of electronic medical records from the initial HIV clinic visits of 826 sexually active, nonpregnant, 18-49-year old women in southwestern Uganda in 2009. We examined whether contraceptive use was associated with HIV status disclosure to one's spouse.

RESULTS

The proportion reporting use of contraception was 27.8%. The most common method used was injectable hormones (51.7%), followed by condoms (29.6%), and oral contraceptives (8.7%). In multivariable analysis, the odds of contraceptive use were significantly higher among women reporting secondary education, higher income, three or more children, and younger age. There were no significant independent associations between contraceptive use and HIV status disclosure to spouse.

DISCUSSION

Contraceptive use among HIV-positive females enrolling into HIV care in southwestern Uganda was low. Our results suggest that increased emphasis should be given to increase the contraception uptake for all women especially those with lower education and income. HIV clinics may be prime sites for contraception education and service delivery integration.

"Maybe his blood is still strong": a qualitative study among HIV-sero-discordant couples on ART in rural Uganda

Background

HIV-negative members of sero-discordant couples are at high risk for HIV acquisition but few behavioral prevention interventions have been implemented in sub-Saharan Africa and discordance is not well understood by couples themselves.

Methods

In this nested sub-study, we interviewed 40 HIV sero-discordant couples before and after a 6-month behavioral intervention that was comprised of four group discussions on specific HIV prevention and care topics. The content of the sessions included: 1) understanding HIV serodiscordance and reducing risk, 2) couple communication, 3) reproductive health and HIV serodiscordance, 4) coping with HIV serodiscordance and ongoing support. Couple members were interviewed individually. Data were analyzed thematically using ‘Framework Analysis’ which incorporated dyadic factors to address couple issues.

Results

Analysis revealed pre-identified concepts and emergent themes that were relevant to the final conceptual model. Four major categories of factors affecting couple relations, beliefs and current risk behaviors emerged: intervention factors, structural/contextual factors, physical health factors, and past risk behavior. The topics within the intervention most relevant were communication and reproductive health. The contextual factors highlighted by couples were gender norms around sexual decision-making and multiple partnerships. Individual beliefs regarding HIV serodiscordance persisted over all time points for some couples. Interestingly, some couple members had divergent views about their HIV status; some believing the HIV-negative member was negative while others described multiple beliefs around the negative member’s blood surely being positive for HIV. Couple communication emerged as an important theme mediating beliefs and behavior.

Conclusions

In addition to biomedical and behavioral interventions, HIV-serodiscordant couple interventions must embrace the contextual complexity and cultural understanding of HIV infection and discordance as well as the dynamic nature of couple communication to influence risk behavior.

HIV-1 prevention for HIV-1 serodiscordant couples

A substantial proportion of HIV-1 infected individuals in sub-Saharan Africa are in stable relationships with HIV-1 uninfected partners, and HIV-1 serodiscordant couples thus represent an important target population for HIV-1 prevention. Couple-based HIV-1 testing and counseling facilitates identification of HIV-1 serodiscordant couples, counseling about risk reduction, and referrals to HIV-1 treatment, reproductive health services, and support services. Maximizing HIV-1 prevention for HIV-1 serodiscordant couples requires a combination of strategies, including counseling about condoms, sexual risk, fertility, contraception, and the clinical and prevention benefits of antiretroviral therapy (ART) for the HIV-1-infected partner; provision of clinical care and ART for the HIV-1-infected partner; antenatal care and services to prevent mother-to-child transmission for HIV-1-infected pregnant women; male circumcision for HIV-1-uninfected men; and, pending guidelines and demonstration projects, oral pre-exposure prophylaxis (PrEP) for HIV-1-uninfected partners.