Fertility desires and unmet need for family planning among HIV infected individuals in two HIV clinics with differing models of family planning service delivery

The intersection between migration, HIV, and contraceptive use in Uganda: a cross-sectional population-based study

BACKGROUND

Low use of modern methods of contraception has been linked to HIV seropositivity and to migration, but few studies have evaluated the intersection of both risk factors with contraceptive use.

METHODS

We analyzed cross-sectional data from sexually active female participants aged 15 to 49 years in the Rakai Community Cohort Study (RCCS) between 2011 and 2013. The RCCS is an open population-based census and individual survey in south-central Uganda. Recent in-migrants (arrival within approximately 1.5 years) into RCCS communities were identified at time of household census. The primary outcome was unsatisfied demand for a modern contraceptive method (injectable, oral pill, implant, or condom), which was defined as non-use of a modern contraceptive method among female participants who did not want to become pregnant in the next 12 months. Poisson regression models with robust variance estimators were used to identify associations and interactions between recent migration and HIV serostatus on unsatisfied contraceptive demand.

RESULTS

There were 3,417 sexually active participants with no intention of becoming pregnant in the next year. The mean age was 30 (± 8) years, and 17.3% (n = 591) were living with HIV. Overall, 43.9% (n = 1,500) were not using any modern contraceptive method. Recent in-migrants were somewhat more likely to have unsatisfied contraceptive demand as compared to long-term residents (adjusted prevalence risk ratio [adjPRR] = 1.14; 95% confidence interval [95%CI]: 1.02-1.27), whereas participants living with HIV were less likely to have unsatisfied contraceptive demand relative to HIV-seronegative participants (adjPRR = 0.80; 95%CI = 0.70-0.90). When stratifying on migration and HIV serostatus, we observed the highest levels of unsatisfied contraceptive demand among in-migrants living with HIV (48.7%); however, in regression analyses, interaction terms between migration and HIV serostatus were not statistically significant.

CONCLUSIONS

Unsatisfied contraceptive demand was high in this rural Ugandan setting. Being an in-migrant, particularly among those living with HIV, was associated with higher unsatisfied contraceptive demand.

Family Planning Counseling for Women Living with HIV in Low- and Middle-Income Countries: A Systematic Review of the Impact on Contraceptive Uptake, Intention to Use Contraception and Pregnancy Incidence, 2011 to 2022

Women's ability to control their fertility and have the number of children they want when they want them is an internationally recognized human right. This right has been the driving force behind family planning programs in low- and middle-income countries for more than five decades. The HIV epidemic added greater urgency to those efforts once the risk of vertical transmission of the virus from mothers to their infants was recognized. In 2013, we published a systematic review of the evidence of effectiveness of family planning counseling for women living with HIV, emphasizing HIV related behaviors. In this updated review, we examined 23 studies, primarily from sub-Saharan Africa. The evidence we uncovered reflected efforts to integrate services provided to women. These showed that providing contraceptive services, including intensified counseling and support, in the HIV clinics where women living with HIV received their care increased the likelihood of subsequent use of modern contraception by as much as fourfold. These studies reflected a greater focus on women's family planning decisions and behaviors and less focus on HIV-related behaviors. Among the possible causes of this noted difference we include the widespread coverage of antiretroviral treatment for HIV. This advance has apparently changed the rationale and the approach to integrating family planning and HIV services in ways that may not have been fully appreciated. The results, however, are beneficial: greater coverage of family planning for women who wish to control their fertility and a more equal partnership between family planning services and HIV services in pursuit of the mutual goal of providing integrated services to meet women's needs.

Health facility-based interventions and the uptake of contraception among people living with HIV: A systematic review & meta-analysis

BACKGROUND OBJECTIVES

The prong 2 of 4 prong strategy introduced by the World Health Organization aims at averting unintended pregnancies among people living with HIV (PLHIV). This systematic review aimed to generate evidence on the effectuality of facility-based interventions in improving uptake of modern and dual contraception, for reducing unmet family planning (FP) needs and unintended pregnancies among PLHIV.

METHODS

Articles evaluating facility-based interventions to integrate human immunodeficiency virus (HIV) and FP published in English language were included. Eligible studies were identified from electronic and lateral search from three databases (PubMed, Cochrane Library and Web of Science) and grey literature. HIV care with no/minimal focus on FP was considered a comparator. Quality was assessed using design-appropriate tools. Descriptive analysis was presented in tables. Uptake of dual methods, unmet FP needs and unintended pregnancies were included in the meta-analysis to estimate pooled odds ratio (OR) with random effect model, P and I2 values.

RESULTS

The search yielded 2112 results. After excluding duplicates and unfit articles, 17 were found eligible for review and nine for meta-analysis. The pooled OR for uptake of dual contraception was 1.69 (1.14, 2.5) ( P =0.008; I2 =90%), for unmet FP needs was 0.58 (0487, 0.69) ( P <0.00001; I2 =0%) and for unintended pregnancies was 0.6 (0.32, 1.1) ( P =0.1, I2 =38%).

INTERPRETATION CONCLUSIONS

The results of this meta-analysis suggest that health facility-based interventions to integrate HIV and FP services do result in improved uptake of dual methods and reduce unmet need for contraception along with a protective trend on incidence of unintended pregnancies. Such facility-based integration would ensure universal access to effective contraception and facilitate in achieving Sustainable Development Goals that aim at ending epidemics like HIV.

Unmet need for modern contraception by HIV status: findings from community-based studies implemented before and after earlier ART initiation program in rural Tanzania

BACKGROUND

Tanzania Health policy insists on the need to provide all women access to contraception despite HIV status. We used data from two HIV epidemiologic serological surveys carried out at different periods of ART provision in rural Tanzania to assess the level of unmet need for modern contraception by HIV status and associated factors.

METHODS

We performed secondary data analysis of two surveys conducted at the Magu Health and Demographic Surveillance System site, in Mwanza, Tanzania. Information on unmet need for modern contraception was derived from fertility desire and contraception use. Unmet need, HIV status, and socioeconomic and demographic variables were analysed. The percentage of women with unmet needs for modern contraception by HIV status is presented for the 2012 and 2017 surveys. Bivariate and multivariate analyses using logistic regression were used to investigate associated factors showing adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

Data from 3352 and 3196 women aged 15-49 years collected in the 2012 and 2017 surveys, respectively, were analysed. The percentages of women with unmet needs for modern contraception in the 2012 and 2017 surveys were 30.9% (95% CI 29.4-32.6) and 31.6% (95% CI 30.0-33.3), respectively. The unmet need for modern contraception was 26% lower in HIV-uninfected women in 2012 (aOR = 0.74; 95% CI 0.569-0.973); p = 0.031). Risk factors for unmet need for modern contraception in 2012 were HIV uninfected (adjusted OR = 0.74; 95% CI 0.569-0.973); p = 0.031), married marital status (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), higher education (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001), and taking alcohol (adjusted OR = 0.768; 95% CI 0.743-0.794); p < 0.0001). Only two factors were associated with unmet need for modern contraception in 2017: married marital status (adjusted OR = 0.46; 95% CI 0.305-0.722); p = 0.001) and women who earned for their families (aOR = 0.66; 95% CI 0.494-0.887); p = 0.006).

DISCUSSION

Nearly one-third of women had an unmet need for modern contraception, which was lower in HIV-uninfected women than in WLHIV-infected women. The study has identified women whose demand for contraception has not been met: WLHIV, post marital women, women with low education and women who were reported to earn money for their families. Family planning interventions should be tailored to these groups of women.

Piloting Gain and Loss-Framed PrEP and Childbearing Messaging to Promote HIV Testing in Uganda: Perspectives from Couples and Providers

Fears of relationship dissolution and the inability to bear healthy children remain barriers to HIV testing in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) carries both clinical and symbolic benefits that counter these fears. We conducted a pilot messaging intervention through Uganda's assisted partner notification (APN) program, where providers assist HIV-positive index clients in notifying sexual partners and encourage testing. We randomized providers at three clinics to implement phone scripts over two months with (1) gain-framed or (2) loss-framed information about PrEP and childbearing; or (3) usual care. In 23 in-depth interviews with providers, index clients, and partners, five major themes emerged on intervention acceptability and feasibility: (1) value of PrEP and childbearing messaging in APN; (2) value of this messaging coming earlier in APN; (3) overall preference for gain-framed messages; (4) need to tailor timing of messaging; and (5) need for messaging outside of APN. Register data (109 index clients, 145 partners) indicated most index clients (95%) wanted their potential conception partners informed about PrEP. Preliminary trends suggest the intervention sites outperformed usual care in testing rates among potential conception partners. Messaging that highlights PrEP and safe childbearing may be a promising new communication strategy to promote HIV testing.

Integration of family planning into HIV services: a systematic review

BACKGROUND

The unmet need for safe and effective contraception still remains high. In 2017, about 25% of women of childbearing age who wanted to avoid pregnancy in the developing world were not using a modern contraceptive method. The biggest proportion (21%) of these women live in Sub-Saharan Africa. Little attention has been paid to the health systems factors impacting the integration of family planning into HIV services. This systematic review intends to document health systems factors constraining or facilitating the integration of family planning into HIV services.

METHODS

A search of electronic databases such as PubMed and Google Scholar was conducted using keywords. We considered peer-reviewed articles which were published in English between 1^st January 2010 and 31^st December 2020. The peer-reviewed articles which were considered focussed on identifying barriers and facilitators at the levels of the health system which influence the success or failure of integrated family planning and HIV programs, availability of integrated family planning services in HIV care, the evidence on the feasibility, effectiveness and cost-effectiveness of integrating family planning and HIV services and investigating the outcomes of programs aimed at strengthening family planning integration in HIV counselling, testing and care. Twenty-seven articles that identify factors affecting integration of family planning into HIV services met the inclusion criteria and were thematically analysed.

RESULTS

Health systems factors constraining integration of family planning and HIV services were human resource turnover and shortages, lack of policy guidance on integrated care, poor oversight, unclear service delivery guidelines, inadequate infrastructure and insufficient monitoring systems. Facilitators to the successful integration of family planning into HIV services were identified as training in family planning for service providers, the creation of a supportive policy environment to accommodate service integration, supportive supervision and a positive attitude by service providers towards service integration.

CONCLUSION

Increase in the health workforce to support integrated service delivery, skills enhancement for service providers and improvement in family planning commodity stock levels play a key role in facilitating the integration of family planning into HIV services.

No association between fertility desire and HIV infections among men and women: Findings from community-based studies before and after implementation of an early antiretroviral therapy (ART) initiation program in the rural district of North-western Tanzania

Background: Fertility is associated with the desire to have children. The impacts of HIV and antiretroviral therapy (ART) on fertility are well known, but their impacts on the desire for children are less well known in Tanzania. We used data from two studies carried out at different periods of ART coverage in rural Tanzania to explore the relationship between HIV infection and fertility desires in men and women. Methods: We conducted secondary data analysis of the two community-based studies conducted in 2012 and 2017 in the Magu Health and Demographic system site, in Tanzania. Information on fertility desires, HIV status, and social-economic and demographic variables were analyzed. Fertility desire was defined as whether or not the participant wanted to bear a child in the next two years. The main analysis used log-binomial regression to assess the association between fertility desire and HIV infection. Results: In the 2012 study, 43% (95% CI 40.7-45.3) of men and 33.3% (95% CI 31.8 - 35.0) women wanted another child in the next two years. In 2017 the percentage rose to 55.7% (95% CI 53.6 - 57.8) in men and 41.5% (95% CI 39.8 - 43.1) in women. Although fertility desire in men and women were higher in HIV uninfected compared to HIV infected, age-adjusted analysis did not show a statistical significance difference in both studies (2012: PR=1.02, 95%CI 0.835 - 1.174, p<0.915 and 2017: PR = 0.90 95%CI 0.743 - 1.084 p= 0.262). Discussion: One-third of women and forty percent of men desired for fertility in 2012, while forty percent of women and nearly half of men desired for fertility in 2017. The data showed fertility desire, in 2012 and 2017 were not related to HIV infection in both periods of ART coverage.

The Effect of Integration of Family Planning Into HIV Services on Contraceptive Use Among Women Accessing HIV Services in Low and Middle-Income Countries: A Systematic Review

There is substantial unmet need for family planning (FP) among women living with HIV (WLHIV), leading to unintended pregnancies and may contribute indirectly to increasing the risk of transmission of HIV. This review aims to determine whether integration of FP into HIV testing and care results in increased use of contraception, a reduction in unmet need for FP, improved use of safer conception methods and a reduction in unintended pregnancies in low and middle-income countries. A systematic review was undertaken incorporating studies from PubMed, EMBASE, CINAHL, Web of Science and Global Health, the International AIDS Society Abstract Archive, the World STI & HIV Congress Abstract Archive and the Conference on Retroviruses and Opportunistic Infections Abstract Archive published between 2016 and 2021, updating previous systematic reviews. After screening, 13 studies were included, 11 conducted in sub-Saharan Africa and 2 in India. The primary outcome of the review was contraceptive uptake and secondary outcomes included unmet need for FP, safer conception and unintended pregnancy. Integrated FP-HIV facilities were found to increase dual contraceptive use by at least 8% in five studies and modern contraceptive use by at least 8% in four studies. Findings from two studies suggested integration decreased the unmet need for contraception. Limited data prevented a conclusion from being drawn regarding whether integration increases safer conception. There was no evidence of integration reducing unintended pregnancies. The median quality score of studies was 3/9. Overall, integrated facilities have the potential of improving reproductive health of women accessing HIV services in LMICs. FP may be enhanced by including a safer conception component for WLHIV.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021251008, identifier: CRD42021251008.

Dual Contraceptive Use and Factor Associated with People Living with HIV/AIDS: A Systematic Review and Meta-Analysis

Introduction

A dual contraceptive method is the usage of any modern contraceptive method with male or female condoms which could lower sexually transmitted diseases and unwanted pregnancy. Ethiopian standard utilization of dual contraceptive is low. The hassle is more severe for HIV/AIDS-infected people. Therefore, this review was aimed at assessing dual contraceptive utilization and factor associated with people living with HIV/AIDS in Ethiopia.

Method

International databases (PubMed/MEDLINE, Hinari, Embase, African Journals Online, Scopus, and Google Scholar) and Ethiopian university repository online have been covered in this review. Microsoft Excel was used for extraction, and the Stata 14 software program was used for analysis. We detected the heterogeneity between studies using the Cochran Q statistic and I² test. Publication bias was assessed by funnel plot and Egger's and Begg's tests.

Result

The overall prevalence of dual contraceptive use among people living with HIV/AIDS was 27.73% (95% CI: 20.26-35.19) in Ethiopia. Discussion with the partner (OR: 3.78, 95% CI: 3.08-4.69), HIV status disclosure to the spouse/partner (OR: 2.810, 95% CI: 2.26-3.48), postdiagnosis counseling (OR: 5.00, 95% CI: 3.71-6.75), schooling in secondary and above education (OR: 3.78, 95% CI: 2.41-5.93), partner involvement in counseling (OR: 2.76, 95% CI: 1.99-3.82), urban residence (OR: 2.84, 95% CI 2.03-3.94), and having no fertility desire (OR: 4.01, 95% CI 2.91-5.57) were significantly associated with dual contraceptive use.

Conclusion

Dual contraceptive utilization among people living with HIV/AIDS was found to be low in Ethiopia. This will be a significant concern unless future intervention focuses on rural residence, involvement of the partner in postdiagnosis counseling, encouraging the people living with HIV/AIDS to disclose HIV status, and discussion with the partner. Providing counseling during the antenatal and postnatal period also enhances dual contraceptive use.

Unmet need for family planning among reproductive-age women living with HIV in Ethiopia: A systematic review and meta-analysis

Background

Closing the gap of unmet for family planning is crucial to eliminate new pediatric HIV infections likewise to improve maternal and child health among reproductive-age women living with HIV. However, studies conducted on unmet need for family planning among reproductive-age women living with HIV showed inconsistent and non-conclusive findings on the magnitude of the problem. Moreover, there was no meta-analysis conducted in this area. So this systematic review and meta-analysis were conducted to estimate the pooled prevalence unmet need for family planning among reproductive-age women living with HIV in Ethiopia.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed to review both published and unpublished studies in Ethiopia. All studies in PubMed, Cochrane Library, Hinari, Google Scholar, CINAHL, and Global Health databases were searched. Meta-analysis was performed using STATA 14 software. The heterogeneity and publication bias were assessed using the I² statistics and Egger regression asymmetry test, respectively. Forest plots were used to present the pooled prevalence with a 95% confidence interval (CI).

Results

This review included 7 studies, and 3333 study participants. The pooled prevalence of unmet need for family planning among reproductive-age women living with HIV in Ethiopia was 25.13% (95%CI: 19.97, 30.29). The pooled prevalence of unmet need for spacing and limiting was 13.91% (95%CI: 10.11, 17.72) and 9.11% (95%CI: 6.43, 11.78), respectively.

Conclusions

One-fourths of reproductive-age women living with HIV had an unmet need for family planning. A variety of programmatic investments are needed to achieve more meaningful progress toward the reduction of unmet need for family planning among reproductive-age women living with HIV.

Unmet need for family planning and associated factors among married women attending anti-retroviral treatment clinics in Dire Dawa City, Eastern Ethiopia

BACKGROUND

Unmet need for family planning is a measure of the gap between women's contraceptive behavior and their fertility desires. It should be measured among different population groups to effectively implement public health interventions. Thus, this study aimed to determine the magnitude of unmet need for family planning and associated factors among HIV- positive women in Dire Dawa city Anti-retroviral treatment (ART) clinics, Eastern Ethiopia.

METHODS

We carried out a facility-based cross-sectional study (March-June 2020) among 409 married women aged 15-49 on ART, using systematic random sampling. A face-to-face interview was done using a structured questionnaire. Bivariable and multivariable logistic regression was done to identify factors associated with unmet need for family planning.

RESULTS

Overall, 33% [95% confidence interval (CI): 28.9-37.9] of the respondents had unmet need for family planning. Woman's residing in a rural area (adjusted odds ratio (AOR): 2.41 [95% CI: 1.24-4.67]), woman's not attained formal education (AOR: 4.14 [95% CI: 1.73-9.93]) and attaining primary education (AOR: 2.97 [95% CI: 1.54-5.74]), poor knowledge (AOR: 2.87 [95% CI: 1.52-5.40]), and unfavorable attitude towards family planning (AOR: 2.21 [95% CI: 1.12-4.34]), clients not satisfied with family planning service (AOR: 6.34 [95% CI: 3.31-12.15]), the woman not having decision making power on family planning (AOR:3.97 [95% CI: 2.14-7.38]) and not getting family planning counseling in ART clinics (AOR: 2.87 [95% CI: 1.54-5.35]) were positively associated with having unmet need for family planning.

CONCLUSION

This study indicates there a high unmet need for family planning among married HIV-positive women. Factors like a place of residence, educational status of women, knowledge and attitude towards family planning, client satisfaction with FP service, women decision-making power, and FP counseling service in ART. Therefore, we recommend that the concerned bodies should collaborate with ART clinics to design interventions that enhance access to family planning programs to combat the high unmet need for family planning among HIV-positive women.

Determinants of unmet need for family planning in Gambia & Mozambique: implications for women's health

Background

In low-middle-income countries, unmet need for family planning (FP) constitutes a major challenge for prevention of unintended pregnancies and associated health and psychological morbidities for women. The factors associated with unmet need for family planning have been studied for several countries in sub-Saharan Africa, but not much is known about the situation in Gambia and Mozambique. The purpose of this study was to perform a comparative analysis of the prevalence of unmet need for FP, and its sociodemographic correlates in Gambia and Mozambique to better inform FP policies and programs aimed at reducing associated negative health outcomes for women and their families.

Methods

In this analysis we used nationally representative data from Demographic and Health Surveys in Gambia (2013) and Mozambique (2011). Sample population were 23,978 women (n = 10,037 for Gambia and 13,745 for Mozambique) aged 15–49 years. Women who want to stop or delay childbearing but were not using any contraceptive method were considered to have unmet need for FP. Association between unmet need for FP and the explanatory variables was measured using binary logistic regression models

Results

Prevalence of unmet need for FP was 17.86% and 20.79% for Gambia and Mozambique, respectively. Having employment in professional/technical/managerial position showed an inverse association with unmet need both in Gambia [OR = 0.843, 95% CI 0.730, 0.974] and Mozambique [OR = 0.886, 95% CI 0.786, 0.999]. Education and household wealth level did not show any significant association with unmet need. The only positive association was observed for rural [OR = 1.213, 95% CI 1.022, 1.441] women in the richer households in Gambia. Having access to electronic media [OR = 0.698, 95% CI 0.582, 0.835] showed a negative effect on having unmet need in Mozambique. Women from female headed households in Gambia [OR = 0.780, 95% CI 0.617, 0.986] and Mozambique [OR = 0.865, 95% CI 0.768, 0.973] had lower odds of unmet need for FP.

Conclusion

The situation of unmet need for FP in Gambia and Mozambique was better than the Sub-Saharan African average (25%). Nonetheless, there is room for improvement in both countries. Significant assocations with lower unmet need for family planning and women’s occupational status (more education & higher skilled employment), access to mass media communication, and female-headed households provide possible areas for intervention for improved FP opportunities in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01267-8.

The Level of Unmet Need for Family Planning and Its Predictors among HIV-Positive Women in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

Studies indicated that the need for family planning appears to be greater for human immuno-deficiency virus- (HIV-) positive women than the general population to reduce the risk of pediatrics HIV infection and related consequences of unintended pregnancy. We aimed to assess the level of unmet need for family planning and its predictors among HIV-positive women in Ethiopia.

METHODS

Online databases such as PubMed, SCOPUS, EMBASE, HINARI, Google Scholar, and digital libraries of universities were used to search for studies to be included in this systematic review and meta-analysis. Quality assessment of included studies was conducted using the Newcastle-Ottawa Quality Assessment Scale (NOS). Data were extracted using the format prepared on Excel workbook and analyzed by the Stata 11 software. Cochran (Q test) and I 2 test statistics were used to assess the heterogeneity of studies. Similarly, the funnel plot and Egger's regression asymmetry test were used to assess publication bias.

RESULT

This systematic review and meta-analysis was conducted using nine primary studies with a total of 6,154 participants. The pooled prevalence of unmet need for family planning among HIV-positive women was found to be 25.72% (95% CI: 21.63%, 29.81%). Participants age 15-24 years ((OR = 3.12; 95% CI: 1.59, 6.11) I 2 = 27.5%; p = 0.252), being illiterate ((OR = 2.69; 95% CI: 1.69, 4.26) I 2 = 0.0%; p = 0.899), failure to discuss FP with partner ((OR = 3.38; 95% CI: 2.20, 5.18) I 2 = 0.0%; p = 0.861), and no access to family planning information ((OR = 4.70; 95% CI: 2.83, 7.81) I 2 = 0.0%; p = 0.993) were found to be a significant predictors of unmet need for family planning among HIV-positive women.

CONCLUSION

The level of unmet need for family planning among HIV-positive women was found to be high in Ethiopia. Being young age, illiteracy, failed to discuss family planning issues with a partner, and no access to family planning information were found to be the significant predictors of unmet need for family planning among HIV-positive women in Ethiopia. Improving information access and encouraging partners' involvement in family planning counseling and services could reduce the level of unmet need for family planning.

Unmet need for family planning and associated factors among women living with HIV in Gondar city, Northwest Ethiopia: cross-sectional study

INTRODUCTION

all women, including those living with HIV, have the right to choose the timing, spacing, and number of their births and need access to family planning services. This study aimed at assessing the prevalence and factors associated with an unmet need for family planning among women receiving Antiretroviral Therapy (ART) services.

METHODS

a facility-based cross-sectional study was conducted from March to April 2018 in Gondar city, Ethiopia. A systematic random sampling technique was used to recruit 441 reproductive-age women on ART. The data were collected using a pretested structured questionnaire. The bivariate and backward multivariable logistic regression model was fitted to identify factors associated with the unmet need for family planning.

RESULTS

the prevalence of the unmet need for family planning among women living with HIV was 24.5%. Increase in women´s age (AOR: 0.90, 95% CI (0.85, 0.95)), having more than three children (AOR: 0.13, 95% CI (0.04, 0.38)), intention to have more children (AOR: 0.09, 95% CI (0.03, 0.23)), not disclosing sero-status to partner (AOR: 0.40, 95% CI (0.20, 0.82)) and having no experience of contraception use (AOR: 0.43, 95% CI (0.21, 0.90)) were protective factors against unmet need for family planning. Rural residence (AOR: 2.17, 95% CI (1.05, 4.46)) was associated with increased odds of unmet need for family planning.

CONCLUSION

one in every four women living with HIV had an unmet need for family planning. So, continuous awareness-raising activities on family planning for women on ART should be given by emphasizing the rural and younger age women.

Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples

OBJECTIVE

To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services.

DESIGN

Implementation and modelling.

SETTING

Fifty-five government health facilities in Zambia.

SUBJECTS

Patients in government health facilities.

INTERVENTION

Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015.

MAIN OUTCOME MEASURES

We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year.

RESULTS

Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use.

CONCLUSION

Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.

Factors associated with unmet need for limiting childbirth among women living with HIV in Togo: An averaging approach

BACKGROUND

Access to antiretroviral treatment has improved the life expectancy of HIV-positive patients, most often associated with a desire to limit childbearing. Women living with HIV (WLHIV) commonly have unmet need for contraception and could be at risk of unintended pregnancy. Preventing unintended pregnancies among women living with HIV are effective strategies to eliminate mother-to-child transmission of HIV.

OBJECTIVE

The aim of this study was to assess unmet need for limiting childbirth and its associated factors among women living with HIV in Togo.

METHODS

This facility based cross-sectional study was conducted, between June and August 2016, among WLHIV in their reproductive age (15-49 years) in HIV-care settings in Centrale and Kara regions Data was collected using a structured and pretested questionnaire. WLHIV who desired to limit childbirth but not using contraception were considered to have unmet need of birth limitations. Univariate and multivariate Poisson regression models with robust variance were performed to identify associated factors with unmet needs. A multi-model averaging approach was used to estimate the degree of the association between these factors and the unmet need of birth limitations.

RESULTS

A total of 443 WLHIV were enrolled, with mean age of 34.5 years (standard deviation [SD] = 7.0). Among them 244 (55.1%) were in couple and 200 (45.1%) had at least the secondary level of education. 39.1% were followed-up in a private healthcare facility. At the time of the survey, 40.0% did not desire childbearing but only 9.0% (95% CI [6.7-12.1]) of them expressed unmet needs for limiting childbirth. In multivariable analysis, associated factors with unmet needs of birth limitations were: being aged 35 years or more (adjusted prevalence ratio (aPR) = 3.11, 95% confidence intervals (95% CI) [1.52-6.38]), living in couple (aPR = 2.32 [1.15-4.65]), living in Kara region (aPR = 0.10 [0.01-0.76]), being followed in a private healthcare facility (aPR = 0.08[0.01-0.53]) and having severe HIV symptoms (aPR = 3.50 [1.31-9.37]).

CONCLUSION

Even though the unmet need for births limitation was relatively low among WLHIV in Togo, interventions to improve more access to contraceptive methods, and targeting 35 to 49 years old women, those in couple or followed in the public healthcare facilities would contribute to the eradication of mother-to-child transmission of HIV.

Modern contraceptive use among postpartum women living with HIV attending mother baby care points in Kabarole District, Uganda

BACKGROUND

Preventing unintended pregnancies among women living with HIV is important for improving maternal and child health outcomes. Despite multiple contacts between postpartum women and healthcare providers at health facilities, modern contraceptive use during postpartum period remains low even among women with intentions to limit or delay childbearing. We estimated postpartum modern contraceptive use, unmet need and factors associated with modern contraceptive use among HIV positive women attending mother-baby HIV care points.

METHODS

We conducted a cross-sectional study, between April and May 2016, among HIV positive women attending postpartum care at six health facilities in Kabarole district, Uganda. Health facilities were stratified by level prior to selecting participants using systematic sampling. We administered structured questionnaires to women who had delivered within the last two to 18 months. Women who reported current use of a modern method were categorized as modern contraceptive users. Women not using but wanted to stop childbearing or space childbirth by at least 2 years were considered to have unmet need for modern contraception. We estimated a modified Poisson regression model to examine variations in the use of modern methods by various characteristics of participants.

RESULTS

We interviewed 369 women. Forty percent of them were using a modern method, with injectables being the most widely used. A third (33%) of the women had unmet need for modern methods, with unmet need for spacing (24%) being higher than for limiting births (9%). Modern contraceptive use was significantly higher among women who had delivered seven or more months earlier (Adj.PR = 2.02; CI: 1.49, 2.74); women who were counseled on family planning during antenatal care (Adj.PR = 1.53; CI: 1.07, 2.18); those who obtained methods through the care points (Adj.PR =2.27; CI: 1.32, 3.90); and those who jointly made decisions regarding childbearing with their partners (Adj.PR = 1.49; CI: 1.02, 2.17).

CONCLUSION

Use of modern contraceptives was low while unmet need was high among postpartum women living with HIV. The findings suggest that there are gaps which indicate the need to strengthen contraceptive service delivery at these care-points. Providing family planning counseling early would improve uptake of contraception upon resumption of menses and sexual activity.

Status of family planning integration to HIV care in Amhara regional state, Ethiopia

BACKGROUND

Preventing unintended pregnancies among HIV positive women is one component of HIV prevention strategies. However, programs to prevent mother-to-child transmission (PMTCT) of HIV started in antenatal care. The objective of this study was to examine the status of family planning integration to HIV care from client and facility perspectives and identify factors associated with current family planning use.

METHODS

A facility-based cross-sectional study was conducted from December 2017 to April 2018. Data were coded and double entered into EPI Info version 3.5.4 and exported to STATA version 14 for analysis. Bi-variable and multivariable logistic regression analyses were conducted to assess the association of variables with the current family planning use.

RESULTS

A total of 518 HIV-positive women were included in the study. Among HIV-positive women, 35.3% had an unmet need for family planning, and 21.4% responded that their pregnancies were unwanted. About two-thirds (68.1%) of women were using a modern family planning method at the time of the study. Among women who were currently using family planning, 88.8% got the service from a family planning clinic in the same facility, and only 1.1% got the service from the HIV care unit. Women who were not knowledgeable on PMTCT (AOR 0.47, 95% CI = 0.24-0.90), divorced or separated women (AOR 0.19, 95% CI = 0.10-0.37) and women in the age group of 25-34 years (AOR 0.42, 95% CI = 0.20-0.88) and 35-49 years (AOR 0.41, 95% CI = 0.17-0.99) were less likely to use modern family planning methods compared with those women who were knowledgeable, married and women in the age group of 15-24 years. Besides, women with higher income (AOR 2.12, 95% CI = 1.26-3.57) were more likely to use modern family planning methods compared with women with lower incomes.

CONCLUSION

This study indicated that there is a high unmet need for family planning among HIV-positive women and low family planning services integration in the PMTCT/ART clinics. Efforts should be strengthened to tackle the factors which hinder the use of modern family planning and improve family planning service integration.

Dual contraception method utilization and associated factors among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia: a cross sectional study

BACKGROUND

Mother to child transmission is responsible for 90% of child infection with human immune deficiency virus (HIV). Dual contraceptive use is one of the best actions to prevent mother's human immune deficiency virus transmission to her child and partner. This study aimed at assessing the prevalence and factors associated with dual contraceptive use among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia.

METHODS

An institution based cross sectional study was conducted in Gondar City public health facilities from December 1 to 31, 2018. Systematic random sampling technique was utilized to include 563 study participants. Data were collected by interview using a structured questionnaire. Descriptive analysis was made to compute mean, median and proportion. Finally, multivariable logistic regression model was fitted to identify the factors associated with dual contraceptive method utilization. Analysis was performed by using Statistical Package for Social Sciences (SPSS) software version 20.

RESULTS

The overall prevalence of dual contraceptive method utilization among sexually active women on antiretroviral therapy was 28.8% (95% CI: 24.9, 32.7). Women aged 35-49 years (Adjusted odds ratio (AOR): 6.99; 95% CI: 3.11, 15.71)), who lived in urban areas (AOR: 4.81; 95% CI: 2.04, 11.31), attended secondary and above education (AOR: 4.43; 95% CI: 1.92, 10.22), and disclosed HIV status to sexual partners (AOR: 9.84; 95% CI: 3.48, 27.81) were more likely to use dual contraceptive method.

CONCLUSION

In this study, the proportion of women who utilized dual contraceptive method was low. Age, place of residence, educational status and disclosure of HIV status were factors associated with dual contraceptive use. Therefore, providing education about the advantages of disclosing HIV status to sexual partners and strengthening of counseling about the advantages of dual contraceptive use will be helpful in enhancing the use of dual contraceptive method among sexually active women on antiretroviral therapy.

Provider-Initiated Family Planning Within HIV Services in Malawi: Did Policy Make It into Practice?

Four years after Malawi embraced a policy of provider-initiated family planning (PIFP) within its HIV Clinical Guidelines, this policy remained largely unimplemented at the health facility level. Strengthening PIFP in Malawi’s public and private health facilities will require targeted and comprehensive systems changes.

Malawi’s guidelines for Clinical Management of HIV in Children and Adults promote the practice of provider-initiated family planning (PIFP) for all clients over the age of 15. The guidelines recommend that providers should offer all clients condoms, offer injectables to female clients, and refer clients to another provider or site if clients prefer another family planning method. This study assessed to what extent family planning services had been integrated into HIV services among 41 facilities in Malawi (hospitals, health posts, health centers; public and nonprofit private) and how the reproductive rights of people living with HIV were being addressed. Data were collected through facility audits (N=41), provider interviews (N=122), client exit interviews (N=425), and mystery client visits (N=58). This study found that contrary to clinical protocols, only 14% of clients at the antiretroviral therapy (ART) clinic had reported being asked about their family planning/fertility intentions during the visit that day. Only 24% of providers at the facility had received training on family planning-HIV integration, and 21% had no family planning training at all. Overwhelmingly, ART clients relied on condoms to meet their family planning needs. Only 24% of ART clinics had injectables available, and only 15% of ART clinics had a full range of family planning methods (short- and long-acting, hormonal and non-hormonal) available to clients. These findings suggest that Malawi’s strong national policies on family planning-HIV integration, and specifically PIFP, are not being implemented in practice and thus not adequately addressing the family planning needs of clients with HIV. To improve PIFP, Malawi requires targeted systems changes. Facilities need to broaden their family planning method mix offerings. Furthermore, providers need more training on family planning and the importance of HIV clients having access to family planning services, and referral services need to be strengthened so providers can ensure clients have access to their method of choice in a timely manner.

Pregnancy Incidence and Fertility Desires Among Couples by HIV Status in Rakai, Uganda

BACKGROUND

The desire for more children and pregnancy rates are influenced by many relationship dynamics and HIV serostatus of couples.

SETTING

Rakai Community Cohort Study in Uganda.

METHODS

Couple data were retrospectively linked from survey rounds between 2007 and 2015 to assess drivers of fertility desire and pregnancy incidence by HIV status (M-F-; M+F+; M-F+; and M+F-). Multivariable modified Poisson regression was used to estimate prevalence ratios of fertility desire, whereas multivariable Poisson regression was used to estimate incidence rate ratios of pregnancy associated with couple characteristics.

RESULTS

Six thousand six hundred forty-seven couples contributed to 7656 person-years. Approximately 40% of couples (where at least 1 HIV+) desired more children. Unmet need for family planning was evident; couples of medium or low Socioeconomic status and with coresident children had lower fertility desires but higher pregnancy rates. Older age, being in a polygamous union, and having a HIV+ spouse in care were associated with lower fertility desire while having an older male partner was associated with higher fertility desire. Pregnancy incidence was lower with older age, among women using hormonal contraception and condoms, HIV+ concordant couples and couples where the HIV+ spouse was in care while pregnancy incidence were higher among women who desired more children, and serodiscordant couples (M-F+).

CONCLUSIONS

There are many drivers of fertility desires and pregnancy rates, and HIV does not diminish the desire for more children. Unmet need for family planning was evident and highlighted the need to understand and meet the contraceptive needs of couples.

Impact of internal female migration on unmet need for modern contraception in Zambia

Background

Unmet need for contraception, the proportion of women who want to limit or delay childbirth but use no form of contraception, is the core indicator to evaluate the effectiveness of family planning programs. Understanding how migration influences unmet need is important to identify to whom and how to target sexual and reproductive health programs. We assessed how migration status in rural and urban settings is associated with having an unmet need for family planning.

Methods

Data on sexually active, fecund, reproductive-aged (15–49 years) women from the 2013–14 Zambia Demographic and Health Survey were analysed through univariate and multivariate logistic regression models.

Results

Unmet need for modern contraceptive methods was significantly higher among rural to rural migrant women (OR 1.30, 95%CI 1.00–1.70 p < 0.05) and rural non-migrant women (OR 1.41, 95%CI 1.06–1.85 p < 0.01) compared to urban non-migrant women after controlling for age, marital status, parity, religion, education and wealth.

Conclusion

Women residing in, and migrating between, rural areas were significantly more likely to have an unmet need for contraception. Our findings highlight the importance of understanding migration and migrant streams to strengthen family planning programs. In Zambia, a focus on rural-rural migrants, rural non-migrants and the poorest could improve the health of the entire population.

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.

Unmet need for contraception among HIV-positive women in Ile-Ife, Nigeria

As mother-to-child transmission of HIV is difficult to predict and also hard to prevent in practice, pregnancy among women living with HIV/AIDS (WHA) needs to be taken with considerable aforethought. The prevention of unwanted pregnancy among WHA is therefore a public health issue. The aim of our study was to determine the unmet need for contraception among HIV-positive women and the associated factors. Ours was a cross-sectional study involving 425 non-pregnant WHA attending an adult HIV clinic in Nigeria. Interviewer-administered, structured questionnaires designed for the study were used to obtain data. The contraceptive uptake was 47% while the unmet need for contraception was 20%. There were significant associations between unmet need for contraception and age group ( P < 0.001), religion ( P < 0.001), ethnic group ( P < 0.001), knowledge about contraceptives ( P = 0.02), educational status ( P = 0.01) and partners' retroviral status ( P = 0.008) The unmet need for contraception was high. Advocacy programs should perhaps be focused on older women, Christians and those with little or no education.

HIV Positive Patients' Experience of Receiving Health Care Services: A Phenomenology Study in Iran

Introduction:

Most of the studies on HIV/AIDS health care status are usually conducted in big cities while small towns and rural areas are faced with specific challenges. This study aimed to identify the barriers and problems encountered by HIV-positive patients when receiving health services in the small cities and rural areas of Iran.

Methodology:

This is a qualitative study that was conducted using an interpretive phenomenology method in 2016. This study was conducted through a semi-structured interview for which a purposeful sampling method was used. In the present study, data saturation was observed after 15 interviews, but more than 17 interviews were conducted to ensure the reliability of the interview. Data were analyzed by Colaizzi's method using MAXQDA10 software.

Findings:

Barriers and problems encountered by patients when receiving health care services consisted of 10 categories, 32 main themes and 67 sub-themes. The categories were as follows: fear of revealing the disease, fear of confronting providers, seeking support, not visiting health care providers, inappropriate behavior of health care staff, concealing the disease, hardship endurance, financial concerns, psychological stress and pressure, and disclosure of patient information.

Conclusion:

Recognizing the problems of HIV-positive patients in using health care services and resolving them can help to reassure the patients about the health system. Introduction of supporting policies and regulations, appropriate public education, training health sector personnel, and provision of medical equipment and facilities would positively affect the process of solving the problems of HIV-Patients (treating HIV patients).

Changes in Providers' Self-Efficacy and Intentions to Provide Safer Conception Counseling Over 24 Months

High rates of fertility desires, childbearing and serodiscordant partnerships among people living with HIV (PLHIV) in Uganda underscore the need to promote use of safer conception methods (SCM). Effective SCM exist but few PLHIV benefit from provider-led safer conception counseling (SCC) and comprehensive national SCC guidelines are still lacking. Providers' self-efficacy, intentions and attitudes for SCC impact provision and should inform development of services, but there are no longitudinal studies that assess these important constructs. This study reports on changes in providers' knowledge, attitudes, motivation and confidence to provide SCC among a 24-month observational cohort of Ugandan HIV providers. Compared to baseline, providers evidenced increased awareness of SCM, perceived greater value in providing SCC, saw all SCM but sperm washing as likely to be acceptable to clients, reported consistently high interest in and peer support for providing SCC, and perceived fewer barriers at the 24-month follow-up. Providers' intentions for providing SCC stayed consistently high for all SCM except manual self-insemination which decreased at 24 months. Self-efficacy for providing SCC increased from baseline with the greatest improvement in providers' confidence in advising serodiscordant couples where the man is HIV-infected. Providers consistently cite the lack of established guidelines, training, and their own reluctance to broach the issue with clients as significant barriers to providing SCC. Despite providers being more interested and open to providing SCC than ever, integration of SCC into standard HIV services has not happened. Concerted efforts are needed to address remaining barriers by establishing national SCC guidelines and implementing quality provider training.

A Prospective Cohort Study of Fertility Desire, Unprotected Sex, and Detectable Viral Load in HIV-Positive Female Sex Workers in Mombasa, Kenya

BACKGROUND

Little is known about fertility desire in HIV-positive female sex workers. Fertility desire could increase HIV transmission risk if it was associated with condomless sex or lower adherence to antiretroviral therapy.

METHODS

A prospective cohort study was conducted among 255 HIV-positive female sex workers in Mombasa, Kenya. Using generalized estimating equations, fertility desire was evaluated as a risk factor for semen detection in vaginal secretions by prostate-specific antigen (PSA) test, a biomarker of condomless sex, detectable plasma viral load (VL), and HIV transmission potential, defined as visits with positive PSA and detectable VL.

RESULTS

The effect of fertility desire on PSA detection varied significantly by nonbarrier contraception use (P-interaction < 0.01). At visits when women reported not using nonbarrier contraception, fertility desire was associated with higher risk of semen detection [82/385, 21.3% vs. 158/1007, 15.7%; adjusted relative risk (aRR) 1.58, 95% confidence interval (CI): 1.12 to 2.23]. However, when women used nonbarrier contraception, fertility desire was associated with lower risk of PSA detection (10/77, 13.0% vs. 121/536, 22.6%; aRR 0.58, 95% CI: 0.35 to 0.94). Fertility desire was not associated with detectable VL (31/219, 14.2% vs. 128/776, 16.5%; aRR 0.82, 95% CI: 0.46 to 1.45) or higher absolute risk of transmission potential (10/218, 4.6% vs. 21/769, 2.7%; adjusted risk difference = 0.011, 95% CI -0.031 to 0.050).

CONCLUSIONS

Fertility desire was associated with higher risk of biological evidence of semen exposure when women were not using nonbarrier contraceptives. Low HIV transmission potential regardless of fertility desire suggests that the combination of condoms and antiretroviral therapy adherence was effective.

Factors associated with uptake of dual contraception among HIV-infected women in Bungoma County, Kenya: a cross-sectional study

INTRODUCTION

dual contraception, the use of non-barrier contraceptive method in combination with condoms, is an effective strategy in the elimination of mother-to-child transmission (eMTCT) of human immunodeficiency virus (HIV) and the achievement of zero new HIV infections. Despite its effectiveness, dual contraception use among HIV-infected women in Kenya remains low. We identified factors associated with dual contraceptive uptake in Bungoma County, Kenya.

METHODS

this was a facility-based cross-sectional study in eight hospitals in Bungoma County. We interviewed women using structured questionnaires. We calculated descriptive statistics about the womens' baseline characteristics, examined the association between dual contraceptive use and other factors by calculating Odds Ratios (OR) and 95% Confidence Intervals (CI) and performed logistic regression.

RESULTS

we recruited 283 HIV-infected women.Among all enrolled women, 190 (67.1%) were aware of dual method and only 109 (38.5%) used dual contraception. The preferred dual pattern was male condom plus injectable contraceptive used by 53.2% of women (58/109). Among the 174 women who did not use dual contraception, 86 (49.4%) preferred using male condoms alone for contraception. Women were more likely to use dual contraception method if they were aware of dual contraception (AOR 12.2, 95% CI 4.7 - 31.7), used non-barrier contraceptives (AOR 9.8 95%; CI 4.5 - 21.3) and had disclosed their HIV status (AOR 7.1 95% CI 2.8 - 18.2) compared to those who did not.

CONCLUSION

dual contraceptive prevalence was low. Advocacy on dual contraception as an approach to preventing vertical transmission of HIV should be escalated in order to improve its uptake.

Untangling the Relationship Between Antiretroviral Therapy Use and Incident Pregnancy: A Marginal Structural Model Analysis Using Data From 47,313 HIV-Positive Women in East Africa

Supplemental Digital Content is Available in the Text.

Background:

Scale-up of triple-drug antiretroviral therapy (ART) in Africa has transformed the context of childbearing for HIV-positive women and may impact pregnancy incidence in HIV programs.

Methods:

Using observational data from 47,313 HIV-positive women enrolled at 26 HIV clinics in Kenya and Uganda between 2001 and 2009, we calculated the crude cumulative incidence of pregnancy for the pre-ART and on-ART periods. The causal effect of ART use on incident pregnancy was assessed using inverse probability weighted marginal structural models, and the relationship was further explored in multivariable Cox models.

Results:

Crude cumulative pregnancy incidence at 1 year after enrollment/ART initiation was 4.0% and 3.9% during the pre-ART and on-ART periods, respectively. In marginal structural models, ART use was not significantly associated with incident pregnancy [hazard ratio = 1.06; 95% confidence interval (CI): 0.99 to 1.12]. Similarly, in Cox models, there was no significant relationship between ART use and incident pregnancy (cause-specific hazard ratio: 0.98; 95% CI: 0.91 to 1.05), but effect modification was observed. Specifically, women who were pregnant at enrollment and on ART had an increased risk of incident pregnancy compared to those not pregnant at enrollment and not on ART (cause-specific hazard ratio: 1.11; 95% CI: 1.01 to 1.23).

Conclusions:

In this large cohort, ART initiation was not associated with incident pregnancy in the general population of women enrolling in HIV care but rather only among those pregnant at enrollment. This finding further highlights the importance of scaling up access to lifelong treatment for pregnant women.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

Behavioral interventions for improving contraceptive use among women living with HIV

BACKGROUND

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling or education, can help women choose and use an appropriate contraceptive method.

OBJECTIVES

We systematically reviewed studies of behavioral interventions for HIV-positive women intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.

SEARCH METHODS

Until 2 August 2016, we searched MEDLINE, CENTRAL, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP. For the initial review, we examined reference lists and unpublished project reports, and we contacted investigators in the field.

SELECTION CRITERIA

Studies evaluated a behavioral intervention for improving contraceptive use for family planning (FP). The comparison could have been another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive versus HIV-negative women. We included non-randomized studies as well as randomized controlled trials (RCTs).Primary outcomes were pregnancy and contraception use, e.g. uptake of a new method or improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception or a specific contraceptive method.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. We evaluated RCTs according to recommended principles. For non-randomized studies, we examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Given the need to control for confounding factors in non-randomized studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs and interventions, we did not conduct meta-analysis.

MAIN RESULTS

With three new reports, 10 studies from seven African countries met our eligibility criteria. Eight non-randomized studies included 8980 participants. Two cluster RCTs had 7136 participants across 36 sites. Three studies compared a special FP intervention versus usual care, three examined FP services integrated with HIV services, and four compared outcomes for HIV-positive and HIV-negative women.In four studies with high or moderate quality evidence, the special intervention was associated with contraceptive use or pregnancy. A study from Nigeria compared enhanced versus basic FP services. All sites had integrated FP and HIV services. Women with enhanced services were more likely to use a modern contraceptive method versus women with basic services (OR 2.48, 95% CI 1.31 to 4.72). A cluster RCT conducted in Kenya compared integrated FP and HIV services versus standard referral to a separate FP clinic. Women with integrated services were more likely to use more effective contraception (adjusted OR 1.81, 95% CI 1.24 to 2.63). Another cluster RCT compared an HIV prevention and FP intervention versus usual care in Kenya, Namibia, and Tanzania. Women at the special intervention sites in Tanzania were more likely to use highly effective contraception (adjusted OR 2.25, 95% CI 1.24 to 4.10). They were less likely to report unprotected sex (no condom use) at last intercourse (adjusted OR 0.23, 95% CI 0.14 to 0.40). Across the three countries, women at the special intervention sites were less likely to report any unprotected sex in the past two weeks (adjusted OR 0.56, 95% CI 0.32 to 0.99). A study in Côte d'Ivoire integrated HIV and FP services. HIV-positive women had a lower incidence of undesired pregnancy, but not overall pregnancy, compared with HIV-negative women (1.07 versus 2.38; reported P = 0.023).

AUTHORS' CONCLUSIONS

The studies since 2009 focused on using modern or more effective methods of contraception. In those later reports, training on FP methods and counseling was more common, which may strengthen the intervention and improve the ability to meet clients' needs. The quality of evidence was moderate from the more recent studies and low for those from the 1990s.Comparative research involving contraceptive counseling for HIV-positive women is limited. The FP field needs better ways to help women choose an appropriate contraceptive and continue using that method. Improved counseling methods are especially needed for limited resource settings, such as clinics focusing on people living with HIV.

Use of Modern Family Planning Methods in Fishing Communities of Lake Victoria, Uganda

Introduction

Fishing communities (FCs) in Uganda have high HIV infection rates but poor access to health services including family planning (FP). Although FP is a cost-effective public health intervention, there is a paucity of data on knowledge and use of modern FP in FCs. This study determined knowledge and use of modern FP methods in FCs of Uganda.

Methods

Data were accrued from a 12-month follow up of 1,688 HIV-uninfected individuals, 18–49 years from 8 FCs along Lake Victoria, between September 2011 and March 2013. Data on knowledge and use of modern FP were collected through a semi-structured questionnaire. Prevalence Risk Ratios with corresponding 95% CIs were used to determine factors associated with Modern FP knowledge and use.

Results

The mean age was 31.4 years, with nearly half (48.8%) being females while more than half (58.6%) had attained up to primary education level. Knowledge of modern FP was high, 87.5% (1477/1688); significantly higher among females [adj. PRR = 4.84 (95% CI; 3.08, 7.61)], among older respondents (25–29 years) [adj. PRR = 1.83 (95% CI; 1.12, 2.99)] compared to younger ones (18–24 years) and among those conducting business [adj. PRR = 2.42(95% CI; 1.02, 5.74)] relative to those primarily in fishing. Just over a third (35.2%, 595/1688) reported use of at least one modern FP method. Use of modern FP methods was significantly higher among females [adj. PRR = 2.04 (95% CI; 1.56, 2.65, and among those reporting multiple sexual partnerships [adj. PRR = 2.12, 95% CI; 1.63, 2.76)]. Nonuse of modern methods was mostly due to desire for more children (30.6%), fear of side effects (12.2%) and partner refusal (5.2%).

Conclusion

Despite their high knowledge of FP, FCs have low use of modern FP methods. Key barriers to use of modern FP methods were high fertility desires, fear of perceived side effects and partner refusal of methods.