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

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.

Prevalence and correlates of induced abortion: results of a facility-based cross-sectional survey of parturient women living with HIV in South Africa

BACKGROUND

There is a paucity of studies examining the prevalence and correlates of induced abortion among women living with HIV. Our study fills this gap by examining the prevalence and correlates of induced abortion among parturient women living with HIV in Eastern Cape, South Africa.

METHODS

We analysed cross-sectional survey data of the East London Prospective Cohort Study, which took place between September 2015 and May 2016 in three large maternity facilities in the Buffalo/Amathole districts of the Eastern Cape Province of South Africa. A total of 1709 parturient women living with HIV who gave birth over the study period were recruited. We carried out descriptive and inferential statistics.

RESULTS

The prevalence of induced abortion was 19% (95% CI: 17.2-20.9%), but varied by women's socio-demographic characteristics. Induced abortion prevalence was higher among women aged 25 years and over (21.4%), than among women aged less than 25 years (11.0%). Those ever married or cohabiting (26.8%) reported a higher level of induced abortion than those never-married women (15.6%). Those already diagnosed HIV positive before their index pregnancy (20.2%) had a higher prevalence of induced abortion than those diagnosed during their index pregnancy (14.1%). In the adjusted logistic regression, women were more likely to have ever induced abortion if they were ever married or cohabiting (aOR; 1.86 95% CI; 1.43-2.41), ever smoked (aOR: 1.51; 95% CI: 1.01-2.28) and diagnosed with HIV before their index pregnancy (aOR:1.44; 95% CI: 1.02-2.05) but less likely if younger than 25 years (aOR; 0.51 95% CI:0.35-0.73).

CONCLUSION

About one in five women living with HIV had ever induced abortion in the study settings, indicating that abortion service is one of the main reproductive health services needed by women living with HIV in South Africa. This is an indication that the need for abortion is somewhat high in this group of women. The finding, therefore, highlights the need for concerted efforts from all stakeholders to address the unmet need for contraception among women living with HIV to prevent unintended pregnancy.

Contraceptive trajectories postpartum: A longitudinal qualitative study of women living with HIV in Cape Town, South Africa

BACKGROUND

Supporting the ability of women living with HIV (WLWH) to avoid unintended pregnancy during the postpartum period decreases the number of new pediatric HIV infections, reduces pregnancy-related morbidity and mortality, and is a cost-effective strategy for the elimination of mother-to-child transmission. However, little is currently known about the contraceptive intentions and experiences of reinitiating family planning use among mothers living with HIV as they transition from pregnancy into postpartum.

STUDY OBJECTIVES

To (1) understand the contraceptive trajectories of women living with HIV during pregnancy and postpartum in Cape Town, South Africa, and (2) identify factors shaping differing contraceptive trajectories during the postpartum period.

METHODS

Thirty pregnant WLWH were interviewed during their eighth month of pregnancy and completed follow-up interviews at 6-8 weeks and 9-12 months postpartum (n = 81 total interviews). Interview topics included postpartum contraception intentions, contraceptive use, and experiences accessing family planning services. Trajectory analysis of contraceptive intentions was applied after initial thematic coding.

RESULTS

While nearly half of women interviewed during pregnancy expressed an intention to utilize a non-injectable contraceptive option after childbirth (e.g. implant, IUD, sterilization, oral contraceptive pills), all women interviewed at one year postpartum had received at least one injection. Three main contraceptive trajectories were identified. (1) realization of contraceptive intentions postpartum; (2) unrealized contraceptive intentions postpartum; and (3) change in contraceptive intention over time. Provider influence, coordination of services, and low contraceptive inventory were identified as potential factors shaping the contraceptive trajectories of participants enrolled in the study.

CONCLUSION

Disparities between contraceptive method intentions articulated by WLWH during pregnancy and methods attained postpartum suggest that significant barriers remain for women who are unsatisfied with injectable contraception. Failing to provide postpartum mothers living with HIV their intended family planning method undermines efforts to prevent unintended pregnancy, a key pillar of elimination of mother-to-child transmission.

Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers

BACKGROUND

An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa.

MATERIALS AND METHODS

A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software.

RESULTS

The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives.

CONCLUSIONS

Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.

Subfertility among HIV-affected couples in a safer conception cohort in South Africa

BACKGROUND

Subfertility among couples affected by HIV has an impact on the well-being of couples who desire to have children and may prolong HIV exposure. Subfertility in the antiretroviral therapy era and its determinants have not yet been well characterized.

OBJECTIVE

The objective of the study was to investigate the burden and determinants of subfertility among HIV-affected couples seeking safer conception services in South Africa.

STUDY DESIGN

Nonpregnant women and male partners in HIV seroconcordant or HIV discordant relationships desiring a child were enrolled in the Sakh'umndeni safer conception cohort at Witkoppen Clinic in Johannesburg between July 2013 and April 2017. Clients were followed up prospectively through pregnancy (if they conceived) or until 6 months of attempted conception, after which they were referred for infertility services. Subfertility was defined as not having conceived within 6 months of attempted conception. Robust Poisson regression was used to assess the association between baseline characteristics and subfertility outcomes; inverse probability weighting was used to account for missing data from women lost to safer conception care before 6 months of attempted conception.

RESULTS

Among 334 couples enrolled, 65% experienced subfertility (inverse probability weighting weighted, 95% confidence interval, 0.59-0.73), of which 33% were primary subfertility and 67% secondary subfertility. Compared with HIV-negative women, HIV-positive women not on antiretroviral therapy had a 2-fold increased risk of subfertility (weighted and adjusted risk ratio, 2.00; 95% confidence interval, 1.19-3.34). Infertility risk was attenuated in women on antiretroviral therapy but remained elevated, even after ≥2 years on antiretroviral therapy (weighted and adjusted risk ratio, 1.63; 95% confidence interval, 0.98-2.69). Other factors associated with subfertility were female age (weighted and adjusted risk ratio, 1.03, 95% confidence interval, 1.01-1.05 per year), male HIV-positive status (weighted and adjusted risk ratio, 1.31; 95% confidence interval, 1.02-1.68), male smoking (weighted and adjusted risk ratio, 1.29; 95% confidence interval, 1.05-1.60), and trying to conceive for ≥1 year (weighted and adjusted risk ratio, 1.38; 95% confidence interval, 1.13-1.68).

CONCLUSION

Two in 3 HIV-affected couples experienced subfertility. HIV-positive women were at increased risk of subfertility, even when on antiretroviral therapy. Both male and female HIV status were associated with subfertility. Subfertility is an underrecognized reproductive health problem in resource-limited settings and may contribute to prolonged HIV exposure and transmission within couples. Low-cost approaches for screening and treating subfertility in this population are needed.

Relative patterns of sexual activity and fertility among HIV positive and negative women-Evidence from 46 DHS

Objectives

Projections of fertility of HIV positive women as ART scales up are needed to plan prevention of mother-to-child transmission (PMTCT) services. We describe differences in exposure to pregnancy between HIV positive and HIV negative women by age, region and national ART coverage to evaluate the extent to which behavioural differences explain lower fertility among HIV positive women and assess whether exposure to pregnancy has changed with antiretroviral treatment (ART) scale-up.

Methods

We analysed 46 nationally representative household surveys in sub-Saharan Africa conducted between 2003 and 2015 to estimate risk of exposure to recent sex and pregnancy of HIV positive and HIV negative women by age using a log binomial model. We tested for regional and urban/rural differences and associations with national ART coverage. We estimated an adjusted fertility rate ratio of HIV positive to HIV negative women adjusting for differences in exposure to pregnancy.

Results

Exposure to pregnancy differs significantly between HIV positive and negative women by age, modified by region. Younger HIV positive women have a higher exposure to pregnancy than HIV negative women and the opposite is true at older ages. The switch occurs at 25–29 for rural women and 30–34 for urban women. There was no evidence that exposure to pregnancy of HIV positive women have changed as national ART coverage increased. The inferred rate of fecundity of HIV positive women when adjusted for differences in exposure to pregnancy were lower than unadjusted fertility rate ratios in women aged 20–29 and 20–24 in urban and rural areas respectively varying between 0.6 and 0.9 over regions.

Discussion

The direct effects of HIV on fertility are broadly similar across ages, while the dramatic age gradient that has frequently been observed is largely attributable to variation in relative sexual exposure by age.

Prevalence and Factors Associated with Contraceptive Use among HIV-Infected Women of Reproductive Age Attending Infectious Disease Clinic at Gulu Regional Referral Hospital, Northern Uganda

Background

Reproductive planning by HIV-infected women is essential, as it helps to prevent transmission of HIV to their unborn babies. Integrating contraceptive services to routine HIV care significantly increases the use of modern contraceptive methods, thus reducing vertical transmission of HIV.

Objectives

To determine the prevalence and factors associated with contraceptive use among HIV-infected women attending Infectious Disease Clinic (IDC) at Gulu Regional Referral Hospital (GRRH) in Northern Uganda.

Methodology

A hospital-based cross-sectional study was performed. We used simple random sampling to recruit HIV-infected women receiving routine care from IDC, GRRH, into our study. Sample size was estimated using modified Kish-Leslie formula and semistructured questionnaire was used for data collection. Data was entered into EpiData version 3.1 and analysed using Stata v11.0. We used logistic regression model to assess the associations and any factor with p≤0.05 was considered statistically significant.

Results

The prevalence of contraceptive use was found to be 36% (95% CI 31 – 40%). Factors which promoted contraceptive use were as follows: being married (aOR=2.68, 95% CI 1.54-4.65, p<0.001) and monthly income of $35 -250 (aOR= 2.38, 95% CI: 1.39- 4.09, p=0.002). Factors that hindered contraceptive use were having no child (nulliparity) (aOR= 0.16; 95% CI: 0.05-0.49; p=0.002) and age range of 31-49 years (aOR= 0.53; 95% CI: 0.33 - 0.84; p=0.007).

Conclusion

In this study, just over a third of sexually active HIV-infected women reported use of modern contraceptives. This is a low level of usage and, therefore, clinicians and stakeholders should sensitise HIV-infected women on the importance of contraceptive use in the fight against HIV/AIDS and encourage them to use contraceptives to avoid vertical transmission of HIV through unintended pregnancy.

Pattern and determinants of contraceptive usage among women of reproductive age from the Digo community residing in Kwale, Kenya: results from a cross-sectional household survey

Background

Contraceptive usage has been associated with improved maternal and child health (MCH) outcomes. Despite significant resources being allocated to programs, there has been sub-optimal uptake of contraception, especially in the developing world. It is important therefore, to granulate factors that determine uptake and utilization of contraceptive services so as to inform effective programming.

Methods

Between March and December 2015, we conducted a cross-sectional survey among women of reproductive age (WRA) from the Digo community residing in Kwale County, Kenya. The study aimed to describe the pattern and determinants of contraceptive usage in this population. Respondents were selected using stratified, systematic sampling and completed a household sexual and reproductive health (SRH) questionnaire.

Results

We interviewed 745 respondents from 15 villages in 2 out of 4 sub-counties of Kwale. Their median (interquartile range, IQR) age was 29 (23–37) years. 568 (76%) reported being currently in a marital union. Among these, 308 (54%) were using a contraceptive method. The total unmet need, unmet need for spacing and for limiting was 16%, 8% and 8%, respectively. Determinants of contraceptive usage were education [adjusted Odds Ratio, aOR = 2.1, 95% confidence interval, CI: 1.4–3.4, P = 0.001]; having children [aOR = 5.0, 95% CI: 1.7–15.0, P = 0.004]; having attended antenatal care (ANC) at last delivery [aOR = 4.0, 95% CI: 1.1–14.8, P = 0.04] as well as intention to stop or delay future birth [aOR = 6.7, 95% CI: 3.3–13.8, P < 0.0001].

Conclusions

We found high levels of contraceptive usage among WRA from the Digo community residing in Kwale. To further improve uptake and utilization of contraception in this setting, programs should address demand-side factors including ensuring female educational attainment as well as promotion of ANC and skilled birth attendance.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0497-5) contains supplementary material, which is available to authorized users.

Changes in Fertility at the Population Level in the Era of ART in Rural Malawi

Introduction:

HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women.

Methods:

Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births.

Results:

From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15–49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005–2006 to 5.1 (4.8–5.5) in 2011–2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2–6.1) in 2011–2014. In 2011–2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007–2010 to 3.5% in 2011–2014.

Conclusions:

Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants.

Sexual Practices, Fertility Intentions, and Awareness to Prevent Mother-to-Child Transmission of HIV Among Infected Pregnant Women at the Yaounde Central Hospital

Introduction

The sexual and reproductive health of people living with HIV is fundamental for their well-being. Antiretroviral therapy and reproductive technologies have significantly improved quality of life of people living with HIV in developed countries. In sub-Saharan Africa, the epicenter of HIV, the sexual practices and fertility of women infected with HIV have been understudied.

Aim

To assess the sexual behavior, fertility intentions, and awareness of preventing mother-to-child transmission of HIV in pregnant women with HIV-negative partners in Yaounde Central Hospital (Yaounde, Cameroon).

Methods

A cross-sectional survey using a semistructured, interviewer-administered questionnaire was conducted at the antenatal unit and HIV clinic in 2014.

Main Outcome Measures

Ninety-four pregnant women infected with HIV provided consistent information on (i) sociodemographic characteristics, (ii) sexual and fertility patterns, (iii) awareness of preventing mother-to-child transmission of HIV, and (iv) their unmet needs.

Results

Although sexual desire had significantly changed since their HIV diagnosis, the women were highly sexually active. Approximately 19% of women had more than one sexual partner and 40% had regular unprotected sex during the 12-month period before the interviews (P < .0001). Twenty-nine percent of women preferred intermittent sexual intercourse and inconsistent condom use to delay pregnancy, but the abortion rate remained high. Age, marital status, and education affected women's awareness of mother-to-child transmission (P < .05); and no association existed between the number of living children and future pregnancies (r_s = −0.217; P = .036).

Conclusion

HIV-infected women living with HIV-negative partners in Cameroon expressed high sexual and fertility intentions with several unmet needs, including safer sexual practices and conception. Incorporating and supporting safe sexual educational practices and conception services in maternal care can decrease risky sexual behavior and vertical transmission.

Combination Antiretroviral Therapy for HIV in Rwandan Adults: Clinical Outcomes and Impact on Reproductive Health up to 24 Months

Adult women (n = 113) and men (n = 100) initiating combination antiretroviral therapy (cART) and women not yet eligible for cART (n = 199) in Kigali, Rwanda, were followed for 6–24 months between 2007 and 2010. In the cART groups, 21% of patients required a drug change due to side effects and 11% of patients had virological failure (defined as >1,000 HIV RNA copies/mL) after 12 months of cART. About a third of the pregnancies since HIV diagnosis were unintended. The proportion of women in the pre-cART group using modern contraception other than condoms (50%) was similar to women in the general population, but this proportion was only 25% in women initiating cART. Of the women who carried at least one pregnancy to term since having been diagnosed HIV-positive, a third reported to have participated in a prevention-of-mother-to-child-transmission (PMTCT, option A) intervention. Many patients were coinfected with herpes simplex virus type 2 (79–92%), human papillomavirus (38–53%), and bacterial sexually transmitted infections (STIs) with no differences between groups. We applaud the Rwandan government for having strengthened family planning and PMTCT services and for having introduced HPV vaccination in recent years, but additional work is needed to strengthen STI and HPV-related cancer screening and management in the HIV-positive population.