HIV This Week

Andia I, Kaida A, Maier M, Guzman D, Emenyonu N, Pepper L, Bangsberg DR, Hogg RS. Highly Active Antiretroviral Therapy and Increased Use of Contraceptives Among HIV-Positive Women During Expanding Access to Antiretroviral Therapy in Mbarara, Uganda. Am J Public Health. 2009; 99(2):340-7.

Andia and colleagues investigated whether the prevalence of contraceptive use among women who are HIV-positive varied according to use of highly active antiretroviral therapy (HAART) in Mbarara, Uganda. They used data from a cross-sectional survey of 484 women who were HIV-positive (18-50 years) and were attending Mbarara University’s HIV clinic, 45% of whom were receiving HAART. Multivariate logistic regression was used to investigate the association between HAART use and contraceptive use. Data were collected between November 2005 and June 2006. Overall, 45% of the women were sexually active in the previous 3 months. Of these, 85% reported using contraceptive methods, with 84% reporting use of barrier contraceptive methods. Women receiving HAART were more than twice as likely to use contraceptive methods (adjusted odds ratio [AOR]=2.64; 95% confidence interval [CI]=1.07, 6.49) and more than 3 times as likely to use barrier contraceptive methods (AOR=3.62; 95% CI=1.54, 8.55) than were women not receiving HAART. The authors conclude that these findings support the need for increased attention to better integration of reproductive health and HIV services for women who are HIV positive.

Editors’ note: The Ugandan women on antiretroviral treatment in this study had been on treatment for a relatively short period (median 15 months) and 62% of them reported being sexually abstinent, possibly as a result of situational abstinence (30% of them were widows) rather than deliberate abstinence. Only 14% wanted more children but improved health status may increase fertility desires, a question that longer follow-up can help answer. In the meantime, this study underscores the importance of ensuring that antiretroviral treatment programmes offer women reproductive health care on site so that they can make informed choices and have the tools to act on them.

Homsy J, Bunnell R, Moore D, King R, Malamba S, Nakityo R, Glidden D, Tappero J, Mermin J. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a prospective cohort study. PLoS ONE. 2009;4(1):e4149.

Antiretroviral therapy may influence the biological, social and behavioural determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on antiretroviral therapy in Africa. Using a prospective cohort design, Homsy and colleagues analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated antiretroviral therapy between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioural questionnaires administered every quarter in year 1 after initiating antiretroviral therapy, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting antiretroviral therapy. The authors tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. They modelled repeated measurements of all variables related to the women’s desire for children over time using a generalized estimating equation extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting antiretroviral therapy. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years in the first quarter to 9.5 per 100 women-years at 24 months (p<0.0001). This was paralleled by an increase in the proportion of women reporting sexual activity in the past 3 months, from 24.4% at baseline to 32.5% over 24 months of follow-up (p = 0.001). Only 14% of women used permanent or semi-permanent family planning methods by their second year on ART. In the multivariate model, younger age (HR = 2.71 per 10-year decrease, 95% CI: 2.95-3.78), having a body mass index>18.5 (HR = 1.09, CI:1.01-1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02-3.13) were independently associated with pregnancy. Women on antiretroviral therapy and their partners should be consistently counselled on the effects of antiretroviral therapy in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.

Editors’ note: Again from Uganda (see Andia et al abstract), this home-based AIDS care study documents the gap between not wanting more children and falling pregnant. The incidence of pregnancy increased over follow-up despite the fact that 93% of women repeatedly expressed not wanting or not planning to have more children. Following the study results, counsellors and nurses were retrained and then pro-actively counselled all registered clients on family planning quarterly, delivered hormonal contraceptives at home, and actively referred and followed up women opting for hormonal implants or tubal ligation. This is a good example of knowledge translation into action.