The correct and consistent use of condoms is the most effective way for HIV-positive individuals who are sexually active to prevent the transmission of HIV infection to HIV-negative sexual partners1–3. For most of those who are sexually active with opposite-sex partners, pregnancy prevention is also a relevant goal. In theory, the best way to protect simultaneously against pregnancy and STI/HIV infection is the concurrent use of an effective barrier method such as condoms with an effective pregnancy prevention method. However, many individuals choose one or the other, so that the use of an effective pregnancy prevention method may discourage the use of a barrier method, and vice versa4,5. In addition, those who use two methods may be less consistent in their use of one of the methods, compromising use effectiveness6. The use of contraceptive methods in HIV-infected populations has been little studied. Interviews with 1232 sexually active HIV-infected women aged 18–50 years showed that 47% had used condoms as a form of contraception in the past 12 months, with lower use among women who had tubal ligations or used oral contraceptives7.
The objectives of this study were: (1) to ascertain the prevalence of use of specific contraceptive methods among heterosexual HIV-infected women in the USA; and (2) to identify demographic and attitudinal factors predicting condom use in this population.
Data are from the Risk and Prevention (R&P) Study of the HIV Cost and Services Utilization Study (HCSUS) cohort, a probability sample of HIV-positive adults who had at least one visit for healthcare at a facility other than a military, prison, or emergency department facility during a 2-month period in early 1996 in the 48 contiguous states of the USA. The R&P Study, conducted in the fall of 1998, included a stratified random sample of 1794 of the 2267 individuals who completed a second HCSUS follow-up interview (August 1997–January 1998), excluding non-English speakers and those of unknown sex. Interviews were obtained with 1421 individuals, for a response rate of 84%.
Analyses of contraceptive use reported here focused on R&P female participants for whom pregnancy prevention was a potential concern: 278 women aged 20–50 years who had sex with one or more male partners in the past 6 months and answered questions about contraceptive methods. Results were weighted to adjust for differential probabilities of selection and for attrition.
All women who were heterosexually active in the past 6 months were asked a series of questions: ‘In the last 6 months, have you or a partner used (method)?’ For each method used, follow-up questions asked whether the method was used to prevent pregnancy, was used for other reasons, and was used concurrently with condoms.
We used chi-square tests to compare distributions of categorical variables for those who did and did not report using condoms.
The population was heavily minority (52% African-American, 17% Hispanic, 30% white), and 26% of women had been infected through injection drug use. Eighty-five per cent were either married or in a heterosexual relationship. Many had advanced HIV disease; 49% of women had a lowest-ever CD4 cell count of less than 200 cells/mm3.
Eighty-nine per cent of women reported using at least one contraceptive method in the past 6 months. Seventy-eight per cent of women and their partners used condoms, including 45% to prevent pregnancy. Thirty-five per cent of women reported having had a tubal ligation. Five per cent of women reported using oral contraceptives. Other effective methods of pregnancy prevention received little use. Six per cent of women reported the use of microbicides.
Demographic characteristics positively associated with condom use (for any reason) included being Hispanic (94% use of condoms versus 74% for non-Hispanic women, P < 0.05), having some college education (89 versus 75%, P < 0.05), being partnered but not married (86 versus 67% for all other women, P < 0.01), and having a spouse or partner who was HIV negative (85 versus 69% for women with an HIV-positive partner or spouse, P < 0.05). Attitudes predicting condom use included perceived norms supporting condom use with HIV-negative partners (82 versus 36%, P < 0.001), perceived efficacy of condoms for reducing HIV risk (84 versus 61%, P < 0.01), and low optimism about the efficacy of HIV treatment (86 versus 74%, P < 0.01).
Discussion and Conclusion
The use of condoms in this population is highly prevalent, and is nearly universal among those using any contraceptive method. Among those not using condoms, HIV transmission risk depends on the HIV status of partners. Except for tubal ligation, the most effective methods of pregnancy prevention (e.g. OCs, IUD) are not widely used, even by women who do not desire children. Counseling and other interventions to help HIV-positive women prevent both HIV transmission and pregnancy may thus be of value. However, clinicians and counselors should be sensitive to the fact that many women who are HIV-positive desire and intend to have children8.
The strong association between condom use and attitudes suggests that for secondary prevention, clinicians and counselors should reinforce attitudes that are conducive to condom use, including beliefs that HIV transmission can occur even if an individual is on antiretroviral therapy, that the correct and consistent use of condoms is effective in reducing the risk of HIV transmission, and that HIV-positive individuals should use condoms with all sexual partners who are or could be HIV negative.
This research was supported by grant R01HD35040 from the National Institute of Child Health and Human Development.
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