Most HIV-infected women and women at risk of HIV live in sub-Saharan Africa. Most of these women are married. Many countries in Africa are strongly pro-natalist, and it is not clear what impact HIV will have on family planning.
Two long-term cohorts in Rwanda (1988–1992) and Zambia (1994–1998) were followed at 3–6 monthly intervals. In Rwanda, contraceptive use and pregnancy incidence are compared before and after the provision of modern contraceptive methods. In Zambia, a three-armed randomized controlled trial (RCT) of dual method promotion is used to compare hormonal contraceptive use in couples with one or both partners HIV-infected after the provision of hormonal contraception at the study clinic (intervention 1) with or without a motivational message (intervention 2). All participants were advised of their HIV test results and provided with free condoms throughout.
In the Rwanda cohort enrolled in prospective studies in 1988, 85% of participants were married, and many asked if their partners could also be tested. When HIV testing services were offered, 33% of husbands sought testing. Fourteen per cent of tested couples had one HIV-infected and one HIV-negative partner and 25% had two HIV-infected partners. Two years after VCT, condom use increased substantially: the two strongest predictors were a positive HIV status and a male partner who sought testing. HIV seroconversion rates were reduced in women whose partners tested (4.2–1.4/100 PY), not in women tested alone. Gonorrhea rates were reduced by 50% among HIV-infected women.
Two years after voluntary counselling and testing (VCT), 57% of HIV-negative women and 43% of HIV-infected women had had a new pregnancy. Male participation in VCT had no impact on pregnancy incidence, and the pregnancy rate was no different in condom users and non-users. Among HIV-infected women, having less than four children was independently predictive of incident pregnancy.
During the first 2 years of follow-up, 20% of women used hormonal contraception at any given time. Of these, half used OC and half used injectables. In the year after VCT, the discontinuation rate was 59% among HIV-infected and 36% among HIV-negative women. They were replaced by new users (8%), and the use of hormonal contraception at any given time remained stable. The discontinuation of OC or injectable methods was unrelated to condom use. Subsequently, when hormonal methods were offered at the study clinic, there was a 50% increase in OC and injectable use with no change in condom use. Incident pregnancy decreased from 22% per year to 9% per year among HIV-infected women, and from 29% per year to 20% per year among HIV-negative women. Male participation in VCT/family planning education was again unrelated to hormonal use or pregnancy.
In a pilot RCT of reduction in unplanned pregnancy in 251 Zambian couples with one (95%) or both (5%) partners HIV-infected, contraceptive initiation and pregnancy incidence were compared in three arms. The control arm received family planning education and referral to planned parenthood. Intervention 1 was provided with ‘enhanced access’ with hormonal methods available at the study clinic, and intervention 2 received access to methods at the study clinic plus a motivational intervention including education about inheritance law and will preparation. OC or injectables were initiated by 33% of the control group, 80% of the ‘access’ group, and 76% of the ‘access plus motivation’ group. There was no difference in baseline uptake between HIV-infected and HIV-negative women, but less attrition among HIV-infected injectable users, with a corresponding significantly lower incidence of pregnancy among HIV-infected women who initiated injectable contraceptive use. This was not noted among HIV-negative women.
In qualitative assessments, side-effects were the most commonly cited reason for method discontinuation. Hormonal methods were considered ‘bad for health’, and this was a particular concern among HIV-infected women. The motivational intervention did increase the number of wills prepared, but the prospect of death was not imminent.
African couples are the largest HIV risk group in the world, and total fertility rates in Africa remain high despite decades of family planning programme efforts. The prevention of HIV transmission and unplanned pregnancy must be addressed together. Given poor compliance and concerns about the side-effects of OC and injectable contraceptives, more emphasis should be placed on longer-acting, user-independent methods such as IUD, implant, and BTL. The biggest obstacle to this is provider bias: nurses do not know how to insert IUD and implants. Clients have little knowledge and few preconceptions about these methods. New methods-focused messages should prioritize the most effective modern contraceptive methods, improve knowledge of how contraceptives work, and reassure clients about side-effects. Motivational interventions for African couples with HIV should include a broad approach to ‘family planning’, with emphasis on near-term outcomes, in particular keeping existing children in school.
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