Contraceptive use and method preference among women in Soweto, South Africa: The influence of expanding access to HIV care and treatment services

Objective: Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. Methods: We used survey data from 563 sexually active, non-pregnant women (18-44 years) recruited from the Perinatal HIV Research Unit in Soweto (May-December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use. Results: Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIVnegative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIVpositive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods. Conclusion: Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health. © 2010 Kaida et al. With 5.5 million HIV-infected residents, South Africa is the country with the world's largest absolute number of people living with HIV [1]. The national adult (aged 15–49 years) HIV prevalence is 19% and the antenatal HIV prevalence is 30% [1]. The South African epidemic is highly feminized as women account for 60% of all infected adults and among 15–24 year olds, women account for 90% of incident HIV infections [34]. HIV prevalence in the study site, Soweto, an urban township of Johannesburg, is among the highest in the country [33]. Each year an estimated 220,000 women living with HIV in South Africa become pregnant [2]. Although coverage of prophylactic antiretroviral therapy to prevent MTCT increased from 15% to 73% between 2004 and 2008 [2], recent estimates report that over 64,000 infants are infected with HIV via MTCT each year [35]. Combination antiretroviral therapy became available in South Africa's public sector clinics in 2004 and by the end of 2008 an estimated 700 000 adults were receiving HAART, an antiretroviral therapy coverage of 31% [2]. Effective contraceptive methods, including injectables (Nur-Isterate and Depo Provera), oral contraceptive pills, the intrauterine device (IUD), condoms, and male and female sterilization, are available at no-cost in government health centres throughout Soweto. Elective termination of pregnancy is legal in South Africa and available at no-cost up to 12 weeks gestation. This study was conducted at the Perinatal HIV Research Unit (PHRU), a large clinical and research site housed within one of the world's largest hospitals: Chris Hani Baragwanath Hospital in Soweto. The PHRU sees over 5 000 adult visits monthly and provides antiretroviral therapy and clinical care to medically-eligible HIV-positive individuals and ongoing wellness care for those not yet eligible for HAART. The PHRU also operates a Voluntary Counseling and Testing (VCT) centre. All PHRU services (including HIV prevention, testing, treatment and care and family planning) are provided free-of-charge. Since April 2006, onsite no-cost family planning services have been available to HIV-positive women accessing antiretroviral therapy at the PHRU. These services offer barrier, oral, and injectable contraceptive methods as well as family planning counseling from a trained family planning nurse. Treatment-naïve HIV-positive women may also access family planning services from the PHRU, however, they are not routinely queried about their contraceptive use during regular clinical follow-up. The PHRU primarily serves residents of Soweto. This analysis is based on cross-sectional survey data of HIV-positive (HAART receiving and HAART-naïve) and HIV-negative women seeking services at the PHRU. A medical chart review was also conducted to confirm HIV serology and HAART use history of HIV-positive women. To be eligible to participate in the overall study, women were required to be 18–49 years of age, attending a PHRU clinic, residing in Soweto, competent to give informed consent, and willing to allow medical record review for the purposes of confirming HIV status and HAART history. We considered women to be HAART users if they had been receiving HAART for at least one month. We considered women to be HAART-naïve if they had never taken HAART. We enrolled 751 women, including 253 HIV-positive women receiving HAART, 249 HIV-positive but HAART-naïve women, and 249 HIV-negative women. This sampling strategy provided one case group (HAART users) and two comparison groups (HAART-naïve and HIV-negative women). HAART users were sampled from the PHRU's President's Emergency Plan for AIDS Relief (PEPFAR) Clinic, which has provided free antiretroviral therapy to medically eligible patients since July 2004. Currently, the PEPFAR clinic has over 1,000 patients receiving HAART, 75% of who are female. PEPFAR patients are followed-up every three months and generally receive one of two standard HAART regimens. Regimen 1 consists of stavudine (d4T), lamivudine (3TC), and efavirenz (EFV) or nevirapine (NVP). Regimen 2 consists of zidovudine (AZT), didanosine (ddI), and lopinavir/ritonavir (LPV/r) [36]. HIV-positive HAART-naïve women were sampled from the PHRU's Wellness Clinic, initiated in January 2003 with the goal of providing preventive care to HIV-positive individuals. Wellness patients are followed-up approximately every six months. When patients become medically eligible for HAART, they are referred to the PEPFAR clinic or to one of the nearby government ART clinics. There are approximately 3,000 active patients in the Wellness Clinic. HIV-negative women were sampled from the PHRU's VCT clinic, which was initiated in mid-2002 and sees approximately 400 people per month. Testing is conducted onsite during visits that last an average of two hours. Approximately 65% of attendees are women and 30% of all attendees test HIV-positive. For this analysis on contraceptive use, we restricted the study sample to women aged 18–44 years who were currently sexually active (i.e., reported sexual activity in the previous six months), not currently pregnant, and pre-menopausal as per self-report). This was done to enhance the comparability of findings with other studies investigating reproductive and sexual health among HIV-positive populations. The restriction yielded an analytic sample of 563 women (75% of total sample), including 171 women on HAART, 178 HAART-naïve women, and 214 HIV-negative women. Every female patient attending the PEPFAR Clinic and the VCT clinic was consecutively approached by a research assistant to assess eligibility and interest in participating in the study. Since many more women attend the Wellness Clinic, a list was made of chart numbers of women attending the clinic each day. A random sample of chart numbers (40% of the total number of charts present) was then drawn and the corresponding women were approached to assess eligibility and interest in participating in the study. After confirming eligibility and seeking written informed consent, all participants were asked to complete a 15–25 minute interviewer-administered questionnaire in English. The study interviewers were multilingual and trained to ensure accurate and consistent translation of the questionnaire if required or requested by the participant. Pilot testing of 45 women revealed that women were able to understand and answer the questionnaire. Pilot testing helped to ensure a more comprehensive list of responses were available for structured questions and that terms such as “sexual intercourse” were defined to refer specifically to “vaginal sex between a man and a woman”. Approximately 12 women were interviewed daily by three trained research assistants between May and December 2007. Research assistants were women from the local community who had previous research experience and were recent Social Sciences' graduates of a local university. Interviewers were supervised by an experienced research nurse. Two research nurses with HIV training conducted the medical record review. Participants were given transport reimbursement as compensation. The questionnaire assessed socio-demographic characteristics; HIV status, diagnosis, and treatment; clinical stage of disease; HAART history; fertility intentions; fertility history; contraceptive practices; and sexual history. The survey instrument was developed from a validated questionnaire used in an earlier pilot study [37]. We reviewed medical records of HIV-positive women to confirm HIV status and HAART history, and to obtain clinical data including CD4 cell counts and WHO stage of disease. Viral load measures were only available for women receiving HAART as only patients receiving treatment in the PEPFAR clinic undergo viral load testing. The primary outcome was self-reported contraceptive use in the previous six months. Contraceptive methods queried included male and female condoms (restricted to those reporting “Always” use), injections (depomedroxyprogesterone acetate (DMPA) or norethisterone enantate), oral contraceptive pills, diaphragm, intrauterine devices (IUD), female tubal ligation, hysterectomy, and male partner sterilization. In assessing the contraceptive method profile, dual protection was defined as use of both a barrier contraceptive method (primarily the male condom) and use of a hormonal or permanent contraceptive method [38]. The primary explanatory variables were HIV status and current receipt of HAART. Covariates included age, education, employment, household income, current sexual partnership, HIV status of regular sexual partners, parity, number of living children, fertility intentions, and HIV clinical variables. We computed and compared the prevalence of contraceptive use between HIV-positive women and HIV-negative women overall and then between each of the three groups of women. We conducted two separate models to measure the presence and strength of the association between HAART use and the odds of contraceptive use, controlling for covariates. The first model compared HAART users and HAART-naïve women to HIV-negative women. The second model compared HAART users to HAART-naïve women and allowed adjustment for HIV-associated clinical characteristics. In both models, univariate analyses were used to assess the relationship between HIV status, receipt of HAART, contraceptive use, and covariates. Differences in contraceptive use between groups are reported using Pearson's chi-squared test (for categorical variables) and ANOVA, or Student's independent t-test (for continuous variables). After testing for co-linearity (using Spearman's rho (ρ)) [39] and interaction [40], all covariates with significant associations in the univariate analysis were included in multivariate logistic regression models to obtain adjusted estimates of the association between HIV status, receipt of HAART, and contraceptive use. Age was forced into both multivariate models regardless of its univariate associations. All statistical tests were two-sided and considered significant at α = 0.05. Among women who reported using contraception, we analyzed types of methods used by women in each of the three groups and overall. In addition to reporting use of each contraceptive method individually, we collapsed the data into four mutually exclusive groups including “Use of dual protection”, “Consistent condom use only”, “Use of Hormonal/Permanent method only”, and “Not using any contraceptive method” and tested for differences by HIV and HAART use status using Pearson's chi-squared test. We assessed the association between duration of HAART use and prevalence of contraceptive use using Pearson's test for trend. HAART-naïve women were included in the “0 months on HAART” category. We conducted the same analyses described above but restricted our sample to women aged 18–34 years to investigate the potential impact of differences in mean baseline age between HIV-positive and HIV-negative women in our study. This age group corresponds with the peak childbearing years among women in South Africa [41]. All participants provided voluntary informed consent and all procedures were approved by the Human Research Ethics Committee of the University of the Witwatersrand, the University of British Columbia Health Research Ethics Board, the Simon Fraser University Office of Research Ethics, and the University of California San Diego Institutional Review Board. Information letters and consent forms were available in English and two local languages (isi-Zulu and Sesotho) to ensure comprehensive understanding of the study objectives, potential risks, and benefits.