Family planning use and fertility desires among women living with HIV in Kenya Global health

Background: Enabling women living with HIV to effectively plan whether and when to become pregnant is an essential right; effective prevention of unintended pregnancies is also critical to reduce maternal morbidity and mortality as well as vertical transmission of HIV. The objective of this study is to examine the use of family planning (FP) services by HIV-positive and HIV-negative women in Kenya and their ability to achieve their fertility desires. Methods: Data are derived from a random sample of women seeking family planning services in public health facilities in Kenya who had declared their HIV status (1887 at baseline and 1224 at endline) and who participated in a longitudinal study (the INTEGRA Initiative) that measured the benefits/costs of integrating HIV and sexual/reproductive health services in public health facilities. The dependent variables were FP use in the last 12 months and fertility desires (whether a woman wants more children or not). The key independent variable was HIV status (positive and negative). Descriptive statistics and multivariate logistic regression analysis were used to describe the women’s characteristics and to examine the relationship between FP use, fertility desires and HIV status. Results: At baseline, 13 % of the women sampled were HIV-positive. A slightly higher proportion of HIV-positive women were significantly associated with the use of FP in the last 12 months and dual use of FP compared to HIV-negative women. Regardless of HIV status, short-acting contraceptives were the most commonly used FP methods. A higher proportion of HIV-positive women were more likely to be associated with unintended (both mistimed and unwanted) pregnancies and a desire not to have more children. After adjusting for confounding factors, the multivariate results showed that HIV-positive women were significantly more likely to be associated with dual use of FP (OR∈=∈3.2; p∈<∈0.05). Type of health facility, marital status and household wealth status were factors associated with FP use. Factors associated with fertility desires were age, education level and household wealth status. Conclusions: The findings highlight important gaps related to utilization of FP among WLHIV. Despite having a greater likelihood of reported use of FP, HIV-positive women were more likely to have had an unintended pregnancy compared to HIV-negative women. This calls for need to strengthen family planning services for WLHIV to ensure they have better access to a wide range of FP methods. There is need to encourage the use of long-acting reversible contraceptive (LARC) to reduce the risk of unintended pregnancy and prevention of vertical transmission of HIV. However, such policies should be based on respect for women's right to informed reproductive choice in the context of HIV/AIDS. Trial registration: NCT01694862

The Integra Initiative was a multi-country research study measuring the feasibility, effects and costs of integrated HIV and sexual and reproductive health services in Kenya and Swaziland. The integrated HIV and FP service model developed explicit linkages with FP services and relevant HIV/AIDS services, and enabling linkage with antiretroviral therapy (ART) services for eligible clients, either on-site or through referral to other health facilities. Before recruitment of participants, providers in study intervention facilities were trained in provision of integrated services using a Balanced Counselling Strategy Plus algorithm (BCS+) and a standardised mentorship strategy described elsewhere [33]. Study implementation begun after intervention-facility providers were certified as attaining a pre-determined minimum level of clinical skills. To be eligible for inclusion in the FP-HIV study, the women had to be aged 15 years and over, be revisit FP clients, be living in the catchment area of the health facility, and willing to give their informed consent to be interviewed. The study methodology used to evaluate the intervention is described in detail elsewhere [34]. The data were collected through the INTEGRA Initiative – a multi-country research study measuring the benefits and costs of integrated HIV and sexual and reproductive health services (www.integrainitiative.org). The study sample was selected randomly from women seeking family planning services at 12 public health facilities in Kenya. Participants were recruited between November 2009 and May 2010 as a cohort of women using FP that were followed for 24 months during which measures were made three times to determine trends in several reproductive health indicators, including fertility desires, pregnancy status (both planned and unintended), consistency in use of FP, and HIV status. A total of 1959 women were recruited at baseline, of which 1636 (83.5 %) were reported being HIV-negative and 251 (12.8 %) reported being HIV-positive; 72 women declined to report their HIV status. At endline, 1224 women remained in the cohort, of which 1068 (87.3 %) were HIV-negative and 156 (12.7 %) were HIV-positive. For this analysis, we used baseline and endline data only, and included only women willing to report their HIV status. The desired sample size of 1959 was calculated to test the larger study hypothesis that exposure to the FP model of intervention would lead to an increase in condom use in addition to another contraceptive method by at least 5 percent among sexually active women over two years and to allow for 30 % loss-to-follow up. The women were recruited from 12 public health facilities which were purposively selected based on provision of a minimum range of services (FP, voluntary counseling and testing (VCT), STI treatment, and PMTCT) and a minimum number of FP clients (100 or more per month). The health facilities were located in peri-urban and rural areas of five counties in Kenya; the facilities comprised four hospitals and eight health centres. All women seeking FP services from the health facilities on the days when the research team was present were approached for recruitment until the desired sample size was reached. For inclusion, the women had to be aged 15 years and over, live in the catchment area of the health facility, and give their informed consent to be interviewed. All adolescents 15 – 17 years were only interviewed following parental consent. A closed-ended questionnaire was used to collect data on women’s fertility intentions, pregnancy, use of FP, other SRH and STI/HIV-related behaviors and health-seeking behaviors. Women were also asked whether they ever had an HIV test, whether they knew their status, and if so, whether they were willing to voluntarily disclose their status. There was no pressure for them to disclose their HIV status and unwillingness to do so was not a criterion for exclusion from participating in the INTEGRA study. Trained research assistants conducted the interviews using hand-held personal digital assistants (PDAs) loaded with the questionnaire tool translated into Swahili. Every respondent was given a full description of the study and gave their informed consent in writing prior to interview. Descriptive, bivariate and multivariate analyses were carried out using STATA ® version 10. The descriptive and bivariate analyses were used to describe the characteristics of the sample and explore the associations between FP use in the last 12 months, fertility desires and the woman’s HIV status. Chi-square (X2) and Fisher’s Exact tests were used for bivariate analyses. Multivariate logistic regression analysis was conducted to examine these relationships controlling for potential confounding factors (including marital status, education, and household socioeconomic status (SES) identified in previous research [21, 30, 35–37]. The analysis models included an interaction term between HIV status and timing of data collection to assess changes in FP use and fertility desires over time. Table 1 summarizes the operational definitions for the study variables. Definition of variables in the analysis aHousehold SES was computed using the principal component analysis technique and the items used for computation included ownership of different household items such as television, radio, bicycle and use of different types of sources of fuel for cooking The study was approved by the Kenya Medical Research Institute (KEMRI) Ethical Review Board (IRB approval numbers 113 and 114), the Population Council’s Institutional Review Board (IRB approval numbers 443 and 444), and the Ethics Review Committee of the London School of Hygiene & Tropical Medicine (LSHTM) (IRB approval number 5426). The Integra Initiative is registered on the Clinical Trials registration site: ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01694862","term_id":"NCT01694862"}}NCT01694862. All research staff were trained and certified in research ethics. Written informed consent was obtained from all participants.

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