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Background: In sub-Sahara Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Maternal to child transmission is responsible for 90% of childhood HIV infection. Preventing unwanted pregnancy among HIV positive women is imperative to reduce maternal and infant morbidity and mortality. Methods: A cross-sectional survey was conducted among 964 HIV positive women in selected 12 health centers of Tigray region. In this paper, analysis was restricted only for 847 women who were sexually active and non-pregnant. In each health center the number of study participants was allocated proportionally to the load of HIV positive women in chronic care clinics. The data were entered into EpiData version 3.1, and cleaned and analyzed using Stata version 11.1. Descriptive summary of data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05. Findings: Three hundred ninety four (46.5%) of all HIV positive women had intension to have more children. Three hundred seventy five (44.3%) were using contraceptive methods at time of survey. Injectable (70.7%) and male condom (47.6%) were most commonly used type of contraceptives. In the multivariable analysis, women who were urban dwellers (AOR = 2.55; 95% CI: 1.27, 5.02), completed primary education (AOR = 2.27; 95% CI: 1.12, 2.86) and those openly discussed about contraceptive methods with their husbands or sexual partners (AOR = 6.3; 95% CI: 3.42, 11.76) were more likely to use contraceptive. Women who have one or more living children were also more likely to use contraceptive compared with women with no child. Conclusion: Less than half of women used contraceptive methods. The use of condoms could impact unintended pregnancies and reduced risks of vertical and sexual transmission. Efforts to increase contraceptive utilization focusing on the barrier methods should be strengthen in HIV/AIDS chronic care units.©2014 Melaku, Zeleke.
Tigray region has an estimated total population of 4,664,071, of which 2,367,032 are females. More than 80% of the population is estimated to be rural inhabitants [25]. According the regional health bureau report of 2012, Tigray had 14 hospitals, 205 health centers and 552 health posts [26]. Antenatal care surveillance data in 2009 reported that the HIV prevalence in Tigray was 2.2% (5.0% urban and 1.3% rural) [27]. The 2011 EDHS estimated that overall HIV adult prevalence (15–49 years) to be 1.8% (1.9% among women and 1.0% among men) [3]. In 2012, the Federal HIV/AIDS Prevention and Control Office (HAPCO) estimated that there were about 56,900 HIV positive individuals in the region [28]. HIV prevalence in Tigray varies widely across zones from 0.4% (Central zone) to 2.2% (Western) [29]. In the region there were 60 health centers which were supported by Ethiopian Network of HIV/AIDS Treatment, Care and Support (ENHAT-CS). All health centers provide services including HIV prevention, testing, treatment and care and all family planning methods free-of-charge. Family planning services include barrier, oral, and injectable contraceptive methods as well as family planning counseling from a trained family planning nurse. This study was conducted at chronic follow up care (both pre-ART and ART) clinics in 12 ENHAT-CS supported health centers in Tigray region ( Figure 1 ) from May to June 2013. This analysis is based on a cross-sectional survey data of HIV positive women seeking services at ENHAT-CS supported health centers in the region. Medical chart was reviewed to confirm HIV status, ART use history and other medical characteristics of HIV positive women. To be eligible to participate in the overall study, women were required to be 15–49 years of age, attending a chronic follow up care, competent to give informed consent, and willing to allow medical record review for the purposes of confirming HIV sero-status and other medical histories. We considered a woman to be ART user if she was taking ART at the time of interview. We considered woman to be pre-ART (not using ART) if she had never taken ART before. Twenty percent of ENHAT-CS supported health centers were selected with simple random sampling technique using lottery method. The numbers of health centers in each administrative zone (6 zones of the region) were determined proportionally considering the total number of ENHAT-CS supported health centers in each zone. The numbers of study participants in each health center were determined using proportion to population size (HIV positive women registered in the health centers). In this case, the number of women who were HIV positive and were on chronic follow up care was taken in to account to determine the number of samples in each health center ( Figure 2 ). To select each woman in each health center pre-arrival systematic random sampling technique was used. The first woman to contact was selected by lottery method after determining the interval between two study units. The analysis was restricted to 847 women aged 15–49 years who were sexually active, and were not pregnant. This was done to enhance the comparability of findings with other studies investigating reproductive and sexual health among HIV positive women. After confirming eligibility and seeking written informed consent, participants were asked to complete a 25–35 minute interviewer-administered questionnaire in local language called “Tigrenga”. Approximately 6 women were interviewed daily by a data collector at each heath center from May to June 2013. Data collectors were trained women from the local community who had previous research experience and were holders of Bachelor degree. In each health center, nurses with HIV/AIDS related training reviewed medical records of participants. The questionnaire assessed socio-demographic characteristics, fertility intentions, fertility history, contraceptive practice, and sexual history. The survey instrument was developed by organizing variables from previously conducted researches [10], [30], [31]. Medical records of HIV positive women were reviewed to confirm HIV status and other medical history, and to obtain all necessary clinical data including CD4 cell counts and WHO stage of disease using data extraction tool (checklist). The primary outcome was self-reported contraceptive use at the time of the survey. Contraceptive utilization refers to use of any form of either modern or traditional contraceptive methods to avoid or delay pregnancy. Current use of contraceptive method referred to respondents who responded positively for use of contraceptive methods at time of the survey to delay or avoid pregnancy. Contraceptive method queries 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 addition, traditional methods (coitus interrupts and calendar method) were incorporated as part of the responses in the questionnaire. In assessing the contraceptive method profile, dual protection was defined as use of both a barrier contraceptive method (male condom) and use of a hormonal or permanent contraceptive method [32]. The explanatory variables were current receipt of ART, age, education, employment, current sexual partnership, number of living children, fertility intentions, and HIV clinical variables. “Sexual intercourse” were defined to refer specifically to “vaginal-penile penetrative sex between a man and a woman”. We define HIV-positive women on chronic care as women who had at least one visit to the selected pre-ART or ART units for care who may be receiving ART or not. Fertility intention was defined as HIV positive women on chronic follow up care would like to have child/children in the future. First code was given to the completed questionnaires and then data were entered into Epidata Version 3.1 database and transferred to STATA version 11.1 (Stata Corporation, College Station, TX, USA) statistical packages for analysis. Pretest of questionnaire was conducted out of study health centers. Supervisors had checked filled questionnaires and checklists for consistency, completeness and accuracy on daily base for all clients. Supportive supervision by investigators was also rendered for each data collectors and supervisors. Cleaning of data was done to check the consistency and completeness of the data set. Frequencies, proportions and summary statistics were used to describe the study population in relation to relevant variables. Both bivariable and multivariable logistic regression were used to identify significant predictors. The degree of association between independent and dependent variables was assessed using odds ratio with 95% confidence interval. Differences in contraceptive use between groups were reported using Pearson’s chi-square or score test for trends of odds for categorical variables. After testing for co-linearity [33] and interaction [34], all covariates with statistically significant associations in the bivariable analysis were included in multivariable logistic regression models to obtain adjusted estimates of the association between covariates and contraceptive use. All statistical tests were two-sided and considered statistical significant at P value of 0.05. ArcGIS version 10.0 was used to map study area and locate health centers. Information letters and written consent forms were available in English and “Tigrenga”. Ethical clearance was obtained from the Institutional Review Board of Mekelle University, College of Health Sciences. The members of Institutional Review Board were nominated by the management body of Mekelle University and consist of experts in the field of subject matter, Medical ethics and statistics. Permission letters were gained from Tigray regional health bureau, respective district health offices and health centers. After explaining the objective and contents of the study, written consent has been obtained from each respondent or next-of-kin when the respondent were under 18 years of age. Some of the study participants were unable to read and write. In this case, trained interviewers fully explained the purpose, process, benefits, and risks to all study participants before consent was obtained and inked index finger print was used as a signature. This consent procedure was reviewed and approved by Mekelle University College of Health Sciences Institutional Review Board. The information collected was purely used for research works and name of respondents has remained anonymous. All the interviews with study participants were made with strict privacy and assuring confidentiality. Each interview was conducted in a separate room which was prepared for this purpose. The participants were told that they have the right to either refuse to participate in the study or withdraw after responding for some of the questions. Respondents’ name and identity were not recorded, included and linked in the questionnaire. Data were kept confidential by locking in boxes with key and by password in the computer to avoid access of the data by third party. Only card numbers of the clients were used to review secondary data and link with the primary data of the clients. Similarly, the names of the clients have not been reviewed and were not recorded. The collected data also were not linked with the individual identity at all level of data processing and analysis.
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