Abstract
ObjectivesFertility intentions and contraceptive use are often not assessed in the context of clinical HIV care, representing a possible programming gap if women’s family planning needs change over time. We aimed to identify longitudinal patterns of unmet need for contraception over a 12-month period among women living with HIV taking antiretroviral therapy (ART).Study design850 non-pregnant, HIV-positive women aged 18–35 on or initiating ART in Johannesburg, South Africa, were enrolled into a prospective cohort study in 2009–2010. Fertility intentions and contraceptive use were assessed during routine HIV care visits via an interviewer-administered questionnaire, and women were referred for on-site contraceptive counseling. We used group-based trajectory modeling to identify patterns of unmet need for contraception over 12 months, first in the entire population and then in a subset of recent ART initiators.ResultsIn the full population we identified four patterns of unmet need for contraception over one year. Half of the enrolled women were predicted to have a consistently high probability of unmet need, 22.9% a consistently low probability, 16.7% a decreasing probability, and 10.4% an increasing probability over time. Contraceptive method discontinuation and rapidly changing fertility intentions were the primary drivers of changing (increasing or decreasing) unmet need over follow-up. Results were similar in recent ART initiators.ConclusionsHalf of women were estimated to have a high probability of unmet need that persisted over time, and more than a quarter were estimated to experience patterns of changing unmet need over 12 months. Family planning needs should be assessed more regularly in HIV-positive women to prevent unintended pregnancies and support safer conception among women trying to conceive.
Highlights
Prevention of unintended pregnancy through reliable contraceptive methods improves women’s health and reduces both maternal and infant mortality among women living with HIV [1,2]
Contraceptive method discontinuation and rapidly changing fertility intentions were the primary drivers of changing unmet need over follow-up
Half of women were estimated to have a high probability of unmet need that persisted over time, and more than a quarter were estimated to experience patterns of changing unmet need over 12 months
Summary
Prevention of unintended pregnancy through reliable contraceptive methods improves women’s health and reduces both maternal and infant mortality among women living with HIV [1,2]. Prevention of unintended pregnancy is an effective strategy to reduce mother-tochild HIV transmission [3], and is the second prong of WHO’s four-pronged framework for prevention of mother-to-child transmission (PMTCT) [4] For these reasons and to ensure women’s reproductive rights, South African national contraception and family planning guidelines promote the availability of accessible and comprehensive contraceptive services to meet the family planning needs of women living with HIV [5]. Planning needs of women living with HIV are likely to change over time, yet these changes may go undetected due to facility- and provider-level factors that preclude providers from routinely assessing fertility preferences and contraceptive use in the context of HIV clinical care. To the extent that fertility intentions and contraceptive use are dynamic, this presents a missed opportunity for intervention
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