A majority of women receiving care at an HIV clinic in Nashville did not use any form of contraception, and pregnancy rates were high, according to a study published in Open Forum Infectious Diseases.
These findings suggest that “continued efforts to ensure access to effective contraception options are needed in HIV clinics,” study authors Manasa Bhatta, of Vanderbilt University, and colleagues concluded.
Women make up nearly a quarter of people living with HIV in the United States and accounted for 19% of new HIV diagnoses in 2019. A majority of newly diagnosed women are of reproductive age, but previous research has shown that contraception use among women with HIV is low, and more than half of pregnancies are unintended. Unplanned pregnancy is associated with poor HIV and mental health outcomes, the researchers noted as background. What’s more, women who don’t plan their pregnancies may miss out on appropriate prenatal care to prevent mother-to-child HIV transmission.
Bhatta’s team analyzed contraception use among women who received care at the Vanderbilt Comprehensive Care Center in Nashville between 1998 and 2018. The clinic provides primary and specialty care for people living with HIV, including screening for sexually transmitted infections and cervical cancer, family planning services and prenatal care. For most women, this serves as their primary care clinic.
This retrospective cohort study included 737 cisgender women ages 18 to 45 with at least two clinic visits during the first year. Women who previously had a tubal ligation sterilization or a hysterectomy were excluded, as were those diagnosed with breast, cervical or ovarian cancer before clinic entry. A majority (58%) were Black, 36% were white and the median age was 31 years. Only 39% were already using antiretroviral therapy when they started care at the clinic, and the median CD4 count was approximately 400. The average follow-up time was about four years.
Using medical records, the researchers looked at all forms of effective contraception, including hormonal birth control pills, patches, injections or implants; vaginal rings; intrauterine devices (IUDs); and tubal ligation. Injectable contraception and referrals for tubal ligation were available from the beginning of the study period, while IUDs and hormonal implants were available since 2008. Information about the use of condoms or rhythm methods, frequency of sex or desire for pregnancy was not available.
When they started care at the clinic, only 47 women (6%) were using contraception—3% oral, 3% injectable and 1% IUDs—and 164 (22%) women were pregnant. Among those initially not using contraception, 142 women (27%) started to do so during follow-up, opting for injections (42% of those who started), pills (31%), tubal ligation (20%) or IUDs (6%). During the study, 84 women (16%) became pregnant. There were no cases of mother-to-child HIV transmission.
Over the course of the study, the median annual proportion of time spent on any type of contraception among women who were not pregnant was 32%. Contraception use remained stable throughout the study period.
Younger women were both more likely to use contraception and more likely to become pregnant. Women with mental health conditions were about half as likely to use contraception and nearly twice as likely to get pregnant. Pregnant women were more likely to start contraception after giving birth than those who were never pregnant during the study. Race/ethnicity, substance use and HIV-related measures (use of antiretroviral therapy, viral load and CD4 count) were not significantly associated with either contraception use or pregnancy after adjusting for other factors.
The study authors suggested that several factors may contribute to low contraception use among women with HIV, including hesitancy to discuss family planning—possibly reflecting the fact that HIV-positive women were historically advised to use permanent contraception methods.
Concerns about using antiretrovirals and hormonal contraception together may also contribute to hesitancy among patients and providers, they added. However, the Department of Health and Human Services HIV treatment guidelines state that all HIV-positive women who are sexually active and don’t desire pregnancy should be offered contraception and can use all available methods after consideration of potential drug interactions.
“Women with HIV in our study had persistently low rates of contraception use over time with persistently low uptake of [long-acting reversible contraception] and higher rates of tubal ligation,” the researchers wrote. “These findings highlight a need for improving reproductive health services in care for women with HIV.”
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