The unmet need for contraception services for women receiving ART
Polly Clayden, HIV i-Base
Two oral presentations clearly highlighted the importance of contraception services for HIV positive women receiving ART and PMTCT services.
Valeriane Leroy presented findings from a study of the ANRS 1201-1202 Ditrame Plus Cohort in Abidjan, Côte d’Ivoire, looking at the incidence of a new pregnancy among HIV-positive women followed postpartum over 24 months after a PMTCT intervention, who chose either replacement or breast feeding. The study hypothesis was that non-breastfeeding women are exposed to a greater risk of unwanted pregnancy.
The analysis included all women in the Abidjan cohort between March 2001 and July 2003, age <49 years, who received a short course ARV prophylaxis regimen (AZT + single-dose NVP+/-3TC), delivered a live infant and initiated one of the two infant feeding options offered (replacement feeding or exclusive breastfeeding for 4 months).
Contraceptive methods were promoted and provided free of charge according to the infant feeding option: replacement feeders used oral or injectable contraception; breast feeders followed the lactational amenorrhea method for 4 months, then injectable or oral contraception. Condoms were provided to both feeding groups.
The study evaluated the occurrence of first new pregnancy within the 24 months follow-up period. The start of pregnancy was estimated using the reported date of last menstrual period and the gestational age as assessed by ultrasound.
724 women were assessed, 332 (46%) replacement feeders, and 392 (54%) breast feeders. Use of a contraceptive method was similarly high in both groups: formula feeders, 78.1% vs. 77.5% breast-feeders (p=0.87).
The investigators reported 79 new pregnancies over 24 months. At 12 months, the incidence of a new pregnancy was similar between the two groups: 4.4% (95% CI: 2.7-7.2%) in breast-feeders and 4.1% (CI: 2.4-7.0%) in formula-feeders. They found correlates of incidence of a new pregnancy within 12 months were an advanced WHO clinical stage 3-4 vs 1-2 (adjusted relative risk: 0.2; 95% CI: 0.1-0.8, p=0.02) and the death of the last-born child (adjusted RR: 6.6; 95% CI: 2.6-16.6, p<0.0001)
At 24 months the incidence of a new pregnancy was significantly lower in formula feeders than in breast feeders, 10.0% vs. 16.5% (adjusted RR: 0.5; 95% CI: 0.3-0.9, p=0.02). Factors associated with pregnancy at this time point were: the follow-up clinic, the number of live-born children and the death of the last-born child (adjusted RR: 3.5; 95% CI: 1.4-8.7, p=0.008).
The investigators concluded: “Replacement feeding is not responsible for a greater incidence of pregnancy in this urban West African population. Our results highlight the public health importance to deliver appropriate family planning services for HIV-infected women”.
Jaco Hornsy then showed findings from a cohort of 733 HIV-positive women enrolled in the Home Based AIDS Care (HBAC) study in Uganda and receiving HAART.
This was a prospective cohort study of women age 18-49 who initiated HAART from March 2003 – June 2006, in which trends and predictors of pregnancy, desire for children, and use of family planning were analysed.
Women were counselled on the effect of HAART on restoring fertility and sexual activity, HIV prevention and family planning. They received free condoms on request.
The investigators conducted detailed social and behavioral questionnaires in the women’s homes. These were quarterly the first year after initiating HAART, and every 6 to 12 months thereafter.
There was no provision or referral for termination of pregnancy in this study; abortion is illegal in Uganda. However, women who aborted were asked about their experiences and treated for any complications.
The analysis included 708 women with a median follow-up of 2.05 years (IQR 2.0 to 2.1). After initiation of HAART, 120 (16.9%) women had 140 pregnancies (20 repeat pregnancies). The median time to conception was 12.4 months (IQR 7.9-18.0). There were 144 pregnancy outcomes (4 sets of twins); 106 live births (74%), 4 (3%) miscarriages, 8 (5%) still births and 26(18%) induced abortions.
The investigators reported an increased incidence in pregnancy from 3.46/100 person-years in the first quarter of HAART to 11.71/100 person-years in the fourth quarter (p=0.0001). They noted that this paralleled an increase in the proportion of women reporting sexual activity in the past 3 months from 24.4% to 32.5% over 24 months of follow-up, p=0.001.
Predictors of pregnancy were: age (per 10 year decrease) (adjusted HR 2.7, 95% CI 1.9-3.8, p<0.001), having a body mass index >18.5 (adjusted HR 1.1, 95% CI 1.0 to 1.1, p=0.02), and inconsistent condom use (adjusted HR 1.8, 95% CI 1.0 – 3.2).
Despite 93% to 97% of all women in this study reporting that their pregnancies were unwanted or unplanned, only 14% and 13% of women used permanent or semi-permanent family planning methods and 3.5% and 4.3% used dual contraception at 18 and 24 months respectively.
The investigators recommended:
- Family planning services should be an integral part of HAART interventions in Africa.
- Counselling is critically needed to explain the restorative effect of HAART on fertility and sexual activity.
- Younger women and their partners should be particularly targeted.
- Dual contraceptive services should be available to all for free.
The first part of the conclusion from the Abijan study was curious; the effectiveness of the lactational amenorrhea method of contraception has been well documented and is reported to be 98% effective “with perfect use”.
Surely any differences in pregnancy incidence between the two feeding groups would be masked by the high rate of uptake of contraception by all the women in this study, which at 78% is to be applauded and is considerably higher than the background rate in Cote d’Ivoire (<10%) and most African countries.
As Karen Beckerman remarked following the presentation, “free contraception and counselling works, it contributes to pregnancy spacing and, if offered, women will take up this life saving intervention”.
With regards to the finding that women with WHO stage 3-4 vs 1-2 were more likely to become pregnant within 12 months, it would be useful to know if these women were receiving HAART (baseline variables in this study included maternal eligibility for HAART but these data were not presented).
In the second study, the HBAC investigators describe an “unmet need” for family planning services as part of ART programmes. The rate of unwanted pregnancy (93% – 97%) in this cohort was scary – even within the Ugandan setting with a fertility rate of 6.7 children.
This presentation ended with quotes from HBAC women, which made uncomfortable listening, and included: “I wanted to abort so badly. I tried all the methods I was told locally but I failed. And there was no way I could ask the doctors to do an abortion. That is why I carry the pregnancy today…”
Policy makers and healthcare providers have responsibilities to include contraception services alongside ART and PMTCT programes, and the need becomes even greater in settings where termination of pregnancy is illegal.
Although not really discussed in either study, it deserves mentioning that, in addition to considerable advantages to women’s health, even a minimal reduction in unplanned pregnancies can have the equivalent impact to PMTCT interventions in reducing infant infection. One previous study suggested that in Kenya and Zambia, lowering the pregnancy rate by 5.6% and 6.6%, respectively would have the equivalent impact to providing single dose nevirapine. 
These two studies highlight both the need for and the potential uptake of such services.
1. Viho I, Becquet R, D Ekouevi D et al. Alternatives to prolonged breastfeeding and incidence of pregnancies among HIV-infected women: The ANRS 1201-1202 Ditrame Plus Cohort in Abidjan, Côte d’Ivoire, 2001 to 2005. 15th CROI. February 2008. Boston, US. Oral abstract 73
2. Homsy J, Bunnell R, Moore D et al. Incidence and determinants of pregnancy among women receiving ART in Rural Uganda. 15th CROI. February 2008. Boston, US. Oral abstract 74.
3. Clayden P. Time to Move On : More Questions about Single-dose Nevirapine. GMHC Treatment Issues November/December 2004.