High rate of unintended pregnancy among HIV positive African women on ART

Polly Clayden, HIV i-Base

Unintended pregnancy is widespread among HIV positive African women and about 90% of these pregnancies are attributed to non-use of effective family planning methods. Long acting reversible contraceptives are acceptable – although under used. These findings from the US-PEPFAR PROMOTE cohort study were presented at AIDS 2018.

More than 90% of global reproductive health need is in sub-Saharan Africa: women of reproductive potential make up more than 60% of people with HIV and several countries have over 60% unmet need for modern family planning methods.

Over 85% of unintended pregnancies are linked to non-use of effective family planning methods, defined as: injectable, oral, interuterine device (IUD), levonorgestrel-releasing implant or tubal ligation.

The most common reasons for not using effective family planning include infrequent sex, safety/side effects, postpartum/breastfeeding, partner opposition and access. These deficits could undermine global goals of improving women’s health.  

PROMOTE is an extension to the completed PROMISE trial. HIV positive women, receiving ART, and their children are recruited from the eight highest enrolling sites in Malawi, South Africa, Uganda, and Zimbabwe. Follow up is until 2021 – the findings presented were from baseline data among women enrolled between December 2016 to June 2017. The study used standardised questionnaires to collect demographic and reproductive health data.

There was a very high frequency of unintended pregnancies in this cohort. Among 1,985 women included in the analysis, 49.9% overall reported that their last pregnancy was not intended. This proportion ranged from 28.7% in Kampala, Uganda to 81.9% in Durban, South Africa (p<0.001).

Injectables were the commonest method of contraception (40.6%) – especially at the South African sites (56.1%) – followed by condoms (19.3%) and implants (15.7%). Zimbabwe was different from the other countries with oral contraceptives being the most common (44.1%), followed by injectables (21.2%).

Overall 79.9% of sexually active women reported using effective family planning methods. But only 18.8% reported using long acting reversible contraceptive methods (LARC: implants or IUD).

In multivariate analysis, women with no formal employment (p = 0.008), those receiving ART (p=0.001), and those with a viral load >1000 copies/mL (p=0.003) were less likely to report LARC use. Age, marital status, desiring more children, clinic travel time, and household electricity were not associated with contraceptive choice.

Adjusted RR estimates for baseline correlates showed women who desired another child, aRR.0.92 (95% CI 0.87 to 0.99), p=0.017; those who had no sex in the last three months, aRR 0.81 (95% CI 0.76 to 0.87), p<0.001; and those who had not completed primary education, aRR 0.92 (95% CI 0.85 to 0.99), p=0.03, were less likely to use effective family planning. But women with viral load <1000 copies/mL were more likely to use this, aRR 1.10 (95% CI 1.02 to 1.19), p=0.013.

Unintended pregnancy, marital status, no formal income, clinic travel time and household electricity were not associated with use of effective family planning.

Estimates for LARC use showed women with no formal income, aRR 0.66 (95% CI 0.48 to 0.91), p=0.011, were less likely to use it. But women with electricity in the household, aRR 1.33 (95% CI 1.01 to 1.76), p=0.04, and those with viral load <1000 copies/mL, aRR 1.64 (95% CI 1.20 to 2.23), p=0.002, were more likely to do so.

Unintended pregnancy, desire for another child, no sex in the last three months, marital status, completion of primary education and clinic travel time, were not associated with LARC use.

Future planned cohort analyses from PROMOTE include incidence and correlates of unintended pregnancy through 18 months follow up and an evaluation of interactions between ART (efavirenz in particular) and hormonal contraception and risk of unintended pregnancies.


These data are sobering, particularly with the recent spotlight on the potential elevated risk of neural tube defects with preconception dolutegravir exposure and guidance recommending women use reliable and effective contraception with dolutegravir-based ART. 


Aizire J et al. High frequency of unintended pregnancy and predictors of contraceptive choice among HIV-infected African women on life-long antiretroviral therapy (ART). The US-PEPFAR PROMOTE Cohort Study.AIDS 2018. Amsterdam. 23–27 July 2018. Oral abstractTHAB0301. (abstract) (webcast)

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