ACCESS TO AND USE OF ACCESS TO AND USE OF FAMILY PLANNING BY FAMILY PLANNING BY

WOMEN WITH HIVWOMEN WITH HIV

IAS, Cape TownIAS, Cape TownRevisiting Contraception Revisiting Contraception and HIV Bridging Sessionand HIV Bridging Session

2222ndnd July 2009 July 2009

J Smit, H Rees, M BeksinskaReproductive Health and HIV Research

Unit

CONTRACEPTIVE USE PATTERNSCONTRACEPTIVE USE PATTERNS

In sub-Saharan Africa: 14% women

(married/in union) use a modern, reversible,

highly effective method:

OC 4%; IC/implant 6%; IUD 0.5%;

Condom 2%; TL 2%

World Contraceptive Use 2007. Overall rates and country rates.

http://www.un.org/esa/population/publications/contraceptive2007/contraceptive_2007_table.pdf.

WHO Reproductive Choices & Family Planning for People Living with HIV: Counselling Tool

CONTRACEPTIVE METHOD MIXCONTRACEPTIVE METHOD MIX

OCOC%%

ICIC%%

IUDIUD%%

CondomCondom%%

TL%

Any Method%

South Africa(2003 SADHS)

11 29

1 5 14 60Net-En(9 )

DMPA (20 )

South Africa (15-24yrs) (2003 SADHS)

1042

0.5 16 0.5 68NET-EN (29)

DMPA (13)

Zimbabwe* 43 11 0.3 1.4 2 60

Kenya* 8 16 2.4 1.2 4 39

Malawi* 2 30 0.2 2 5 42

*United Nations, World Contraceptive Use 2007

CONTRACEPTIVE USE AMONG WOMEN (15-CONTRACEPTIVE USE AMONG WOMEN (15-24yrs), KNOWN HIV STATUS, IN 4 AFRICAN 24yrs), KNOWN HIV STATUS, IN 4 AFRICAN

COUNTRIESCOUNTRIES

Kenya Lesotho Malawi Zim

n 874 867 931 1877

% HIV+ 8 20 12 19

% Ever used

none 53 38 52 26

Trad 20 14 8 12

OC 17 15 6 58

IC 19 23 29 16

IUD 0.5 0.6 0.2 0.3Leclerc et al, 2008, Hormonal Contraception and HIV in four African countries. Contraception

ISSUES FOR HIV INFECTED WOMENISSUES FOR HIV INFECTED WOMEN

• High unmet need for FP (United Nations, World Contraceptive Use 2007)

• Method skew in many Sub-Saharan countries (IC: Malawi, OC: Zim) (Sullivan et al. 2006. Skewed contraceptive method mix: Why it happens, why it matters. J.Biosoc.Sci,)

• High IC use in countries with high HIV prevalence (United Nations, World Contraceptive Use 2007)

• High IC use amongst young women (Leclerc et al, 2008, Hormonal Contraception and HIV in four African countries. Contraception; 2003SADHS)

• Condom use low within marriage/stable relationships (Morrison et al, 2009. Highly effective contraception and acquisition of HIV

and other sexually transmitted infections. Best Practice & Research Clinical Obstetrics and Gynaecology.)

WHAT IS AVAILABLE FOR HIV WHAT IS AVAILABLE FOR HIV INFECTED WOMENINFECTED WOMEN

Similar to method mix for all women; often skewed

Focus on dual protectionNeed for highly effective

methods• HCs: OCs, ICs, Implants,

EC• Cu-IUDs• LNG-IUS• Barrier methods

(MC,FC)

Fourteen million Fourteen million women with limited women with limited options: HIV/AIDS and options: HIV/AIDS and highly effective highly effective reversible reversible contraception in sub-contraception in sub-Saharan AfricaSaharan AfricaStuart G. 2009. Stuart G. 2009. ContraceptionContraception

WHO Reproductive Choices & Family Planning for People Living with HIV: Counselling Tool

WHAT METHODS DO HIV WHAT METHODS DO HIV INFECTED WOMEN USE? (%)INFECTED WOMEN USE? (%)

ICIC OCOC CONDOMCONDOM FCFC TLTL

Lesotho, DHSAdair. 2007. Dem Health Res

14 11 6 N/A 2

Kenya (postpartum)Balkus et al, 2007. Sex Transm Dis

32 21 N/A N/A N/A

SA, Rural ECPostpartum(Peltzer et al, in 2008 AIDS Behav)

35 13 50 N/A N/A

SA, Soweto (50% on HAART)(Laher et al, 2009, AIDS Behav)

NET-EN (41)

DMPA (20) 3 26 5 2

LITTLE PUBLISHED ON METHODS USED BY HIV INFECTED WOMEN IN AFRICA. THE FOCUS IN THE LITERATURE IS ON FERTILITY INTENTIONS

FACTORS AFFECTING UPTAKE FACTORS AFFECTING UPTAKE AMONG HIV-INFECTED WOMENAMONG HIV-INFECTED WOMEN

Uptake and continuation issues similar to those for all women

• HIV infected women’s desire for children varies• Many women don’t know they are HIV infected• Choosing condoms for contraception allows avoidance of

status disclosure; easier to negotiate condoms for FP than disease

• Female controlled methods desired – partner more likely to use condoms

• Protection against STIs• Whether on ARVs -- DIs• Side effects (e.g. amenorrhoea)

WHAT GUIDANCE DO PROVIDERS WHAT GUIDANCE DO PROVIDERS GIVE WOMEN WITH HIV?GIVE WOMEN WITH HIV?

• Little documented, again focus is on reproductive rights

• Attitudes to HIV & fertility influenced negatively by bio-medical concerns

• Switch from OC to IC (DI)• Concerns about IC use with

ARVs (DI)• Concerns about IUD use in

HIV+ women

Providers’ preferences can influence contraceptive method mix

CONSIDERATIONS FOR METHOD CONSIDERATIONS FOR METHOD MIX FOR HIV INFECTED WOMENMIX FOR HIV INFECTED WOMEN

• Efficacy (DI?)• Side effects• Safety: HIV progression; CI• Acceptability, convenience, discontinuation• potential for inconsistent use• dual protection properties• partner sero-status• female initiated -- need for secrecy/partner approval • Cost

A range of methods is needed

Ramkissoon, Smit et al, SA Health Review 2006. Options for HIV Positive Women

GUIDELINES: CONTRACEPTION GUIDELINES: CONTRACEPTION FOR HIV INFECTED WOMENFOR HIV INFECTED WOMEN

• Continue to use hormonal contraceptives in HIV infected women

• Generally use hormonal contraceptives with ARVs• Consider drug interactions, especially with rifampicin• Continue to use IUDs in HIV infected women but not

for women at individual high risk for STIs• Promote dual method use/ dual protection/ EC• Consider female and male sterilisation, • Consider progestin implants which have better

contraceptive SE profile and are long acting

WHO MEC, 2004. http://www.who.int/reproductive-health/publications/mec/mec.pdf

WHAT IF HCs WERE FOUND TO WHAT IF HCs WERE FOUND TO INCREASE HIV PROGRESSION?INCREASE HIV PROGRESSION?

• Changes in method provision guidance -- what methods would be appropriate?

• Changes in contraceptive counseling• Messages about increased risk

What’s the trade off between offering effective contraception versus avoiding possible increased risk of acquisition or

disease progression among HIV infected women, and what’s the best method for HIV infected women?

ARE NEW METHODS NEEDEDARE NEW METHODS NEEDED ?Little attention paid to new methods

Highly effective reversible methods were not developed in the context of HIV—OCS, ICs, IUDS developed > 40 yrs ago

• New designs of FCs• Microbicides with contraceptive properties• Methods which offer dual

protection, are female controlled• Increase awareness/access to EC

CCONCLUSIONSONCLUSIONSAdequate provision of condoms + comprehensive selection

of highly effective contraceptive methods is a public health priority

Contraceptive guidelines needed for HIV infected people

Integrate family planning in HIV services (PMTCT, ARV) “provider initiated family planning”

Create appropriate messaging, dispel myths

More research:- patterns of use- role of providers in counseling about options- among young women (<25) using HCs

Consider reproductive health rights