Falling short of universal access to reproductive health: unintended pregnancy and contraceptive use among Mexican women with HIV

Contraception values and preferences of people living with HIV: a systematic review

OBJECTIVE

Attention to the contraception values and preferences of those living with HIV is essential to meeting their reproductive rights and health needs. We systematically reviewed the literature on contraception values and preferences among women and men living with HIV.

STUDY DESIGN

We searched ten electronic databases for articles from 1 January 2005 through 27 July 2020 for qualitative and quantitative studies of the values and preferences for contraceptive methods among individuals living with HIV.

RESULTS

Twenty-one studies, primarily from sub-Saharan Africa, met the inclusion criteria. Contraception values and preferences were shaped by several factors: availability, accessibility, and convenience; perceived effectiveness; safety and tolerability; dual protection; fertility desires; partnership dynamics; and provider recommendations. Male condoms were a frequently preferred contraceptive method, offering an affordable and accessible form of dual protection against HIV and unwanted pregnancy. Fears of infertility and side effects decreased interest in hormonal contraceptive methods. Financial burdens incurred by HIV management and a desire to reduce dual reproductive health and HIV care burdens influenced preferences. Healthcare providers contributed to contraceptive preferences of women living with HIV, informing perceptions of safety, tolerability, and effectiveness.

CONCLUSION

Contraception values and preferences among women living with HIV are complex and influenced by factors related and unrelated to their HIV status. Considering contraception values and preferences of people living with HIV will ensure that their autonomy and right to make decisions about the contraceptive methods best for them are upheld.

Access to sexual and reproductive health services for women living with HIV in Latin America and the Caribbean: systematic review of the literature

INTRODUCTION

Systematic reviews show that women living with HIV (WLHIV) have high unmet sexual and reproductive health (SRH) needs due to barriers to access sexual and reproductive health services (SRHS). In Latin America and the Caribbean (LAC), as of 2016, there were nearly one million WLHIV, but the existing evidence of their SRH needs comes from a few individual studies. This systematic review provides an overview of these women's needs to help define new and/or adapt existing public health strategies to the local context. This review synthesizes the evidence from the literature on the use of and access to SRHS related to family planning, antenatal care, abortion services and violence against WLHIV in LAC.

METHODS

Using a systematic review of mixed studies, a search was performed in MEDLINE, EMBASE, LILACS, INASP, POPLINE, SCOPUS, for studies conducted in LAC, from 2004 to 2017, as well as contact with authors and hand search as needed. Two independent reviewers evaluated the quality of the studies using the Mixed Methods Appraisal Tool; inclusion was conducted according to the PRISMA flow diagram. An exploratory narrative synthesis followed by quantitative synthesis data was undertaken. Group analysis or meta-analysis was not considered appropriate given the level of heterogeneity of the studies.

RESULTS

A total of 18 studies in 13 LAC countries for a population of 5672 WLHIV were included. Data from individual studies reported unmet family planning needs; higher, but inconsistent use of condom as the sole contraceptive method OR=1.46 [1.26 to 1.69]; lesser use of other non-permanent contraceptive methods OR=0.26 [0.22 to 0.31]; more unplanned pregnancies OR=1.30 [1.02 to 1.66]; more induced abortions OR=1.96 [1.60 to 2.39]; higher risk of immediate postpartum sterilization; and higher exposure to sexual and institutional violence by WLHIV when compared with women without HIV.

CONCLUSIONS

This review presents evidence from LAC about the SRH unmet needs of WLHIV that must be addressed by decreasing institutional and structural barriers, facilitating services and reducing stigma, and discrimination among healthcare providers to improve access to SRHS based on human rights, so women independently of their HIV status can make their own reproductive decisions, free of violence and coercion.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

From Pill to Condom, or Nothing at all: HIV Diagnosis and Discontinuation of Highly Effective Contraceptives Among Women in Northeast Brazil

This is a cross-sectional study examining highly effective contraceptive (HEC) use among HIV-positive women in Salvador, Brazil. We used multivariate logistic regression to look for predictors of alternative contraceptive choices among women who discontinued HEC after HIV diagnosis. Of 914 participants surveyed, 38.5% of participants used HEC before but not after diagnosis. Of these, 65.9% used condoms alone; 19.3% used no protection; and 14.8% reported abstinence. Use of condoms alone was associated with a history of other sexually transmitted infections (AOR 2.18, 95% CI 1.09-4.66, p = 0.029). Abstinence was associated with recent diagnosis (AOR 8.48, 95% CI 2.20-32.64, p = 0.002). Using no method was associated with age below 25 (AOR 5.13, 95% CI 1.46-18.00, p = 0.011); income below minimum wage (AOR 2.54, 95% CI 1.31-4.92, p = 0.006); HIV-positive partner status (AOR 2.69, 95% CI 1.03-7.02, p = 0.043); and unknown partner status (AOR 2.90, 95% CI 1.04-8.05, p = 0.042). Improved contraceptive counseling is needed after HIV diagnosis. Continuation of HEC should be encouraged for women wishing to prevent pregnancy, and may increase contraceptive coverage among HIV-positive women.

Reproductive decision-making in women living with human immunodeficiency virus: A systematic review

OBJECTIVES

Analyze and synthesize the research evidence to understand the reproductive decisions made by women living with HIV from the beginning of the epidemic to the present. Evaluate the barriers and the facilitators for reproductive decision-making. Identify areas of strength, improvement, and those requiring further research.

DESIGN AND DATA SOURCES

Systematic review following the PRISMA guideline. PubMed, CINAHL, PsycINFO, Cochrane Library, SocINDEX, Embase, and Scopus databases were searched from 1985 to 2016 using the following Keywords: HIV, AIDS, pregnancy, reproduction, and decision-making.

STUDY SELECTION

A total of 42 research papers were included in this review. Initially, 1563 papers were identified for the review by database (n=1544) and hand (n=19) searches. With three review levels, 1521 papers were excluded (title review, n=1272; abstract review, n=136; and full paper review, n=113). Studies published in English in peer-reviewed journals using both quantitative and qualitative methods and addressing reproductive decisions in women living with HIV were included. Thirdly, inclusion eligibility was assessed by title, abstract, and full text.

REVIEW METHODS

Random allocation conducted by the primary researcher assigned an equal number of papers to each researcher for review, including detailed instructions with an abstraction form. Discrepancies were resolved by two researchers. Research quality was assessed using the NCHBL Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, the Critical Appraisal Skills Programme for the qualitative studies and its version for systematic reviews RESULTS: The review included 42 papers, both quantitative (n=24) and qualitative methods (n=14). Most studies were completed by physicians (n=16) or nurses (n=15). More than two-thirds of the studies were performed in urban settings with predominantly African-American women (n=27). Eight factors were identified as influencing the reproductive decision-making process in women living with HIV: 'Socio-demographic, Health status and Pregnancy', 'Religion and spirituality', 'Beliefs and Attitudes about Antiretroviral Therapy', 'Healthcare providers', 'Significant others', 'Motherhood and fulfillment', 'Fear of perinatal infection and infection of partner(s)', 'Birth control and pregnancy management'.

CONCLUSIONS

Health care providers are not providing patient-centered care by applying scientific evidence to their practice when advising women with HIV in making reproductive decisions. Despite the strong evidence indicating pregnancy for women with HIV results in a safe birthing trajectory, one not likely to jeopardize the health of the either the mother or fetus, providers continue to recommend the women with HIV avoid pregnancy and neglect to invite partners to participate in the discussion.

Human rights and the sexual and reproductive health of women living with HIV--a literature review

Introduction

Even as the number of women living with HIV around the globe continues to grow, realization of their sexual and reproductive health and human rights remains compromised. The objective of this study was to review the current state of knowledge on the sexual and reproductive health and human rights of women living with HIV to assess evidence and gaps.

Methods

Relevant databases were searched for peer-reviewed and grey literature. Search terms included a combination of MeSH terms and keywords representing women, HIV/AIDS, ART, human rights, sexual and reproductive health. We included both qualitative and quantitative literature published in English, French, or Spanish between July 2011 and December 2014.

Results and discussion

The search yielded 2228 peer-reviewed articles, of which 40 met the inclusion criteria in the final review. The grey literature search yielded 2186 documents of which seven met the inclusion criteria in the final review. Of the articles and documents reviewed, not a single peer-reviewed article described the explicit implementation of rights in programming, and only two documents from the grey literature did so. With one possible exception, no articles or documents were found which addressed rights comprehensively, or addressed the majority of relevant rights (i.e. equality; non-discrimination; participation; privacy and confidentiality; informed decision making; availability, accessibility, acceptability and quality (3AQ) of services individually or in their totality; and accountability). Additional findings indicate that the language of rights is used most often to describe the apparent neglect or violation of human rights and what does exist only addresses a few rights in the context of a few areas within sexual and reproductive health.

Conclusions

Findings from this review suggest the need to better integrate rights into interventions, particularly with attention to provider training, service delivery, raising awareness and capacity building among the community of women living with HIV. Further research is urgently needed to support the sexual and reproductive health and rights of women living with HIV, to identify what works and to inform future programming and policies to improve care, treatment and support for women living with HIV.

Contraception Use among Iranian Women With HIV: A Qualitative Study

BACKGROUND

The application of family planning methods to people with HIV not only prevents unwanted pregnancy, but also leads to a reduction in the possibility of transmission of the virus from the patient to the sexual partner and the fetus. In order to prevent the spread of HIV and enhance reproductive rights, it is necessary to inform women with HIV of the contraception methods.

OBJECTIVE

The aim of this study was to explore experiences of HIV positive women about contraception use.

METHOD

This qualitative study was conducted on 18 women with HIV who were at reproductive age and had referred the Center for clients with Risky Behavior in Imam Khomeini Hospital. Data were analyzed using the conventional content analysis method in MAXQDA 10.

RESULTS

The following two themes were derived from descriptions of the use of contraception methods by women with HIV: 1) Contraception is the forgotten component of reproductive health services; 2) inconsistent condom use. Each theme also contained three sub-themes.

CONCLUSION

Results of investigations showed that Risky Behavior consultation Centers mostly stress the use of condom for husband/sexual partners without HIV. In addition, since health care practitioners play an important role in provision of reproductive health services, their lack of knowledge and cooperation considerably contribute to the spread of the disease and violation of patient rights.

Women living with HIV still lack highly effective contraception: results from the ANRS VESPA2 study, France, 2011

OBJECTIVES

Advances in antiretroviral treatment (ART) have led to improvements in reproductive health for women living with HIV. This paper aims to investigate the pattern of contraceptive use among women living with HIV in France.

STUDY DESIGN

Data were drawn from the ANRS VESPA2 study, which included a representative sample of HIV-positive people. Contraception methods were documented, including condoms, highly effective contraception methods (HEC) and traditional methods. We measured the frequency of not using any modern contraception (neither condoms nor HEC) and of HEC use and studied their correlates (i.e., geographic origin, age, parity, partnership status, education level, material deprivation, employment status, health insurance, visits to a gynecologist, being on ART, cardiovascular risk) among women at risk of an unintended pregnancy.

RESULTS

Of the 662 women of reproductive age, 327 were in need of contraception. Overall, 20.5% used HEC, 58.8% used condoms and 20.7% used traditional or no methods, with no difference according to geographic origin [sub-Saharan African (SSA) women vs. French and other migrant women]. Among SSA women, being <30years old [odds ratio (OR) 16.39, 95% confidence interval (95%CI) 2.77-97.01], having had at least one child (OR 3.75, 95%CI 1.75-8.04) and being employed (OR 2.36, 95%CI 0.99-5.61) were associated with HEC use; among French and other migrant women, HEC use was associated with being in a stable partnership (OR 4.5, 95%CI 1.2-17.2) and material deprivation (OR 3.3 95%CI 1.4-9.8). Gynecologist visits, health insurance status and cardiovascular risk were not associated with HEC use.

CONCLUSIONS

Condoms remained the predominant contraceptive method despite the absence of restrictions on hormonal contraception and intrauterine device use for HIV-positive women. The recent recommendations about dual method protection should be actively promoted, targeting HIV-positive women, HIV specialists and gynecologists to overcome the barriers to effective contraception.

IMPLICATIONS

The information provided in this study constitutes a major contribution to comprehensively inform the scientific community on contraception practices among women living with HIV in France in the early 2010s. Our results show that the therapeutic advances since the late 1990s and the removal of restrictions on hormonal contraception use have not led to the expected shift in contraception patterns. There is an urgent need to promote dual method protection, as condom use may decrease in the future in the context of the preventive effect of ART.