Hormonal contraceptive use and discontinuation among HIV-infected women in Uganda and Zimbabwe

A systematic review of contraceptive continuation among women living with HIV

BACKGROUND

Women living with HIV (WLHIV) experience high rates of unmet contraceptive need and unintended pregnancy. Contraceptive method-specific continuation rates and associated factors are critical for guiding providers tasked with both reproductive health (RH) and HIV care. We conducted this systematic review to determine whether contraceptive continuation rates differ between WLHIV and uninfected women and, for WLHIV, whether differences are impacted by method type, antiretroviral therapy use or other factors.

METHODS

We searched Ovid MEDLINE, POPLINE and PubMed.gov for studies published between January 1, 2000, and August 31, 2016. Inclusion criteria comprised prospective data of WLHIV, nonbarrier method continuation as an outcome measure, and recorded method switching and/or discontinuation.

RESULTS

Of 939 citations screened, 22 articles from 18 studies were eligible. For studies with comparator groups, data quality was moderate overall based on Grading of Recommendations, Assessment, Development and Evaluations and Newcastle-Ottawa Quality Assessment scales. Of four studies comparing women by HIV serostatus, two showed higher rates of contraceptive continuation among WLHIV versus uninfected women, while two others detected lower continuation rates for the same comparison. Generally, baseline method continuation exceeded 60% for studies with >12months of follow-up. Studies providing contraception had higher continuation rates than studies not providing contraception, while women allocated to contraceptive methods in trials had similar continuation rates to those choosing contraceptive methods. Across all studies, continuation rates differed by method and context, with the copper intrauterine device showing greatest variability between sites (51%-91% continuation rates at ≥12months). Implant continuation rates were ≥86%, though use was low relative to other methods and limited to few studes.

CONCLUSIONS

Contraceptive continuation among WLHIV differs by method and context. More longitudinal studies with contraceptive continuation as a measured outcome following ≥12months are needed to strengthen integration of RH and HIV care.

Factors associated with discussion of sexual activity and contraception in women with HIV

OBJECTIVES

Contraceptive use is important for reproductive-aged women living with HIV to plan and optimise safety of pregnancies. Clinicians play a vital role in counselling patients about contraception and safe sexual activity. This study aimed to determine the frequency and predictors of discussions regarding sexual activity and contraceptive use.

METHODS

Retrospective clinical study of all reproductive-aged women (n=128) treated for HIV between 2010 and 2012 at two metropolitan hospitals. Evidence of discussion between treating doctors and patients regarding sexual activity and contraception and variables including patient age, gender of doctor, time since HIV diagnosis, previous pregnancy, country of birth and antiretroviral regimen were obtained from medical records.

RESULTS

Sexual activity status was documented for 54% of the women and discussion regarding contraception was recorded for less than one-third of the study participants. Contraceptive use was not recorded in 63% of the medical records. In the study cohort 27% of the women used contraception, 10% did not use contraception, and when a discussion regarding sexual activity was documented, contraception was 3.7 times more likely to also be discussed (p=0.04). Excluding women who were pregnant, women who were documented as using contraception were 1.8 times as likely to have had a discussion about contraception documented (p=0.05). After adjustment for other factors, previous pregnancy, gender of doctor and age of patient were not associated with discussions regarding sexual activity or contraception.

CONCLUSIONS

Discussions regarding sexual activity and contraception between HIV-infected women of reproductive age and their clinicians were inconsistent and suboptimal. Mechanisms to facilitate regular discussion about sexual activity and contraception between clinicians and women with HIV warrant further investigation.

Injectable and oral contraception and the incidence and progression of cervical disease in HIV-infected women in South Africa

BACKGROUND

Few data exist regarding the effect of hormonal contraception (HC) on incidence and progression of cervical disease (e.g., cervical dysplasia, squamous intraepithelial lesions, cervical intraepithelial neoplasia) in HIV-infected African women.

STUDY DESIGN

We conducted an observational study of HIV-seropositive women in Johannesburg, South Africa. The effect of individual HC types on the incidence and progression of cervical disease was determined using Poisson regression to obtain adjusted incidence rate ratios.

RESULTS

We evaluated 594 HIV-infected women, with median follow-up time of 445 days; 75 of these women were receiving some form of HC (largely DMPA, NET-EN, or COCs) at baseline. Risks of incidence and progression of cervical disease were similar comparing women not receiving HCs to women receiving DMPA, NET-EN, or COCs both individually by HC-type and considering all HC together.

CONCLUSIONS

There was no statistically significant effect of particular HC methods or of HC use in general on rates of incidence or progression of cervical disease in this study. These results should reassure us that use of HC is unlikely to substantially increase risks of cervical disease among HIV-positive women.