Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

Susannah H Mayhew, Manuela Colombini, James Kelly Kimani, Keith Tomlin, Charlotte E Warren, Integra Initiative, Richard Mutemwa, Susannah H Mayhew, Manuela Colombini, James Kelly Kimani, Keith Tomlin, Charlotte E Warren, Integra Initiative, Richard Mutemwa

Abstract

Background: Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

Methods: Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

Results: Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

Conclusions: WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

Trial registration: Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

Keywords: Africa; Contraception; Fertility; Mixed methods; Women living with HIV.

Conflict of interest statement

Ethics approval and consent to participate

All participants in this study were over 18. They were given the project information sheet and time to consider their involvement. Written informed consent (or in a few cases witnessed thumb-printed consent) was then obtained from all participants before they were interviewed, each time they were interviewed.

Ethical clearance for the study and its consent procedures was granted by the Kenya Medical Research Institute (KEMRI) Ethical Review Board (#113 and 114), the Ethics Review Committee of the London School of Hygiene & Tropical Medicine (LSHTM) (#5426) and the Population Council’s Institutional Review Board (#443 and 444). The Integra Initiative is a registered (non-clinical) trial: ClinicalTrials.gov Identifier: NCT01694862.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

    1. Taulo F, Berry M, Tsui A, Makanani B, Kafulafula G, Li Q, et al. Fertility intentions of HIV-1 infected and uninfected women in Malawi: a longitudinal study. AIDS Behav. 2009;13:20–7. doi:10.1007/s10461-009-9547-9.
    1. Mmbaga EJ, Leyna GH, Ezekiel MJ, Kakoko DC. Fertility desire and intention of people living with HIV/AIDS in Tanzania: a call for restructuring care and treatment services. BMC Public Health. 2013;13:86.
    1. Schwartz SR, Mehta SH, Taha TE, Rees HV, Venter F, Black V. High pregnancy intentions and missed opportunities for patient-provider communication about fertility in a South African cohort of HIV-positive women on antiretroviral therapy. AIDS Behav. 2012;16:69–78.
    1. Myer L, Morroni C, Rebe K. Prevalence and determinants of fertility intentions of HIV-infected men and women receiving antiretroviral therapy in South Africa. AIDS Patient Care STDs. 2007;21:278–285. doi: 10.1089/apc.2006.0108.
    1. Cooper D, Harries J, Myer L, Orner P, Bracken H. “life is still going on”: reproductive intentions among HIV-positive women and men in South Africa. Soc Sci Med. 2007;65(2):274–283. doi: 10.1016/j.socscimed.2007.03.019.
    1. Gregson S. 1994, Will HIV become a major determinant of fertility in Sub-Saharan Africa? The Journal of Development Studies, Volume 30, Issue 3.
    1. Elul B, Delvaux T, Munyana E, Lahuerta M, Horowitz D, Ndagije F, et al. Pregnancy desires, and contraceptive knowledge and use among prevention of mother-to-child transmission clients in Rwanda. AIDS. 2009;23:S19–26. doi:10.1097/01.aids.0000363774.91376.dc.
    1. Keogh S, Urassa M, Kumogola Y, Mngara J, Zaba B et al 2009. Reproductive behaviour and HIV status of antenatal clients in northern Tanzania: opportunities for family planning and preventing mother-to-child transmission integration. AIDS November 2009 - Volume 23 - Issue - p S27–S35 doi:10.1097/01.aids.0000363775.68505.f1.
    1. Heys J, Kipp W, Jhangri G, Alibhai A, Rubaale, T 2009. Fertility desires and infection with the HIV: results from a survey in rural Uganda. AIDS November 2009 - Volume 23 - Issue - p S37–S45 doi:10.1097/01.aids.0000363776.76129.fd.
    1. Kimani J, Warren C, Abuya T, Mayhew S, Askew I. Family planning use and fertility desires among women living with HIV in Kenya. BMC Public Health. 2015;15:909. doi:10.1186/s12889-015-2218-z.
    1. Hoffman IF, Martinson FEA, Powers KA, Chilongozi DA, Msiska ED, Kacchipapa EI, et al. The year-long effect of HIV-positive test results on pregnancy intentions, contraceptive use, and pregnancy incidence among Malawian women. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2008;47:477–83. doi:10.1097/QAI.0b013e318165dc52.
    1. Kaida A, Laher F, Strathdee SA, Janssen PA, Money D, Hogg RS, et al. Childbearing intentions of HIV-positive women of reproductive age in Soweto, South Africa: the influence of expanding access to HAART in an HIV hyperendemic setting. Am J Public Health. 2011;101:350–8. Epub 2009 Mar 24.
    1. Johnson K., Akwara P., Rustein S.O., Berstein S. 2009. Fertility preferences and the need for contraception among women living with HIV: the basis for a joint action agenda. AIDS: November 2009 - Volume 23 - Issue - p S7–S17 doi:10.1097/01.aids.0000363773.83753.27.
    1. Rochat TJ, Richter LM, Doll HA, Buthelezi NP, Tomkins A, Stein A. Depression among pregnant rural South African women undergoing HIV testing. JAMA. 2006;295:1376–8.
    1. Homsy J, Bunnell R, Moore D, King R, Malamba S, Nakityo R, et al. Reproductive intentions and outcomes among women on antiretroviral therapy in rural Uganda: a prospective cohort study. PLoS One. 2009;4:e4149.
    1. Haddad L, Phiri S, Cwiak C, Feldacker C, Hosseinipour M, Hoffman I, et al. Fertility preferences, unintended pregnancy and contraceptive use among HIV-positive women desiring family planning in Lilongwe, Malawi. Contraception. 2011;84(3):325.
    1. WHO, UNAIDS, UNICEF, 2009. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report. WHO, UNAIDS, UNICEF, 2009 (at 96).
    1. Reynolds HW, Janowitz B, Homan R, Johnson L. The value of contraception to prevent perinatal HIV transmission. Sex Transm Dis. 2006;33:350–6.
    1. Wilcher, R, Petruney, T, Reynolds, HW, Cates W, 2008. From effectiveness to impact: contraception as an HIV prevention intervention. Sexually Transmitted Infections, 84, ii54-ii60.
    1. Calvert C, Ronsmans C. Pregnancy and HIV disease progression: a systematic review and meta-analysis. Tropical Med Int Health. 2015;20(2):122–45.
    1. UNAIDS 2011 Countdown to Zero, Geneva: UNAIDS/JC2137E, 2011.
    1. Harrington EK, Newmann SJ, Onono M, Schwartz KD, Bukusi EA, Cohen CR, et al. Fertility intentions and interest in integrated family planning services among women living with HIV in Nyanza Province, Kenya: a qualitative study. Infect Dis Obstet Gynecol. 2012;2012:809682.
    1. Oyebode TA, Sagay SA, Musa J, Ekwenpu CC, Wilfred SO. High rates of unplanned pregnancies and unmet contraceptive needs among HIV positive women in Jos, Nigeria: a call to integrate family planning into HIV treatment clinics. Int J Gynecol Obstet. 2012;119:S449.
    1. Warren C, Abuya T, Askew T et al. FP practices and pregnancy intentions among HIV-positive and HIV-negative postpartum women in Swaziland: a cross sectional survey BMC Preg and Childbirth 2013, 13:150.
    1. KENYA NBS Kenya Demographic and Health Survey 2010, National Bureau of statistics, Nairobi, 2010.
    1. Anand A, Shiraishi RW, Bunnell RE, Jacobs K, Solehdin N, Abdul-Quader AS, et al. Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi. AIDS. 2009;23:1565–1573. doi: 10.1097/QAD.0b013e32832cb10c.
    1. Mak J, Birdthistle I, Church K, et al. Need, demand and missed opportunities for integrated RH-HIV care in Kenya & Swaziland: evidence from household surveys. AIDS. 2013;27(Suppl1):S55–S63. doi: 10.1097/QAD.0000000000000046.
    1. Withers M, Dworkin SL, et al. (2015) ‘women now wear trousers’: men's perceptions of family planning in the context of changing gender relations in western Kenya, Culture, Health & Sexuality, 17:9, 1132-1146, doi:10.1080/13691058.2015.1043144.
    1. Warren C, Mayhew S, Vassall A, et al. Study protocol for the integra initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland. BMC Public Health. 2012;12:973.
    1. Mayhew SH, Ploubidis GB, Sloggett A, Church K, Obure CD, et al. Innovation in evaluating the impact of integrated service-delivery: the Integra indexes of HIV and reproductive health integration. PLoS One. 2016;11(1) doi: 10.1371/journal.pone.0146694.
    1. Colombini M, Mayhew SH, Mutemwa R, Kivunaga J, Ndwiga C, Integra team (2016) Perceptions and Experiences of Integrated Service Delivery Among Women Living with HIV Attending Reproductive Health Services in Kenya: A Mixed Methods Study AIDS and Behaviour doi:10.1007/s10461-016-1373-2
    1. Raftery AE. Bayesian model selection in social research. In (P. V. Marsden, Ed) Sociological Methodology, pp. 111–163, London, Tavistock, 1995.
    1. Pampel FC. Logistic regression. Series: Quantitative applications in the social sciences. London, SAGE, 2000.
    1. Long JS. Regression models for categorical and limited dependent variables: analysis and interpretation. Thousand Oaks (CA), SAGE, 1997.
    1. Wall KM, Haddad L, Vwalikaa B, Khu NH, Brill I et al. Unintended Pregnancy among HIV Positive Couples Receiving Integrated HIV Counseling, Testing, and Family Planning Services in Zambia PLOS One: September 30, 2013. doi:10.1371/journal.pone.0075353.
    1. Withers M, Dworkin SL, Harrington E, et al. Fertility intentions among HIV-infected, sero-concordant couples in Nyanza province, Kenya. Culture, Health and Sexuality. 2013;15(10) doi:10.1080/13691058.2013.811289.
    1. Mantell JE, Smit JA, Stein ZA. The right to choose parenthood among HIV-infected women and men. J Public Health Policy. 2009;30(4):367–378. doi: 10.1057/jphp.2009.35.
    1. Harrington EK, Dworkin S, Withers M, et al. Gendered power dynamics and women’s negotiation of family planning in a high HIV prevalence setting: a qualitative study of couples in western Kenya. Culture, Health & Sexuality. 2016;18(4):453–469. doi: 10.1080/13691058.2015.1091507.
    1. The Inter-agency Task Team for Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and their Children (2012), Preventing HIV and unintended pregnancies: strategic framework 2011–2015.
    1. Unger JA, Richardson BA, Otieno PA, et al. Mode of delivery and postpartum HIV-1 disease progression and mortality in a Kenyan cohort. BMC Pregnancy Childbirth. 2014;14:257. doi: 10.1186/1471-2393-14-257.
    1. Lieve VD, Shafer LA, Mayanja BN, et al. Effect of pregnancy on HIV disease progression and survival among women in rural Uganda. Tropical Med Int Health. 2007;12
    1. Heffron R, Donnell D, Kiarie J, et al. A prospective study of the effect of pregnancy on CD4 counts and plasma HIV-1 RNA concentrations of antiretroviral-naive HIV-1-infected women. J Acquir Immune Defic Syndr. 2014;65(2):231–236. doi: 10.1097/QAI.0000000000000013.
    1. Stanbacka J, Steinera M, Dorflingera L, Solo J, Cates W. WHO Tiered-Effectiveness Counseling Is Rights-Based Family Planning. Glob Health Sci Pract September 10, 2015 vol. 3 no. 3 p. 352–357. doi:10.9745/GHSP-D-15-00096.
    1. O’Shea MS, Rosenberg NE, Hosseinipour MC, Stuart GS, et al. Effect of HIV status on fertility desire and knowledge of long-acting reversible contraception of postpartum Malawian women. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV; 2014.
    1. Khua NH, Vwalikaa B, Karitaa E, Kilemba W, Bayinganaa RA, et al. Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia. Contraception. 2013;88(1):74–82. doi: 10.1016/j.contraception.2012.10.004.
    1. Church K, Mayhew SH. Integration of STI and HIV prevention, care, and treatment into family planning services: a review of the literature. Stud Fam Plan 2009; 40(3):171–186. PMID: 19852408.
    1. Gruskin S, Firestone R, Maccarthy S, Ferguson L. HIV and pregnancy intentions: do Services adequately respond to Women’s needs? Am J Public Health. 2008;98:1746–50.
    1. Nattabi B, Jianghong L, Thompson SC, Orach CGm Earnest J. 2009. A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery. AIDS and Behavior October 2009, Volume 13, Issue 5, pp 949–968 Date: 28 Mar 2009. doi:10.1007/s10461-009-9537-y.
    1. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am. J. Obstet. Gynecol. 2010;203(2):115.e1–e7.

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する