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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
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