We found low contraceptive use (27.8%) among sexually active, not pregnant HIV-positive women enrolling at the ISS Clinic in Mbarara Hospital, consistent with contraception rates of the general Ugandan population [15
], as well as HIV-positive women in Uganda [30
], Kenya, and Malawi [34
]. The use of highly effective contraceptive methods was also low (18%), also consistent with the general Ugandan population [15
] as well as those with HIV [20
]. Thus, the low levels of contraceptive use in the sample may reflect the same root causes for low contraception uptake in Uganda, including insufficient information about the advantages of, fear of side effects from, and lack of access to contraception. In addition, some of these women may have wanted to have children [20
] but our medical records did not capture this desire. Furthermore, some women who want to access contraception may be thwarted by the plans of her spouse or sexual partner [36
Among clients who reported use of contraception, more than half (52%) used hormonal injectable contraception, and 30% used condoms. Other studies conducted at HIV clinics in Uganda found that the most commonly reported contraception method is condom use [17
]. The women in these other studies were either initiating or already on ART and thus may have already been in HIV care for some time with easier access to condoms and frequent exposure to counseling promoting condoms to prevent HIV transmission and pregnancy. In contrast, 70% of the women in our sample were recently diagnosed with HIV and only 7% were on ART. While the Uganda AIDS Control Program National guidelines advocate for dual family planning methods (condoms plus another contraceptive method) to prevent HIV/STI transmission and unintended pregnancies for HIV-positive individuals, only a small proportion used dual protection in this study (2%), consistent with other Ugandan studies [17
]. Use of condoms alone or dual contraception methods may have been low in our study; however, because 70% of married women reported having HIV-infected spouses, they therefore may have been less likely to use condoms to prevent sexual transmission of HIV. The high proportion of women choosing injectable hormonal contraception emphasizes the need to continue to unravel the relationship between hormonal contraception use and HIV risk [39
Our primary predictor variable of interest, HIV status disclosure, was not associated with use of contraception in either bivariate or multivariable analyses. Demographic factors (e.g. marital status, already having several children, younger age) and socioeconomic factors (e.g. education and income) were more strongly associated with contraception use at clinic entry. This is in contrast to a recent study in Uganda that showed that the lack of HIV disclosure was associated with lower odds of use of modern contraceptives among HIV women enrolled in HIV clinics in Uganda, in which 68% of the women were on ART [20
]. In addition, we did not find any significant association between HIV status disclosure and use of condoms, in contrast to the findings of other studies [20
]. Seventy percent of the married women in our study reported seroconcordant positive spouses, thus condoms to prevent HIV transmission may not be perceived to be applicable to this group. The observed association of decreased use of contraception with increased age was consistent with previous findings of lower modern contraceptive use among older women on ART in Zambia [41
] and HIV-infected women in Uganda [20
]. Parity and education have also been associated with contraceptive use in other studies [28
]. Younger age [22
] and having fewer children [22
] are often associated with increased fertility desires and could thus be expected to be associated with decreased contraceptive use [34
]. While the association of younger age with increased contraceptive use in our study is consistent with others, it is the opposite of what would be expected based on fertility desires. Older HIV-positive women may have a larger unmet need for contraception to limit childbearing, while younger women may have a larger unmet need to control spacing of births [15
]. Given that many women in Uganda, especially those with HIV, face difficult economic and social circumstances [47
] including bearing children whom they may raise as widows or divorced, the associations between contraception and education, as well as marital status and monthly income, are particularly important. The low use of contraception by women in this study, most of whom were recently diagnosed with HIV, points to the possibility that entry into HIV care could be a good time to intervene with contraception education and provision.
Our findings are limited by a high degree of missing data that is inherent to data collected as part of routine clinical care. However, the missing data categories were not associated with the use of contraception in the multivariable analysis, suggesting that the data were not missing systematically, and the results did not change when we performed multiple imputation. The data were collected by clinic counselors rather than by research assistants trained in systematic data collection and therefore may be especially subject to interviewer bias and social desirability bias or other types of response bias. In addition, these data do not account for desired pregnancy by the women and/or their partners [25
]. We also recognize that the cross sectional nature of this analysis focusing on contraceptive methods used at point of entry into HIV care does not allow inference about the method used at the time of HIV acquisition. In addition, the women served by the ISS clinic are a mixture of those from rural and urban areas; therefore, the findings may not fully translate to women enrolling in urban HIV clinics or those in very rural settings.
However, the strength of this study is that we were able to study a large number of HIV-infected women of reproductive age entering chronic HIV care, a population which may have had little previous exposure to health care and reproductive services. Our study highlights the need to establish cost effective strategies for lower income countries to improve the uptake of contraception among those infected with HIV who do not want to have children. We also found that dual methods of contraception were rarely used; therefore, contraception programs should also educate clients about the value of dual methods in order to prevent HIV/STI transmission to partners as well as to prevent unintended pregnancies. A study using the same database found an increasing incidence of pregnancies from 2006 to 2010 and the use of contraception was protective against pregnancy [49
Given the low contraceptive use among HIV-infected women in this study, which is comparable to contraception rates among the general population of Ugandan women, we suggest that strategies to improve contraception uptake target all women. We found that demographic and economic factors were important in the uptake of contraception; therefore, as countries plan improvement strategies to enhance contraception uptake among HIV-infected women, it may be important to reach women of lower socioeconomic and educational levels. The low use of certain long-term contraceptive methods available in Uganda [50
], such as implants and IUDs, suggests that more resources and focus may be needed for long-term contraceptive methods. HIV clinics in public health facilities are ideal settings for reaching HIV-positive women; at the ISS Clinic studied here, regular health education on contraception is given to clients and some contraceptive methods are now offered free on site or by voluntary referral to a nearby Maternal Child Health (MCH) clinic as part of routine clinical care. Increased integration of contraceptive services with STI/HIV prevention services would serve the ultimate goal of primary prevention of HIV via unintended pregnancies.
Further work is needed to determine whether this strategy is effective in reducing unintended pregnancies among HIV-positive women in care and reducing transmission of HIV.