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1.  Hormonal Contraception and the Risk of HIV Acquisition: An Individual Participant Data Meta-analysis 
PLoS Medicine  2015;12(1):e1001778.
In a meta-analysis of individual participant data, Charles Morrison and colleagues explore the association between hormonal contraception use and risk of HIV infection in sub-Saharan Africa.
Observational studies of a putative association between hormonal contraception (HC) and HIV acquisition have produced conflicting results. We conducted an individual participant data (IPD) meta-analysis of studies from sub-Saharan Africa to compare the incidence of HIV infection in women using combined oral contraceptives (COCs) or the injectable progestins depot-medroxyprogesterone acetate (DMPA) or norethisterone enanthate (NET-EN) with women not using HC.
Methods and Findings
Eligible studies measured HC exposure and incident HIV infection prospectively using standardized measures, enrolled women aged 15–49 y, recorded ≥15 incident HIV infections, and measured prespecified covariates. Our primary analysis estimated the adjusted hazard ratio (aHR) using two-stage random effects meta-analysis, controlling for region, marital status, age, number of sex partners, and condom use. We included 18 studies, including 37,124 women (43,613 woman-years) and 1,830 incident HIV infections. Relative to no HC use, the aHR for HIV acquisition was 1.50 (95% CI 1.24–1.83) for DMPA use, 1.24 (95% CI 0.84–1.82) for NET-EN use, and 1.03 (95% CI 0.88–1.20) for COC use. Between-study heterogeneity was mild (I2 < 50%). DMPA use was associated with increased HIV acquisition compared with COC use (aHR 1.43, 95% CI 1.23–1.67) and NET-EN use (aHR 1.32, 95% CI 1.08–1.61). Effect estimates were attenuated for studies at lower risk of methodological bias (compared with no HC use, aHR for DMPA use 1.22, 95% CI 0.99–1.50; for NET-EN use 0.67, 95% CI 0.47–0.96; and for COC use 0.91, 95% CI 0.73–1.41) compared to those at higher risk of bias (pinteraction = 0.003). Neither age nor herpes simplex virus type 2 infection status modified the HC–HIV relationship.
This IPD meta-analysis found no evidence that COC or NET-EN use increases women’s risk of HIV but adds to the evidence that DMPA may increase HIV risk, underscoring the need for additional safe and effective contraceptive options for women at high HIV risk. A randomized controlled trial would provide more definitive evidence about the effects of hormonal contraception, particularly DMPA, on HIV risk.
Editors’ Summary
AIDS has killed about 36 million people since the first recorded case of the disease in 1981. About 35 million people (including 25 million living in sub-Saharan Africa) are currently infected with HIV, the virus that causes AIDS, and every year, another 2.3 million people become newly infected with HIV. At the beginning of the epidemic, more men than women were infected with HIV. Now, about half of all adults infected with HIV are women. In 2013, almost 60% of all new HIV infections among young people aged 15–24 years occurred among women, and it is estimated that, worldwide, 50 young women are newly infected with HIV every hour. Most women become infected with HIV through unprotected intercourse with an infected male partner—biologically, women are twice as likely to become infected through unprotected intercourse as men. A woman’s risk of becoming infected with HIV can be reduced by abstaining from sex, by having one or a few partners, and by always using condoms.
Why Was This Study Done?
Women and societies both benefit from effective contraception. When contraception is available, women can avoid unintended pregnancies, fewer women and babies die during pregnancy and childbirth, and maternal and infant health improves. However, some (but not all) observational studies (investigations that measure associations between the characteristics of participants and their subsequent development of specific diseases) have reported an association between hormonal contraceptive use and an increased risk of HIV acquisition by women. So, does hormonal contraception increase the risk of HIV acquisition among women or not? Here, to investigate this question, the researchers undertake an individual participant data meta-analysis of studies conducted in sub-Saharan Africa (a region where both HIV infection and unintended pregnancies are common) to compare the incidence of HIV infection (the number of new cases in a population during a given time period) among women using and not using hormonal contraception. Meta-analysis is a statistical method that combines the results of several studies; an individual participant data meta-analysis combines the data recorded for each individual involved in the studies rather than the aggregated results from each study.
What Did the Researchers Do and Find?
The researchers included 18 studies that measured hormonal contraceptive use and incident HIV infection among women aged 15–49 years living in sub-Saharan Africa in their meta-analysis. More than 37,000 women took part in these studies, and 1,830 became newly infected with HIV. Half of the women were not using hormonal contraception, a quarter were using depot-medroxyprogesterone acetate (DMPA; an injectable hormonal contraceptive), and the remainder were using combined oral contraceptives (COCs) or norethisterone enanthate (NET-EN, another injectable contraceptive). After adjustment for other factors likely to influence HIV acquisition (for example, condom use), women using DMPA had a 1.5-fold increased risk of HIV acquisition compared to women not using hormonal contraception. There was a slightly increased risk of HIV acquisition among women using NET-EN compared to women not using hormonal contraception, but this increase was not statistically significant (it may have happened by chance alone). There was no increased risk of HIV acquisition associated with COC use. DMPA use was associated with a 1.43-fold and 1.32-fold increased risk of HIV acquisition compared with COC and NET-EN use, respectively. Finally, neither age nor herpes simplex virus 2 infection status modified the effect of hormonal contraceptive use on HIV acquisition.
What Do These Findings Mean?
The findings of this individual patient data meta-analysis provide no evidence that COC or NET-EN use increases a woman’s risk of acquiring HIV, but add to the evidence suggesting that DMPA use increases the risk of HIV acquisition. These findings are likely to be more accurate than those of previous meta-analyses that used aggregated data but are likely to be limited by the quality, design, and representativeness of the studies included in the analysis. These findings nevertheless highlight the need to develop additional safe and effective contraceptive options for women at risk of HIV, particularly those living in sub-Saharan Africa, where although contraceptive use is generally low, DMPA is the most widely used hormonal contraceptive. In addition, these findings highlight the need to initiate randomized controlled trials to provide more definitive evidence of the effects of hormonal contraception, particularly DMPA, on HIV risk.
Additional Information.
Please access these websites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment, including personal stories about living with HIV/AIDS and a news report on this meta-analysis
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including detailed information on women, HIV, and AIDS, and on HIV and AIDS in South Africa (in English and Spanish); personal stories of women living with HIV are available
The World Health Organization provides information on all aspects of HIV/AIDS (in several languages); information about a 2012 WHO technical consultation about hormonal contraception and HIV
The 2013 UNAIDS World AIDS Day report provides up-to-date information about the AIDS epidemic and efforts to halt it; UNAIDS also provides information about HIV and hormonal contraception
PMCID: PMC4303292  PMID: 25612136
2.  Attitudes toward Family Planning among HIV-Positive Pregnant Women Enrolled in a Prevention of Mother-To-Child Transmission Study in Kisumu, Kenya 
PLoS ONE  2013;8(8):e66593.
Preventing unintended pregnancies among HIV-positive women through family planning (FP) reduces pregnancy-related morbidity and mortality, decreases the number of pediatric HIV infections, and has also proven to be a cost-effective way to prevent mother-to-child HIV transmission. A key element of a comprehensive HIV prevention agenda, aimed at avoiding unintended pregnancies, is recognizing the attitudes towards FP among HIV-positive women and their spouse or partner. In this study, we analyze FP attitudes among HIV-infected pregnant women enrolled in a PMTCT clinical trial in Western Kenya.
Methods and Findings
Baseline data were collected on 522 HIV-positive pregnant women using structured questionnaires. Associations between demographic variables and the future intention to use FP were examined using Fisher's exact tests and permutation tests. Most participants (87%) indicated that they intended to use FP. However, only 8% indicated condoms as a preferred FP method, and 59% of current pregnancies were unintended. Factors associated with positive intentions to use FP were: marital status (p = 0.04), having talked to their spouse or partner about FP (p<0.001), perceived spouse or partner approval of FP (p<0.001), previous use of a FP method (p = 0.006), attitude toward the current pregnancy (p = 0.02), disclosure of a sexually transmitted infection (STI) diagnosis (p = 0.03) and ethnic group (p = 0.03).
A significant gap exists between future FP intentions and current FP practices. Support and approval by the spouse or partner are key elements of FP intentions. Counseling services should be offered to both members of a couple to increase FP use, especially given the high number of unplanned pregnancies among HIV-positive women. Condoms should be promoted as part of a dual use method for HIV and STI prevention and for contraception. Integration of individual and couple FP services into routine HIV care, treatment and support services is needed in order to avoid unintended pregnancies and to prevent mother-to-child HIV transmission.
PMCID: PMC3753279  PMID: 23990868
3.  When Do HIV-Infected Women Disclose Their HIV Status to Their Male Partner and Why? A Study in a PMTCT Programme, Abidjan 
PLoS Medicine  2007;4(12):e342.
In Africa, women tested for HIV during antenatal care are counselled to share with their partner their HIV test result and to encourage partners to undertake HIV testing. We investigate, among women tested for HIV within a prevention of mother-to-child transmission of HIV (PMTCT) programme, the key moments for disclosure of their own HIV status to their partner and the impact on partner HIV testing.
Methods and Findings
Within the Ditrame Plus PMTCT project in Abidjan, 546 HIV-positive and 393 HIV-negative women were tested during pregnancy and followed-up for two years after delivery. Circumstances, frequency, and determinants of disclosure to the male partner were estimated according to HIV status. The determinants of partner HIV testing were identified according to women's HIV status. During the two-year follow-up, disclosure to the partner was reported by 96.7% of the HIV-negative women, compared to 46.2% of HIV-positive women (χ2 = 265.2, degrees of freedom [df] = 1, p < 0.001). Among HIV-infected women, privileged circumstances for disclosure were just before delivery, during early weaning (at 4 mo to prevent HIV postnatal transmission), or upon resumption of sexual activity. Formula feeding by HIV-infected women increased the probability of disclosure (adjusted odds ratio 1.54, 95% confidence interval 1.04–2.27, Wald test = 4.649, df = 1, p = 0.031), whereas household factors such as having a co-spouse or living with family reduced the probability of disclosure. The proportion of male partners tested for HIV was 23.1% among HIV-positive women and 14.8% among HIV-negative women (χ2 = 10.04, df = 1, p = 0.002). Partners of HIV-positive women who were informed of their wife's HIV status were more likely to undertake HIV testing than those not informed (37.7% versus 10.5%, χ2 = 56.36, df = 1, p < 0.001).
In PMTCT programmes, specific psychosocial counselling and support should be provided to women during the key moments of disclosure of HIV status to their partners (end of pregnancy, weaning, and resumption of sexual activity). This support could contribute to improving women's adherence to the advice given to prevent postnatal and sexual HIV transmission.
In a mother-to-child HIV prevention program in Côte d'Ivoire, Annabel Desgrées-du-Loû and colleagues identify three junctures at which women tend to disclose their HIV status to partners.
Editors' Summary
Since the first reported case of AIDS (acquired immunodeficiency syndrome) in 1981, the number of people infected with the human immunodeficiency virus (HIV), which causes AIDS, has risen steadily. By the end of 2006, nearly 40 million people were infected, 25 million of them in sub-Saharan Africa. HIV is most often spread by having unprotected sex with an infected partner. In Africa, most sexual transmission of HIV is between partners in stable relationships—many such couples do not adopt measures that prevent viral transmission, such as knowing the HIV status of both partners and using condoms if one partner is HIV-positive. HIV can also pass from a mother to her baby during pregnancy, labor, or delivery, or through breastfeeding. Mother-to-child transmission (MTCT) of HIV can be reduced by giving anti-HIV drugs to the mother during pregnancy and labor and to her newborn baby, and by avoiding breastfeeding or weaning the baby early.
Why Was This Study Done?
Many African countries have programs for prevention of MTCT (PMTCT) that offer pregnant women prenatal HIV counseling and testing. As a result, women are often the first member of a stable relationship to know their HIV status. PMTCT programs advise women to disclose their HIV test result to their partner and to encourage him to have an HIV test. But for many women, particularly those who are HIV-positive, talking to their partner about HIV/AIDS is hard because of fears of rejection (which could mean loss of housing and food) or accusations of infidelity. Knowing more about when women disclose their HIV status and what makes them decide to do so would help the people running PMTCT programs to support women during the difficult process of disclosure. In this study, the researchers have investigated when and why women participating in a PMTCT research project in Abidjan (Côte d'Ivoire) told their partner about their HIV status and the impact this disclosure had on their partner's uptake of HIV testing.
What Did the Researchers Do and Find?
At regular follow-up visits, the researchers asked women in the Abidjan PMTCT project whether they had told their partners their HIV status and whether they were breast-feeding or had resumed sexual activity. Nearly all the women who tested negative for HIV, but slightly fewer than half of the HIV-positive (infected) women had told their partner about their HIV status by two years after childbirth. Two-thirds of the HIV-positive women who disclosed their status did so before delivery. Other key times for disclosure were at early weaning (4 months after birth) for women who breast-fed their babies, and when sexual activity resumed. HIV-positive women who bottle fed their babies from birth were more likely to tell their partners of their status than women who breast-fed. Factors that prevented women disclosing their HIV status included living in a polygamous relationship or living separately from their partners. Finally, the researchers report that the partners of HIV-positive women who disclosed their HIV status were about three times more likely to take an HIV test than the partners of HIV-positive women who did not disclose.
What Do These Findings Mean?
These findings identify three key times when women who have had an HIV test during pregnancy are likely to disclose their HIV status to their partner. The main one is before delivery and relates, in part, to how the mother plans to feed her baby. To bottle feed in Abidjan, women need considerable support from their partners and this may be the impetus for disclosing their HIV status. Disclosure at early weaning may reflect the woman's need to enlist her partner's support for this unusual decision—the normal time for weaning in Abidjan is 17 months. Finally, disclosure when sexual activity resumes may be necessary so that the woman can explain why she wants to use condoms. Although these findings need confirmation in other settings, targeting counseling and support within PMTCT programs to these key moments might help HIV-positive women to tell their partners about their status. This, hopefully, would help to reduce sexual transmission of HIV within stable relationships in sub-Saharan Africa.
Additional Information.
Please access these Web sites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS and on HIV infection in women
HIV InSite has comprehensive information on all aspects of HIV/AIDS
Women Children and HIV provides extensive information on prevention of mother-to-child transmission of HIV in developing countries
Information is available from Avert, an international AIDS charity, on HIV and AIDS in Africa and on HIV and AIDS prevention
AIDSinfo, a service of the US Department of Health and Human Services provideshealth information for HIV-positive pregnant women (in English and Spanish)
PMCID: PMC2100145  PMID: 18052603
4.  Contraceptive use and method preference among HIV positive women in Addis Ababa, Ethiopia: a cross sectional survey 
BMC Public Health  2014;14:566.
Prevention of unplanned pregnancies among people living with HIV is essential component of “Global Plan” even in the context of expanded access to highly active antiretroviral therapy (HAART). The study aimed to assess whether contraceptive use and method preference varied by the use of HAART among HIV positive women in Addis Ababa, Ethiopia.
A cross sectional facility based survey was conducted from June to October, 2012 information was gathered using interviewer administered questionnaire and document review was conducted to confirm HIV status and clinical review. A sample of 1418 HIV positive women including 770 women receiving HAART and 648 HAART-naïve recruited randomly from different health institutions in Addis Ababa. Data were principally analyzed using logistic regression.
Overall, 71% women reported using contraception (75% among HAART users and 65% HAART naïve women). Male condom and injectables are the most preferred contraceptive methods among both groups. The odds of contraceptive use among HAART users was higher (AOR 1.60, 95% CI; 1.30-2.12) than HAART naïve women. In addition to this, presence of partner (AOR 2.32, 95% CI 1.60-3.40), disclosure of HIV status to husband (AOR 2.23; 95% CI 1.21-4.12), presence of living children: one (AOR 1.7; 95% CI 1.03-2.40), two (AOR 2.6; 95% CI 1.7-4.02) and three (AOR 3.3; 95% CI 1.90-5.60) respectively were found to be predictors of contraceptive use among HIV positive women.
The contraceptive profile of women in the study area mainly dependent on male condom use, this indicates the need to better integrate tailored counseling and contraceptive options with care and support activities that targets HIV positive women. Moreover, emphasis should be given to dual contraceptive method use along with their regular follow up irrespective of their HAART use.
PMCID: PMC4063250  PMID: 24902478
Contraceptive use; HIV positive women; HAART use; Addis Ababa; Ethiopia
5.  Impact of Antiretroviral Therapy on Incidence of Pregnancy among HIV-Infected Women in Sub-Saharan Africa: A Cohort Study 
PLoS Medicine  2010;7(2):e1000229.
A multicountry cohort study in sub-Saharan Africa by Landon Myer and colleagues reveals higher pregnancy rates in HIV-infected women on antiretroviral therapy (ART).
With the rapid expansion of antiretroviral therapy (ART) services in sub-Saharan Africa there is growing recognition of the importance of fertility and childbearing among HIV-infected women. However there are few data on whether ART initiation influences pregnancy rates.
Methods and Findings
We analyzed data from the Mother-to-Child Transmission-Plus (MTCT-Plus) Initiative, a multicountry HIV care and treatment program for women, children, and families. From 11 programs in seven African countries, women were enrolled into care regardless of HIV disease stage and followed at regular intervals; ART was initiated according to national guidelines on the basis of immunological and/or clinical criteria. Standardized forms were used to collect sociodemographic and clinical data, including incident pregnancies. Overall 589 incident pregnancies were observed among the 4,531 women included in this analysis (pregnancy incidence, 7.8/100 person-years [PY]). The rate of new pregnancies was significantly higher among women receiving ART (9.0/100 PY) compared to women not on ART (6.5/100 PY) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.19–2.54). Other factors independently associated with increased risk of incident pregnancy included younger age, lower educational attainment, being married or cohabiting, having a male partner enrolled into the program, failure to use nonbarrier contraception, and higher CD4 cell counts.
ART use is associated with significantly higher pregnancy rates among HIV-infected women in sub-Saharan Africa. While the possible behavioral or biomedical mechanisms that may underlie this association require further investigation, these data highlight the importance of pregnancy planning and management as a critical but neglected component of HIV care and treatment services.
Please see later in the article for the Editors' Summary
Editors' Summary
Human immunodeficiency virus (HIV) causes Acquired Immunodeficiency Syndrome (AIDS), which is a major global cause of disease and death. More than 33 million people around the world are infected with HIV, with nearly 5,500 dying daily from HIV and AIDS-related complications. HIV/AIDS is especially problematic in sub-Saharan Africa, where it is the leading cause of death. There is no cure for HIV/AIDS, but medicines known as “antiretroviral therapy” (ART) can prolong life and reduce complications in patients infected with HIV. 97% of patients with HIV/AIDS live in low- and middle-income countries. According to the World Health Organization, nearly 10 million of these patients need ART. As patients' access to treatment is often hindered by the high cost and low availability of ART, global health efforts have focused on promoting ART use in resource-limited nations. Such efforts also increase awareness of how HIV is spread (contact with blood or semen, in sexual intercourse, sharing needles, or from mother to child during childbirth). ART reduces, but does not remove, the chance of a mother's passing HIV to her child during birth.
Why Was This Study Done?
By the end of 2007, 3 million HIV-infected patients in poor countries were receiving ART. Many of those treated with ART are young women of child-bearing age. Childbirth is an important means of spreading HIV in sub-Saharan Africa, where 60% of all HIV patients are women. This study questions whether the improved health and life expectancy that results from treatment with ART affects pregnancy rates of HIV-infected patients. The study explores this question in seven African countries, by examining the rates of pregnancy in HIV-infected women before and after they started ART.
What Did the Researchers Do and Find?
The authors looked at the records of 4,531 HIV-infected women enrolled in the Mother-to-Child-Transmission-Plus (MTCT-Plus) Initiative in seven African countries. MTCT -Plus, begun in 2002, is a family-centered treatment program that offers regular checkups, blood tests, counseling, and ART treatment (if appropriate) to women and their families. At each checkup, women's CD4+ cell counts and World Health Organization guidelines were used to determine their eligibility for starting ART. Over a 4-year period, nearly a third of the women starting ART experienced a pregnancy: 244 pregnancies occurred in the “pre-ART” group (women not receiving ART) compared to 345 pregnancies in the “on-ART” group (women receiving ART). The chance of pregnancy increased over time in the on-ART group to almost 80% greater than the pre-ART group, while remaining relatively low and constant in the pre-ART group. The authors noted that, as expected, other factors also increased the chances of pregnancy, including younger age, lower educational status, and use of nonbarrier contraception such as injectable hormones.
What Do These Findings Mean?
This study suggests that starting ART is associated with higher pregnancy rates in sub-Saharan Africa, nearly doubling the chances of a woman becoming pregnant. The reasons for this link are unclear. One possible explanation is behavioral: women receiving ART may feel more motivated to have children as their health and quality of life improve. However, the study did not examine how pregnancy desires and sexual activity of women changed while on ART, and cannot discern why ART is linked to increased pregnancy. By using pregnancy data gathered from patient questionnaires rather than laboratory tests, the study is limited by the possibility of inaccurate patient reporting. Understanding how pregnancy rates vary in HIV-infected women receiving ART helps support the formation of responsive, effective HIV programs. Female HIV patients of child-bearing age, who form the majority of patients receiving ART in sub-Saharan Africa, would benefit from programs that combine starting HIV treatment with ART with education and contraception counseling and pregnancy-related care.
Additional Information
Please access these Web sites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of articles and other sources of information about the primary care of adolescents with HIV
A UNAIDS 2008 report is available on the global AIDS epidemic
The International Planned Parenthood Foundation provides information on sexual and reproductive health and HIV
The International Center for AIDS Care and Treatment Programs at the Columbia University Mailman School of Public health provides information to assist HIV care and treatment programs in resource-limited settings
PMCID: PMC2817715  PMID: 20161723
6.  Contraceptive Use in Women Enrolled into Preventive HIV Vaccine Trials: Experience from a Phase I/II Trial in East Africa 
PLoS ONE  2009;4(4):e5164.
HIV vaccine trials generally require that pregnant women are excluded from participation, and contraceptive methods must be used to prevent pregnancy during the trial. However, access to quality services and misconceptions associated with contraceptive methods may impact on their effective use in developing countries. We describe the pattern of contraceptive use in a multi-site phase I/IIa HIV Vaccine trial in East Africa (Uganda, Kenya and Tanzania) and factors that may have influenced their use during the trial.
Pregnancy prevention counseling was provided to female participants during informed consent process and at each study visit. Participants' methods of contraception used were documented. Methods of contraceptives were provided on site. Pregnancy testing was done at designated visits during the trial. Obstacles to contraceptive use were identified and addressed at each visit.
Overall, 103 (31.8%) of a total of 324 enrolled volunteers were females. Female participants were generally young with a mean age of 29(±7.2), married (49.5%) and had less than high school education (62.1%). Hormonal contraceptives were the most common method of contraception (58.3%) followed by condom use (22.3%). The distribution of methods of contraception among the three sites was similar except for more condom use and less abstinence in Uganda. The majority of women (85.4%) reported to contraceptive use prior to screening. The reasons for not using contraception included access to quality services, insufficient knowledge of certain methods, and misconceptions.
Although hormonal contraceptives were frequently used by females participating in the vaccine trial, misconceptions and their incorrect use might have led to inconsistent use resulting in undesired pregnancies. The study underscores the need for an integrated approach to pregnancy prevention counseling during HIV vaccine trials.
Trial Registration NCT00123968
PMCID: PMC2664465  PMID: 19360102
7.  Pregnancy Prevention and Condom Use Practices among HIV-Infected Women on Antiretroviral Therapy Seeking Family Planning in Lilongwe, Malawi 
PLoS ONE  2015;10(3):e0121039.
Programs for integration of family planning into HIV care must recognize current practices and desires among clients to appropriately target and tailor interventions. We sought to evaluate fertility intentions, unintended pregnancy, contraceptive and condom use among a cohort of HIV-infected women seeking family planning services within an antiretroviral therapy (ART) clinic.
200 women completed an interviewer-administered questionnaire during enrollment into a prospective contraceptive study at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010.
Most women (95%) did not desire future pregnancy. Prior reported unintended pregnancy rates were high (69% unplanned and 61% unhappy with timing of last pregnancy). Condom use was inconsistent, even among couples with discordant HIV status, with lack of use often attributed to partner’s refusal. Higher education, older age, lower parity and having an HIV negative partner were factors associated with consistent condom usage.
High rates of unintended pregnancy among these women underscore the need for integ rating family planning, sexually transmitted infection (STI) prevention, and HIV services. Contraceptive access and use, including condoms, must be improved with specific efforts to enlist partner support. Messages regarding the importance of condom usage in conjunction with more effective modern contraceptive methods for both infection and pregnancy prevention must continue to be reinforced over the course of ongoing ART treatment.
PMCID: PMC4374940  PMID: 25811849
8.  Use of Modern Contraception by the Poor Is Falling Behind 
PLoS Medicine  2007;4(2):e31.
The widespread increase in the use of contraception, due to multiple factors including improved access to modern contraception, is one of the most dramatic social transformations of the past fifty years. This study explores whether the global progress in the use of modern contraceptives has also benefited the poorest.
Methods and Findings
Demographic and Health Surveys from 55 developing countries were analyzed using wealth indices that allow the identification of the absolute poor within each country. This article explores the macro level determinants of the differences in the use of modern contraceptives between the poor and the national averages of several countries. Despite increases in national averages, use of modern contraception by the absolute poor remains low. South and Southeast Asia have relatively high rates of modern contraception in the absolute poor, on average 17% higher than in Latin America. Over time the gaps in use persist and are increasing. Latin America exhibits significantly larger gaps in use between the poor and the averages, while gaps in sub-Saharan Africa are on average smaller by 15.8% and in Southeast Asia by 11.6%.
The secular trend of increasing rates of modern contraceptive use has not resulted in a decrease of the gap in use for those living in absolute poverty. Countries with large economic inequalities also exhibit large inequalities in modern contraceptive use. In addition to macro level factors that influence contraceptive use, such as economic development and provision of reproductive health services, there are strong regional variations, with sub-Saharan Africa exhibiting the lowest national rates of use, South and Southeast Asia the highest use among the poor, and Latin America the largest inequalities in use.
Analysis of demographic and health surveys from 55 developing countries confirms the increasing use of modern contraceptives, but their use by people living in absolute poverty lags considerably behind.
Editors' Summary
Access to safe and effective methods of contraception is seen by many to be a basic human right. Contraception plays an important role in improving women's health (by reducing the risks that would otherwise accompany unwanted births), as well as the social and financial situation of women and their families. However, despite a steady increase in contraceptive use worldwide over the past few decades, the World Health Organization says there is still a significant unmet need for birth control. Very many women worldwide, probably around 123 million, would like to limit the number of children that they might have but, despite this, they are not using contraception. There are probably many factors responsible for this unmet need, including the availability of health services, a woman's level of education, her social and financial situation, and cultural factors.
Why Was This Study Done?
Although it is clear that use of contraception has been increasing worldwide over the past few decades, particularly in developing countries, it is not clear whether the poorest people in each country have also benefited from this trend. Given that contraception has important effects on health and on the financial and social circumstances of a family, it is important to find out whether there are any differences in contraceptive use between the poorest and richer members of society.
What Did the Researchers Do and Find?
This research project was based on data collected by a survey oganization about various aspects of the health, social, and economic status of households worldwide. Over 100 surveys conducted between 1985 and 2003 were used from the publicly available survey database. The researchers then classified each household for which there was survey information as being in the poorest 20% of households or not, worldwide. Importantly, this categorization reflects whether the household was in the “absolute poor” worldwide, not just the poorest for their respective country. Since information about household income was not directly available from the surveys, the researchers had to use an approach based on ownership of consumer goods and services (referred to as “asset-based wealth measures”). The researchers then looked at trends in contraceptive use amongst the poorest households, and examined whether contraceptive use was linked to other factors, such as level of education and average income.
The data showed that use of contraception by poor women was linked to the overall degree of poverty in the woman's country. Poor women from countries where many households were in the poorest 20% worldwide were far less likely to use contraception. Secondly, the researchers found that poor women were less likely to use contraception than average women in their country, and in richer countries, there seemed to be a larger gap in contraceptive use between “average” and “poor” women. Finally, the researchers found that various factors were linked to greater contraceptive use, which included the date of the survey (more recent surveys were more likely to show greater use of contraceptives), the wealth of the country where the survey was done (richer countries showed greater use), and whether women had skilled birth attendants (a marker of access to reproductive health services, and again this pointed to greater use of contraceptives). However, the researchers did find that there was huge variability in use of contraceptives worldwide, even when comparing countries at a similar economic level.
What Do These Findings Mean?
This study shows that although contraception use is increasing over time, its use by poor people is low. The gap in use of contraception between poor people and “average” people also seems to be increasing over time and is wider in richer countries. The reasons behind these findings are not clear, but the data suggest that nations and international health organizations need to focus their attention on providing contraceptive services in a way that will reach people who have very low incomes.
Additional Information.
Please access these Web sites via the online version of this summary at
The World Health Organization's pages on family planning provide evidence-based guidance, official publications, and information on family planning research
There is a helpful Wikipedia entry on birth control (note that Wikipedia is an internet encyclopedia that anyone can edit)
The United Nations Population Fund collects data and helps countries to understand and analyze population trends, and its Web site provides an overview of population issues. It also publishes a yearly report, "State of World Population"
There are also many independent not-for-profit organizations that focus on reproductive health and population issues. One example is Interact Worldwide, and the "links" page on this organization's Web site lists the sites of many other organizations active in this area
The US Centers for Disease Control and Prevention includes relevant data and statistics via its global reproductive health minisite
PMCID: PMC1796626  PMID: 17284155
9.  Contraceptive Use and Method Preference among Women in Soweto, South Africa: The Influence of Expanding Access to HIV Care and Treatment Services 
PLoS ONE  2010;5(11):e13868.
Preventing unintended pregnancy among HIV-positive women constitutes a critical and cost-effective approach to primary prevention of mother-to-child transmission of HIV and is a global public health priority for addressing the desperate state of maternal and child health in HIV hyper-endemic settings. We sought to investigate whether the prevalence of contraceptive use and method preferences varied by HIV status and receipt of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa.
We used survey data from 563 sexually active, non-pregnant women (18–44 years) recruited from the Perinatal HIV Research Unit in Soweto (May–December, 2007); 171 women were HIV-positive and receiving HAART (median duration of use = 31 months; IQR = 28, 33), 178 were HIV-positive and HAART-naïve, and 214 were HIV-negative. Medical record review was conducted to confirm HIV status and clinical variables. Logistic regression models estimated adjusted associations between HIV status, receipt of HAART, and contraceptive use.
Overall, 78% of women reported using contraception, with significant variation by HIV status: 86% of HAART users, 82% of HAART-naïve women, and 69% of HIV-negative women (p<0.0001). In adjusted models, compared with HIV-negative women, women receiving HAART were significantly more likely to use contraception while HAART-naïve women were non-significantly more likely (AOR: 2.40; 95% CI: 1.25, 4.62 and AOR: 1.59; 95% CI: 0.88, 2.85; respectively). Among HIV-positive women, HAART users were non-significantly more likely to use contraception compared with HAART-naïve women (AOR: 1.55; 95% CI: 0.84, 2.88). Similar patterns held for specific use of barrier (primarily male condoms), permanent, and dual protection contraceptive methods.
Among HIV-positive women receiving HAART, the observed higher prevalence of contraceptive use overall and condoms in particular promises to yield fewer unintended pregnancies and reduced risks of vertical and sexual HIV transmission. These findings highlight the potential of integrated HIV and reproductive health services to positively impact maternal, partner, and child health.
PMCID: PMC2974641  PMID: 21079770
10.  Longitudinal study of correlates of modern contraceptive use and impact of HIV care programmes among HIV concordant and serodiscordant couples in Rakai, Uganda 
To assess trends and determinants of family planning use and impact of HIV serostatus among couples.
Couples’ data were retrospectively linked from cohort surveys in Rakai, Uganda between 1999 and 2011, and were classified by HIV status as concordant (M+F+/M−F−) or serodiscordant (M−F+/M+F−). HIV care (HIVC) was grouped into three periods, pre-antiretroviral therapy (pre-HIVC) (<2004), HIVC roll-out (2005–2007) and HIVC scale-up (≥2008). Trends in couple contraceptive use were assessed by chi-square test (χ2) for trend, and multinomial logistic regression was used to estimate adjusted odds ratios (ORs) of predictors of contraceptive use.
A toal of 6139 couples contributed 13 709 observations. Hormonal contraception (HC) use increased over time from 22.9% to 33.9%, p<0.001), with significant increases among M−F− (23.2% to 34.8%, p<0.0001) and M+F+ (20.8% to 32.2%, p=0.0005), but not serodiscordant couples. Condom use significantly increased among M+F+ (30.3% to 48.0%, p<0.001) and serodiscordant couples (24.2% to 48.7%, p<0.001), but not among M−F− couples. Dual use of HC and condoms increased over time, irrespective of HIV status. Factors associated with increases in contraceptive use were: higher education, co-resident children, male non-marital relationship and scaled-up HIVC phase. Enrolment into HIVC was associated with increased HC and condom use among HIV+ concordant [adjusted OR (adjOR)=3.03; 95% confidence interval (CI) 1.69–5.44 and adjOR=4.46, 95% CI 2.53–7.86, respectively], and serodiscordant couples (adjOR=2.21; 95% CI 1.25–3.92 and adjOR=4.75; 95% CI 2.89–7.82, respectively).
Use of modern contraception and dual method use increased over time, particularly after enrolment into HIVC. Integration of HIV and reproductive health services is critical for prevention of unwanted pregnancies and HIV infection.
PMCID: PMC4078711  PMID: 23955379
hormonal contraception; human immunodeficiency virus; condom; family planning service provision
11.  Preventing Unintended Pregnancy and HIV Transmission: Effects of the HIV Treatment Cascade on Contraceptive Use and Choice in Rural KwaZulu-Natal 
Supplemental Digital Content is Available in the Text.
For women living with HIV, contraception using condoms is recommended because it prevents not only unintended pregnancy but also acquisition of other sexually transmitted infections and onward transmission of HIV. Dual-method dual-protection contraception (condoms with other contraceptive methods) is preferable over single-method dual-protection contraception (condoms alone) because of its higher contraceptive effectiveness. We estimate the effect of progression through the HIV treatment cascade on contraceptive use and choice among HIV-infected women in rural South Africa.
We linked population-based surveillance data on contraception collected by the Wellcome Trust Africa Centre for Health and Population Studies to data from the local antiretroviral treatment (ART) program in Hlabisa subdistrict, KwaZulu-Natal. In bivariate probit regression, we estimated the effects of progressing through the cascade on contraceptive choice among HIV-infected sexually active women aged 15–49 years (N = 3169), controlling for a wide range of potential confounders.
Contraception use increased across the cascade from <40% among HIV-infected women who did not know their status to >70% among women who have been on ART for 4–7 years. Holding other factors equal (1) awareness of HIV status, (2) ART initiation, and (3) being on ART for 4–7 years increased the likelihood of single-method/dual-method dual protection by the following percentage points (pp), compared with women who were unaware of their HIV status: (1) 4.6 pp (P = 0.030)/3.5 pp (P = 0.001), (2) 10.3 pp (P = 0.003)/5.2 pp (P = 0.007), and (3) 21.6 pp (P < 0.001)/11.2 pp (P < 0.001).
Progression through the HIV treatment cascade significantly increased the likelihood of contraception in general and contraception with condoms in particular. ART programs are likely to contribute to HIV prevention through the behavioral pathway of changing contraception use and choice.
PMCID: PMC4251916  PMID: 25436821
unintended pregnancy; HIV; AIDS; reproductive health; contraception; condoms; HIV transmission
12.  Contraceptive use and unmet need for family planning among HIV positive women on antiretroviral therapy in Kumasi, Ghana 
BMC Women's Health  2014;14:126.
A key strategy for minimizing HIV infection rates especially via reduction of Mother– to-Child transmission is by reducing the unmet need for family planning. In Ghana, the integration of family planning services into Antiretroviral Therapy services for persons living with HIV/AIDS has largely been ignored. We set out to measure the prevalence of modern methods of contraception, the unmet need for family planning and to identify factors associated with the use of modern methods of contraception among HIV positive women on anti retroviral therapy.
This was a descriptive cross sectional study of HIV positive women in their reproductive ages accessing care at an adult Antiretroviral Therapy Clinic in Kumasi, Ghana. Data was collected using a structured questionnaire. Data analysis was conducted using Epi Info version
A total of 230 women were included in the study. Fifty six percent were in the 30–39 year age group. The mean age (SD) was 36.3 (5.4) years. While 53.5% of respondents desired to have children, partner desire for children was reported by 54.6% of respondents with partners. About 74% had received information on contraception from their provider. 42.6% of participants and/or their partners were using a contraception method at the time of study; the male condom (79.6%) being the most commonly used method. The estimated unmet need for contraception was 27.8%. Contraceptive use was strongly associated with partner knowledge of HIV status (AOR = 3.64; 95% CI 1.36–9.72; p = 0.01) and use of a contraceptive method prior to diagnosis of HIV (AOR = 6.1; 2.65–14.23; p < 0.001).
Contraceptive Prevalence is high among HIV positive women in Kumasi compared with the general Ghanaian population. Despite this, there still is a high unmet need for family planning in this population. We recommend continuous education on contraceptives use to HIV patients accessing HAART services to further increase contraceptive uptake.
PMCID: PMC4286913  PMID: 25306546
Contraception; Unmet need; Ghana; HIV positive women
13.  Pregnancy in HIV Clinical Trials in Sub Saharan Africa: Failure of Consent or Contraception? 
PLoS ONE  2013;8(9):e73556.
Higher than expected pregnancy rates have been observed in HIV related clinical trials in Sub-Saharan Africa. We designed a qualitative study to explore the factors contributing to high pregnancy rates among participants in two HIV clinical trials in Sub-Saharan Africa.
Female and male participants enrolled in one of two clinical HIV trials in south-west Uganda were approached. The trials were a phase III microbicide efficacy trial among HIV negative women using vaginal gel (MDP); and a trial of primary prevention prophylaxis for invasive cryptococcal disease using fluconazole among HIV infected men and women in Uganda (CRYPTOPRO). 14 focus group discussions and 8 in-depth interviews were conducted with HIV positive and negative women and their male partners over a six month period. Areas explored were their experiences about why and when one should get pregnant, factors affecting use of contraceptives, HIV status disclosure and trial product use.
All respondents acknowledged being advised of the importance of avoiding pregnancy during the trial. Factors reported to contribute to pregnancy included; trust that the investigational product (oral capsules/vaginal gel) would not harm the baby, need for children, side effects that led to inconsistent contraceptive use, low acceptance of condom use among male partners. Attitudes towards getting pregnant are fluid within couples over time and the trials often last for more than a year. Researchers need to account for high pregnancy rates in their sample size calculations, and consider lesser used female initiated contraceptive options e.g. diaphragm or female condoms. In long clinical trials where there is a high fetal or maternal risk due to investigational product, researchers and ethics committees should consider a review of participants contraceptive needs/pregnancy desire review after a fixed period, as need for children, partners and health status of participants may alter over time.
PMCID: PMC3769278  PMID: 24039981
14.  Injectable and Oral Contraceptive Use and Cancers of the Breast, Cervix, Ovary, and Endometrium in Black South African Women: Case–Control Study 
PLoS Medicine  2012;9(3):e1001182.
A case-control study conducted in South Africa provides new estimates of the risk of specific cancers of the female reproductive system associated with use of injectable and oral contraceptives.
Oral contraceptives are known to influence the risk of cancers of the female reproductive system. Evidence regarding the relationship between injectable contraceptives and these cancers is limited, especially in black South Africans, among whom injectable contraceptives are used more commonly than oral contraceptives.
Methods and Findings
We analysed data from a South African hospital-based case–control study of black females aged 18–79 y, comparing self-reported contraceptive use in patients with breast (n = 1,664), cervical (n = 2,182), ovarian (n = 182), and endometrial (n = 182) cancer, with self-reported contraceptive use in 1,492 control patients diagnosed with cancers with no known relationship to hormonal contraceptive use. We adjusted for potential confounding factors, including age, calendar year of diagnosis, education, smoking, alcohol, parity/age at first birth, and number of sexual partners. Among controls, 26% had used injectable and 20% had used oral contraceptives. For current and more recent users versus never users of oral or injectable contraceptives, the odds ratios (ORs) for breast cancer were significantly increased in users of oral and/or injectable contraceptives (OR 1.66, 95% CI 1.28–2.16, p<0.001) and separately among those exclusively using oral (1.57, 1.03–2.40, p = 0.04) and exclusively using injectable (OR 1.83, 1.31–2.55, p<0.001) contraceptives; corresponding ORs for cervical cancer were 1.38 (1.08–1.77, p = 0.01), 1.01 (0.66–1.56, p = 0.96), and 1.58 (1.16–2.15, p = 0.004). There was no significant increase in breast or cervical cancer risk among women ceasing hormonal contraceptive use ≥10 y previously (p = 0.3 and p = 0.9, respectively). For durations of use ≥5 y versus never use, the ORs of ovarian cancer were 0.60 (0.36–0.99, p = 0.04) for oral and/or injectable contraceptive use and 0.07 (0.01–0.49, p = 0.008) for injectable use exclusively; corresponding ORs for endometrial cancer were 0.44 (0.22–0.86, p = 0.02) and 0.36 (0.11–1.26, p = 0.1).
In this study, use of oral and of injectable hormonal contraceptives was associated with a transiently increased risk of breast and cervical cancer and, for long durations of use, with a reduced risk of ovarian and endometrial cancer. The observed effects of injectable and of oral contraceptives on cancer risk in this study did not appear to differ substantially.
Please see later in the article for the Editors' Summary
Editors' Summary
Hormonal contraceptives are among the most commonly used medications. Globally, more than 210 million women currently use either hormonal contraceptive pills or injectable contraceptives. Contraceptive pills usually contain manmade versions of the female sex hormones estrogen and progesterone (the combined oral contraceptive, or “pill”); most injectable hormonal contraceptives contain only manmade progesterone preparations. Hormonal contraceptives, which prevent pregnancy by disrupting the cyclical changes in estrogen and progesterone levels that prepare the body for pregnancy, have revolutionized birth control since they first became available in the early 1960s. However, it is now known that taking the pill also influences women's risk of developing cancers of the female reproductive system. Current and recent users have an increased risk of developing breast and cervical cancer (the cervix is the structure that connects the womb to the vagina) compared to never users, although this increased risk quickly disappears when women stop taking the pill. By contrast, women who have used the pill have a reduced risk of developing ovarian cancer and cancer of the womb (endometrial cancer) compared to never users that increases with the duration of pill use and persists for many years after use ceases. These effects on reproductive system cancers are thought to occur because these cancers depend on naturally occurring sex hormones for their development and growth.
Why Was This Study Done?
Although the evidence that the pill influences the risk of developing cancers of the female reproductive system is extensive, much less is known about how injectable hormonal contraceptives affect cancer risk. In this hospital-based case–control study (a study that compares the characteristics of people with and without a specific condition), the researchers investigate the relationship between the use of oral and injectable hormonal contraceptives and cancers of the breast, cervix, ovary, and endometrium among black South African women. Injectable contraceptives have been used for longer in South Africa than elsewhere and are used more commonly than oral contraceptives among black South African women.
What Did the Researchers Do and Find?
As part of the Johannesburg Cancer Case Control Study, which recruits black patients attending Johannesburg public referral hospitals for cancer treatment, the researchers compared hormonal contraceptive use in women with breast, cervical, ovarian, or endometrial cancer with contraceptive use in women diagnosed with other cancers such as lung, colon, and rectal cancers, which are not known to be influenced by hormonal contraceptives. Among the controls, a quarter had used injectable contraceptives and a fifth had used oral contraceptives. After adjusting for other factors that might influence cancer risk such as age, smoking, and number of sexual partners, the odds ratio (OR) of breast cancer among current and recent users of oral and/or injectable contraceptives compared to never users was 1.66. That is, the risk of developing breast cancer among current and recent users of hormonal contraceptives was 1.66 times that among never users. For women using oral contraceptives exclusively or injectable contraceptives exclusively, the ORs of breast cancer were 1.57 and 1.83, respectively. There were also increases in cervical cancer risk among current and recent users of hormonal contraceptives compared to never users, but no significant increase in breast or cervical cancer risk among women who had ceased hormonal contraceptive use more than ten years previously. Finally, the use of hormonal contraceptives for more than five years reduced the risk of both ovarian and endometrial cancer.
What Do These Findings Mean?
These findings indicate that, among black women in South Africa, the use of oral or injectable hormonal contraceptives is associated with a transiently increased risk of breast and cervical cancer, and that extended use of these contraceptives is associated with a reduced risk of ovarian and endometrial cancer. Moreover, they suggest that the effects of oral versus injectable contraceptives on cancer risk do not differ substantially, although for endometrial and ovarian cancer the small number of cases exposed to injectable contraceptives limits the accuracy of the risk estimates. Other limitations of this study include the possibility that the findings may be affected by uncontrolled confounding. That is, women who used hormonal contraceptives may have shared other unidentified characteristics that affected their cancer risk. Nevertheless, these findings provide new information about the effects of oral and injectable hormonal contraceptives on cancer risk that should help women make informed decisions about their choice of contraceptive method.
Additional Information
Please access these web sites via the online version of this summary at
The US National Cancer Institute provides information on breast cancer (including personal stories from breast cancer survivors), cervical cancer, ovarian cancer, and endometrial cancer for patients and health professionals, and a fact sheet on oral contraceptives and cancer risk (in English and Spanish)
Cancer Research UK also provides information on breast cancer, cervical cancer, ovarian cancer, and endometrial cancer and information about the birth control pill and cancer risk
Eyes on the Prize, an online support group for women who have had cancers of the female reproductive system, has personal stories; further personal stories about breast, cervical, and ovarian cancer are provided by the charity Healthtalkonline
PMCID: PMC3295825  PMID: 22412354
15.  To use or not to use a condom: A prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda 
BMC Infectious Diseases  2011;11:144.
Unwanted pregnancy and HIV infection are issues of significant concern to young people. Limited data exists on contraceptive decision-making and practices among HIV-infected and HIV-negative young people in low resource settings with generalized HIV epidemics.
From July 2007 until April 2009, we recruited, and followed up over a one year period, a cohort of 501 HIV-negative and 276 HIV-infected young women and men aged 15-24 years residing in Kampala and Wakiso districts. We compared contraceptive use among HIV-infected and HIV-negative young people and assessed factors associated with contraceptive decision-making and use, using multivariate logistic regression modelling to estimate odds ratios (OR) and 95% confidence intervals (CI).
Contraceptive use among sexually active HIV-infected young people was 34% while it was 59% among the HIV-negative group. The condom was the most frequently used method of contraception. Only 24% of the HIV-infected used condoms consistently compared to 38% among the negative group OR 0.56 (95% CI 0.38, 0.82). HIV-infected young people were more likely to discuss safe sex behaviour with health workers OR 1.70 (95% CI 1.13, 2.57), though its effect on fertility decision-making was not significant. Throughout the year's follow-up, only 24% among the HIV-negative and 18% among the HIV-infected continued to use contraception while 12% and 28% among the HIV-negative and infected respectively did not use contraception at all. At multivariate analysis, the HIV-infected young people were less likely to maintain contraceptive use. Other factors independently associated with sustained contraceptive use were age of the respondent, marital status and being a male. Conversely, HIV-infected young people were less likely to initiate use of contraception. Being married or in a relationship was associated with higher odds of initiating contraceptive use.
Compared to the HIV-negative group, sexually active HIV-infected young people are less likely to use contraception and condoms. Initiating or sustaining contraceptive use was also significantly less among the HIV-infected group. Strengthening family planning services and developing new innovative ideas to re-market condom use are needed. Policy and guidelines that empower health workers to help young people (especially the HIV infected) express their sexuality and reproduction should urgently be developed.
PMCID: PMC3128049  PMID: 21605418
16.  Utilization of contraceptives by persons living with HIV in Eastern Uganda: a cross sectional study 
Reproductive Health  2015;12:40.
In Uganda, there has been an increase in use of contraceptives by 6% from 2006 to 2011 among married women. During the same period HIV prevalence had gone up by 0.9%. Lack of use of contraceptives especially among persons living with HIV may escalate the spread of the virus. The purpose of the study was to determine the rate of contraceptive use and associated factors among persons receiving HIV care and treatment in Eastern Uganda.
A cross-sectional study was conducted in 4 public hospitals of Mbale, Kapchorwa, Atutur and Pallisa in Eastern Uganda. In total, 300 respondents comprising of women aged (15–49) and men (15–54) years were interviewed using interviewer administered questionnaires. However, data from 298 respondents were analyzed using multinomial logistic regression at α = 0.05 in STATA statistical software (Version 10).
Approximately 62% (185/298) of persons living with HIV had used contraceptives within the three months preceding the study. Among the significant predictors, higher proportions of female respondents aged 36–49 years used injectables and male aged 50–54 years used condoms (p = 0.030 and p = 0.034, respectively). Furthermore, higher proportions of respondents with primary, secondary and tertiary education levels were more likely to use condoms (p = 0.004, p = 0.000 and p = 0.005, respectively) compared with those who never went to school. Besides, condoms were being used by Protestants (p = 0.000) compared to Catholics and Muslims. Also, more female respondents (p = 0.000) used condoms with their partners compared with the male counterparts. The main barrier to contraceptive use among non-users was desire for more children.
More efforts are needed to sensitize and provide contraceptives targeting the illiterate clients, youth, men and believers from different religious sects to increase utilization.
PMCID: PMC4429408  PMID: 25948094
Contraceptives; Utilization; HIV; Eastern Uganda
17.  Contraceptive discontinuation and switching among couples receiving integrated HIV and family planning services in Lusaka, Zambia 
AIDS (London, England)  2013;27(0 1):S93-103.
To describe predictors of contraceptive method discontinuation and switching behaviors among HIV positive couples receiving couples' voluntary HIV counseling and testing services in Lusaka, Zambia.
Couples were randomized in a factorial design to two family planning educational intervention videos, received comprehensive family planning services, and were assessed every 3-months for contraceptive initiation, discontinuation and switching.
We modeled factors associated with contraceptive method upgrading and downgrading via multivariate Andersen-Gill models.
Most women continued the initial method selected after randomization. The highest rates of discontinuation/switching were observed for injectable contraceptive and intrauterine device users. Time to discontinuing the more effective contraceptive methods or downgrading to oral contraceptives or condoms was associated with the women's younger age, desire for more children within the next year, heavy menstrual bleeding, bleeding between periods, and cystitis/dysuria. Health concerns among women about contraceptive implants and male partners not wanting more children were associated with upgrading from oral contraceptives or condoms. HIV status of the woman or the couple was not predictive of switching or stopping.
We found complicated patterns of contraceptive use. The predictors of contraception switching indicate that interventions targeted to younger couples that address common contraception-related misconceptions could improve effective family planning utilization. We recommend these findings be used to increase the uptake and continuation of contraception, especially long acting reversible contraceptive (LARC) methods, and that fertility-goal based, LARC-focused family planning be offered as an integral part of HIV prevention services.
PMCID: PMC4070372  PMID: 24088689
Contraceptive discontinuation; couples' voluntary HIV counseling and testing; family planning; long-acting reversible contraception; Zambia
18.  Unmet Need for Family Planning, Contraceptive Failure, and Unintended Pregnancy among HIV-Infected and HIV-Uninfected Women in Zimbabwe 
PLoS ONE  2014;9(8):e105320.
Prevention of unintended pregnancies among women living with HIV infection is a strategy recommended by the World Health Organization for prevention of mother-to-child transmission of HIV (PMTCT). We assessed pregnancy intentions and contraceptive use among HIV-positive and HIV-negative women with a recent pregnancy in Zimbabwe.
We analyzed baseline data from the evaluation of Zimbabwe’s Accelerated National PMTCT Program. Eligible women were randomly sampled from the catchment areas of 157 health facilities offering PMTCT services in five provinces. Eligible women were ≥16 years old and mothers of infants (alive or deceased) born 9 to 18 months prior to the interview. Participants were interviewed about their HIV status, intendedness of the birth, and contraceptive use.
Of 8,797 women, the mean age was 26.7 years, 92.8% were married or had a regular sexual partner, and they had an average of 2.7 lifetime births. Overall, 3,090 (35.1%) reported that their births were unintended; of these women, 1,477 (47.8%) and 1,613 (52.2%) were and were not using a contraceptive method prior to learning that they were pregnant, respectively. Twelve percent of women reported that they were HIV-positive at the time of the survey; women who reported that they were HIV-infected were significantly more likely to report that their pregnancy was unintended compared to women who reported that they were HIV-uninfected (44.9% vs. 33.8%, p<0.01). After adjustment for covariates, among women with unintended births, there was no association between self-reported HIV status and lack of contraception use prior to pregnancy.
Unmet need for family planning and contraceptive failure contribute to unintended pregnancies among women in Zimbabwe. Both HIV-infected and HIV-uninfected women reported unintended pregnancies despite intending to avoid or delay pregnancy, highlighting the need for effective contraceptive methods that align with pregnancy intentions.
PMCID: PMC4140753  PMID: 25144229
19.  Utilization of Modern Contraceptives among HIV Positive Reproductive Age Women in Tigray, Ethiopia: A Cross Sectional Study 
ISRN AIDS  2013;2013:319724.
Background. HIV infected women in sub-Saharan Africa are at substantial risk of unintended pregnancy and sexually transmitted infections. In developing countries including Ethiopia counseling and provision of modern contraceptives of choice to HIV infected women including those on antiretroviral therapy (ART) is an important strategy to prevent unintended pregnancies and sexually transmitted infections. Little is known about the existing practices and utilization of modern contraceptives among HIV positive reproductive age women attending ART units. Objective. The aim of this study was to assess utilization of modern contraceptives and associated factors among HIV positive reproductive age women attending ART units in zonal hospitals of Tigray region, North Ethiopia. Method. Institution based cross-sectional study was conducted by interviewing 364 HIV positive reproductive age women in all zonal hospitals of Tigray region using systematic sampling technique. Structured and pretested questionnaire was used to obtain information from the respondents. Descriptive, bivariate, and multivariate methods were used to analyze utilization of modern contraceptives and the factors associated with it. Result. Three hundred sixty-four subjects participated with a response rate of 99.2%. The mean age of the respondents was 31.9 ± 6.5 (SD) years. About 46% of participants utilized modern contraceptives, 59.9% out of them used dual method. However, a significant proportion of the respondents (46%) reported that they wished to have a desire for children. Being secondary education and higher (AOR: 2.85; 95% CI: 1.17–6.95) and currently on HAART (AOR: 3.23; 95% CI: 1.49–7.01) they were more likely to utilize modern contraceptive. But those women who were ≥25 years old, house wives, single, divorced, or widowed were less likely to utilize modern contraceptive. Conclusion. Results of this study revealed that the number of respondents who were ever heard of modern contraceptives was high. However, modern contraceptive utilization was still low. Additional efforts are needed to promote modern contraceptive utilization in general and dual method use in particular among HIV positive reproductive age women.
PMCID: PMC3800562  PMID: 24224116
20.  The Impact of Contraceptive Counseling in Primary Care on Contraceptive Use 
Whether contraceptive counseling improves contraceptive use is unknown.
To evaluate the association between contraceptive counseling provided by primary care physicians and patients’ contraceptive use.
All women aged 18–50 who visited one of four primary care clinics between October 2008 and April 2010 were invited to complete surveys about their visit. Seven to 30 days post visit, participants completed a survey assessing pregnancy intentions, receipt of contraceptive counseling, and use of contraception at last sexual intercourse. Survey data were linked to medical record data regarding contraceptive prescriptions prior to and during the clinic visit. Women were classified as in need of contraceptive counseling if they were sexually active, were not pregnant or trying to get pregnant, and had no evidence of contraceptive use prior to their index clinic visit.
Fifty percent (n = 386) of women were in need of contraceptive counseling at the time of their visit. Those who received contraceptive counseling from a primary care provider were more likely to report use of hormonal contraception when they last had sex (unadjusted OR: 3.83, CI: 2.25–6.52), even after adjusting for age, race, education, income, marital status, pregnancy intentions, and prior pregnancy (adjusted OR: 2.68, CI: 1.48–4.87). Counseling regarding specific types of contraception was associated with an increased use of those methods. For example, counseling regarding hormonal contraceptives was associated with a greater likelihood of use of hormonal methods (adjusted OR: 4.78, CI: 2.51–9.12) and counseling regarding highly effective reversible methods was highly associated with use of those methods (adjusted OR: 18.45, CI: 4.88–69.84). These same relationships were observed for women with prior evidence of contraceptive use.
Contraceptive counseling in primary care settings is associated with increased hormonal contraceptive use at last intercourse. Increasing provision of contraceptive counseling in primary care may reduce unintended pregnancy.
PMCID: PMC3138576  PMID: 21301983
contraceptive counseling; contraception; primary care; women’s health
21.  Contraceptive Utilization and Associated Factors among HIV Positive Women on Chronic Follow Up Care in Tigray Region, Northern Ethiopia: A Cross Sectional Study 
PLoS ONE  2014;9(4):e94682.
In sub-Sahara Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Maternal to child transmission is responsible for 90% of childhood HIV infection. Preventing unwanted pregnancy among HIV positive women is imperative to reduce maternal and infant morbidity and mortality.
A cross-sectional survey was conducted among 964 HIV positive women in selected 12 health centers of Tigray region. In this paper, analysis was restricted only for 847 women who were sexually active and non-pregnant. In each health center the number of study participants was allocated proportionally to the load of HIV positive women in chronic care clinics. The data were entered into EpiData version 3.1, and cleaned and analyzed using Stata version 11.1. Descriptive summary of data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05.
Three hundred ninety four (46.5%) of all HIV positive women had intension to have more children. Three hundred seventy five (44.3%) were using contraceptive methods at time of survey. Injectable (70.7%) and male condom (47.6%) were most commonly used type of contraceptives. In the multivariable analysis, women who were urban dwellers (AOR = 2.55; 95% CI: 1.27, 5.02), completed primary education (AOR = 2.27; 95% CI: 1.12, 2.86) and those openly discussed about contraceptive methods with their husbands or sexual partners (AOR = 6.3; 95% CI: 3.42, 11.76) were more likely to use contraceptive. Women who have one or more living children were also more likely to use contraceptive compared with women with no child.
Less than half of women used contraceptive methods. The use of condoms could impact unintended pregnancies and reduced risks of vertical and sexual transmission. Efforts to increase contraceptive utilization focusing on the barrier methods should be strengthen in HIV/AIDS chronic care units.
PMCID: PMC3990566  PMID: 24743241
22.  Factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum HIV positive and negative women in Cape Town, South Africa: a cross-sectional study 
BMC Public Health  2012;12:197.
The prevention of unintended pregnancies among HIV positive women is a neglected strategy in the fight against HIV/AIDS. Women who want to avoid unintended pregnancies can do this by using a modern contraceptive method. Contraceptive choice, in particular the use of long acting and permanent methods (LAPMs), is poorly understood among HIV-positive women. This study aimed to compare factors that influence women's choice in contraception and women's knowledge and attitudes towards the IUD and female sterilization by HIV-status in a high HIV prevalence setting, Cape Town, South Africa.
A quantitative cross-sectional survey was conducted using an interviewer-administered questionnaire amongst 265 HIV positive and 273 HIV-negative postpartum women in Cape Town. Contraceptive use, reproductive history and the future fertility intentions of postpartum women were compared using chi-squared tests, Wilcoxon rank-sum and Fisher's exact tests where appropriate. Women's knowledge and attitudes towards long acting and permanent methods as well as factors that influence women's choice in contraception were examined.
The majority of women reported that their most recent pregnancy was unplanned (61.6% HIV positive and 63.2% HIV negative). Current use of contraception was high with no difference by HIV status (89.8% HIV positive and 89% HIV negative). Most women were using short acting methods, primarily the 3-monthly injectable (Depo Provera). Method convenience and health care provider recommendations were found to most commonly influence method choice. A small percentage of women (6.44%) were using long acting and permanent methods, all of whom were using sterilization; however, it was found that poor knowledge regarding LAPMs is likely to be contributing to the poor uptake of these methods.
Improving contraceptive counselling to include LAPM and strengthening services for these methods are warranted in this setting for all women regardless of HIV status. These study results confirm that strategies focusing on increasing users' knowledge about LAPM are needed to encourage uptake of these methods and to meet women's needs for an expanded range of contraceptives which will aid in preventing unintended pregnancies. Given that HIV positive women were found to be more favourable to future use of the IUD it is possible that there may be more uptake of the IUD amongst these women.
PMCID: PMC3328250  PMID: 22424141
PMTCT; Contraception; Fertility intentions; Unintended pregnancies; HIV; IUD; Female sterilization
23.  Sexual behaviour, contraceptive knowledge and use among female undergraduates’ students of Muhimbili and Dar es Salaam Universities, Tanzania: a cross-sectional study 
BMC Women's Health  2014;14:94.
The rate of premarital sexual activity, unwanted pregnancies and illegal abortions remain higher among university students. This calls for understanding the knowledge on contraceptive use and sexual behaviours among this high risk group if the incidence of unintended pregnancy, illegal abortions and high sexual risky behaviour are to be minimized. This study aimed to assess ssexual behaviour, contraceptive knowledge and use among female undergraduates’ students of Muhimbili and Dar es Salaam Universities in Tanzania.
A cross-sectional analytic study was conducted among undergraduate female students in the two Universities located in Dar es Salaam region, Tanzania. The study period was from June 2013 to October 2013. A self-administered questionnaire was given to 281 students. Of these, 253 were retrieved, giving a response rate of 90%. Data was analyzed using Statistical Package for Social Science (SPSS) for Windows version 17.0. Descriptive statistics were summarized. The chi square test was used to examine relationship between various sociodemographic and sexual behaviours variables with contraceptive use. A P-value of less than 0.05 was considered statistically significant.
Results showed that majority (70.4%) of the students have had sexual intercourse. All participants had knowledge of contraception. More than half, 148 (58.5%) of sexually active women reported ever used contraception before while 105 (41.5%) were current contraceptive users. Majority (74.7%) of the sexually active group started sexual activity at young age (19–24 years). Condom, 221(24.3%) and pills, 153 (16.8%) were the known contraceptive methods. The most popular method of contraception used were condoms, withdrawal and periodic abstinence. The main sources of information about contraception were from friends, radio and school (39.5%, 36% and 24%) respectively. Forty (15.8%) women had pregnancies. Of these, 11 (27%) have had unwanted pregnancies among which 54.6% have had induced abortion. Marital status, age at first sex, ever had sex, ever been pregnant and unwanted pregnancies were associated with use of contraception.
Most of the student’s had knowledge of contraception. However, rate of contraception use is still low. Majority of the respondent were sexually active, with the majority started sexual activity at young age. This needs advocacy for adolescence reproductive health education to promote the use of the available contraceptive services amongst university students.
PMCID: PMC4126911  PMID: 25099502
Sexual behaviour; Contraceptive Knowledge; Use; University students Tanzania
24.  Dual method use for protection of pregnancy and disease prevention among HIV-infected women in South East Nigeria 
BMC Women's Health  2014;14:39.
sub-Saharan Africa continue to bear the greatest burden of HIV/AIDS epidemic due to its large population, high fertility rate and unmet contraceptive need, most especially with poor uptake of dual methods (use of condom and another effective family planning method) which protects against STIs/HIV and unplanned pregnancy. The aim of this study was to assess the awareness, pattern and practice of dual methods by HIV infected women, and factors influencing its use in southeast Nigeria.
This was a cross sectional descriptive study of 658 HIV positive women attending the PMTCT/postnatal/family planning clinics in three health facilities in southeast Nigeria. An interviewer administered semi-structured questionnaire was used to abstract needed information. The data were analyzed with Epi-info™ version 7.0 (Centers for Disease Control and Prevention, Atlanta, GA, USA), Odd ratio was determined and the test of statistical significance was with Fisher exact test at 95% CI.
The mean age of the participants was 29 ± 4.3 years. All the respondents were aware of their HIV status, 62.4% did not know their partners status; 23.1% were sero-concordant, while 14.5% were sero-discordant. Most (67.9%) of the respondents lack awareness on dual methods with only 179/658 (27.2%) practicing it. The commonest (141/179; 78.9%) dual method used was a combination of condom and injectable hormonal contraceptives. Lack of awareness (222/479; 46.3%) and non disclosure (133/479; 27.8%) were the main reasons for non use of dual method in the present study. STI’s was higher amongst non users with odd ratio of 1.74 (1.26-2.41), p-value < 0.0004. Unplanned pregnancy was higher in non users with odd ratio of 3.89 (2.52-6.00), p-value < 0.0000 at 95% CI.
The awareness and uptake of dual methods amongst HIV infected women in southeast Nigeria is still low and thus associated with a higher risk of STIs and unplanned pregnancy. It is expected that increased awareness, uptake and consistent use will help prevention new infections of HIV/STIs and unplanned pregnancy.
PMCID: PMC3973850  PMID: 24602410
HIV; AIDS; Dual methods; Safer sex; Parturient; Barrier; Safer sex
25.  Hormonal contraceptive use and risk of HIV-1 disease progression 
AIDS (London, England)  2013;27(2):261-267.
For HIV-1 infected women, hormonal contraception prevents unintended pregnancy, excess maternal morbidity, and vertical HIV-1 transmission. Hormonal contraceptives are widely used but their effects on HIV-1 disease progression are unclear.
In a prospective study among 2269 chronically HIV-1 infected women from 7 countries in East and southern Africa and with enrollment CD4 counts ≥250 cells/mm3, we compared rates of HIV-1 disease progression among those using and not using hormonal contraception (i.e. oral or injectable methods). The primary outcome was a composite endpoint of CD4 decline to <200 cells/mm3, initiation of antiretroviral therapy, or death.
372 women experienced HIV-1 disease progression during 3242 years of follow up (incidence rate=11.5 events per 100 person-years). Rates of HIV-1 disease progression among women who were currently using and not using hormonal contraception were 8.54 and 12.31 per 100 person-years, respectively (adjusted hazard ratio [HR] 0.74, 95% CI 0.56–0.98, p=0.04). Rates were 8.58 and 8.39 per 100 person-years for the subsets using injectable and oral contraception (adjusted HR=0.72, p=0.04 for injectable users and adjusted HR=0.83, p=0.5 for oral users compared to women not using hormonal contraception). Sensitivity analyses assessing enrollment or cumulative contraceptive use during the study demonstrated risk estimates closer to 1.0 with no evidence for accelerated disease progression.
Among African women with chronic HIV-1 infection, use of hormonal contraception was not associated with deleterious consequences for HIV-1 disease progression.
PMCID: PMC3740957  PMID: 23079806
HIV-1; women; hormonal contraception; death; CD4 count; antiretroviral therapy

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