Reproductive health needs of women with HIV in SSA

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The needs for safe conception services and a wider choice of contraception for women living with HIV in sub-Saharan Africa were highlighted recently at the 22nd International AIDS Conference (AIDS 2018) in Amsterdam.

Recent international and country-level guidance on the use of the antiretroviral drug dolutegravir with effective contraception, due to the risk of neural tube defects in infants exposed to the drug during the early weeks of pregnancy, drew attention to gaps in contraceptive availability.

A study by researchers at Johns Hopkins Bloomberg School of Public Health, Centre for the AIDS Programme of Research in South Africa (CAPRISA), Data Management Centre, Durban, University of Zimbabwe College of Health Sciences, Perinatal HIV Research Unit (PHRU), Chris Hani Baragwanath Hospital University of the Witwatersrand, University of North Carolina – Lilongwe, Makerere University Johns Hopkins University – Uganda and the Nelson R Mandela School of Medicine, covering four countries in southern and eastern Africa found high rates of unintended pregnancy among women on antiretroviral treatment due to lack of access to effective contraception.

A second study by researchers at Johns Hopkins University, Witkoppen Health and Welfare Centre in Johannesburg, University of the Witwatersrand and the University of Antwerp, looked at the outcomes of a demonstration project designed to help women with HIV and the HIV-negative partners of men with HIV conceive safely. Among 1,985 women living with HIV on lifelong antiretroviral therapy (ART) from eight sites in Uganda, Zimbabwe, Malawi and South Africa, overall half (49.9%) said their last pregnancy was unintended with over half not wanting to have more children, Dr Jim Aizire, reported on behalf of the long-term PEPFAR-PROMOTE cohort study, at the conference.

The study, an extension of a completed mother-to-child transmission prevention trial, enrolled mothers and their children from December 2016 to June 2017.

Differences in unintended pregnancies varied considerably by site, from over 80% in Durban, South Africa, to close to 30% in Kampala, Uganda, and Harare, Zimbabwe, (p < 0.001). 79.9% of sexually active, non-pregnant women reported using effective contraceptive methods (injectable, oral, intra-uterine device (IUD), implant or tubal ligation). Among women without permanent contraception, 18.8% reported using long-acting reversible contraceptives (LARC) including implants or IUDs. Injectables and implants were the most common methods reported overall, 40.6% and 19.3%, respectively. An estimated 90% of unintended pregnancies among African women are associated with not using effective contraception. Over 60% of women have an unmet need for effective family planning methods in the region, and for women living with HIV it is estimated to be considerably higher. Reasons most often cited for not using modern family planning include infrequent sex, safety, postpartum and breastfeeding, partner’s opposition and access issues. Studies suggest that choice of contraception can influence the sexual health of a women and/or her male partner. Limited data exist on specific contraceptive use and sexual health in sub-Saharan Africa, a region with the highest burden of HIV, of which women of reproductive age account for over 60%. LARC is the most effective reversible contraceptive for extended periods of time, not needing any user action. For many countries in the region, injectables account for over 50% of all reported family planning methods. Age, marital status, having the desired number of children, clinic travel time, household water and electricity in all multivariable models were not associated with contraceptive choice. Unemployed women, p = 0.008, those on ART, p = 0.001, and those with a viral load >1000 copies/ml, p = 0.003 were less likely to report LARC use.

Aizire concluded while unintended pregnancy is common among women living with HIV in sub-Saharan Africa, LARC do offer acceptable contraceptive choices in this context. These findings, he added, support further programmatic research for an integrated approach of delivering ART and LARC for African women living with HIV who face unique reproductive health challenges.

While pregnancy incidence was high among adults (in 334 partnerships with at least one partner HIV-positive) wishing to conceive and enrolled in safer conception care at Witkoppen Clinic in Johannesburg, South Africa between July 2013 and July 2017, women living with HIV were less likely to get pregnant compared to HIV-negative women (incident rate ratio (IRR): 0.48, 95%; CI:0.28-0.87).

Dr Sheree R Schwartz, presented on behalf of the Sakh’umndeni (‘building the family’) demonstration project at the conference.

Of the 98 pregnancies among 88 women, the majority (75) were living with HIV. Overall 66 (67%) delivered a baby while one in four miscarried. There were no HIV transmissions between partners or to the child. Median time to pregnancy was 0.8 years for HIV-negative women, yet it was almost three times as long (2.3 years) for women living with HIV.

Schwartz highlighted the need for ways to reduce onward transmission risks during this lengthy attempted conception given that viral suppression among women on ART cannot be assumed.

HIV affects many couples in South Africa. With prompt and early diagnosis, treatment and adherence, normal life expectancy is possible. Responding to couples attending the HIV clinic who wanted to have children, the Safer Conception Clinic began with the goal to help couples achieve their reproductive wishes while minimising the risk of HIV transmission between partners trying to get pregnant and preventing HIV infection of the baby.

Safer conception strategies include: ART for HIV-positive partners, pre-exposure prophylaxis (PrEP) for HIV-negative partners, timing of unprotected sex to most fertile days (one to two days each month), self-insemination, assisted reproductive technologies, sexually transmitted infection treatment and male medical circumcision (if the man is uninfected).

Each of the 334 partnerships (526 individuals: 334 women/192 men) received tailored safer conception care from a nurse. Monthly visits to provide additional safer conception counselling, HIV clinical management and regular pregnancy and HIV testing were expected.

There were slightly more couples of different HIV status than with the same status, 164 (49%) and 147 (44%), respectively – 57% (192/334) attended as couples, while 43% of the women were unaccompanied. Median age of women and men were 34 (IQR: 30-38) and 37 years (IQR: 33-42), respectively. Viral suppression (< 50 copies/ml) at baseline was 61% (176) and 46% (59) for women and men living with HIV, respectively.

Of the 2,956 safer conception visits 88% of the couples had one or more visits with an average number of 7.5 and 3.8 visits for women and men, respectively. Most women living with HIV were virally suppressed at the time of pregnancy – 85% (63/75) had < 50 copies/ml and 99% (74/75) < 1000 copies/ml. Safer conception strategies for HIV prevention and fertility planning appear effective. However, keeping a patient in regular care over a lengthy period of time to maximise health and then achieve pregnancy is problematic for health systems and patients.


Abstract 7362
Background: About 90% of unintended pregnancies among African women are attributed to non-use of effective family planning (EFP) methods (injectable, oral, intra-uterine device (IUD), implant, or tubal-ligation). Long acting reversible contraceptives (LARC), which include implants or IUDs, are the most effective reversible contraception for an extended period without requiring user action. We report frequency of unintended pregnancy and determinants of contraceptive choice among African women on life-long ART.
Methods: The US-PEPFAR PROMOTE is a long-term cohort study of HIV-infected women (n=1,986) and their children, enrolled from December 2016 to June 2017, as an extension to a completed mother-to-child transmission prevention trial from eight sites in Malawi, South Africa, Uganda, and Zimbabwe. Standardized questionnaires were used to collect demographic and reproductive health data. Baseline enrollment data were analyzed using chi square and Wilcoxon Rank-Sum tests for group comparisons, and multivariable logistic regression to identify determinants of contraceptive choice.
Results: Overall, among 1,984 women included in this analysis, 49.9% (n=990) reported that their last pregnancy was unintended (figure 1), and >50% had no desire for more children. Among sexually-active, non-pregnant women, 81.6% (1,050/1,287) reported EFP use; while 19.0% (227/1,197) without permanent contraception reported LARC methods. Injectables were the commonest method (39%) – especially at the South African sites (>50%), followed by implant (14.4%). Oral pills were popular in Zimbabwe and tubal-ligations were common in Malawi and South Africa. Non-pregnant women whose last pregnancy was unintended versus intended were more likely to report current EFP use, adjusted odds ratio (95% CI), 1.44 (1.10 -1.96), p=0.02; but not LARC use, 1.25 (0.92-1.70), p=0.15. Women with no formal employment were less likely to report LARC use, 0.64 (0.43-0.96), p=0.03, but not EFP-use, 0.92 (0.62-1.35), p=0.60. All multivariable models included age, marital-status, attained desired number of children, clinic travel-time, household water, and electricity, which were not associated with contraception choice.
Conclusions: Unintended pregnancy is common among HIV-infected African women. LARCs are acceptable contraceptive options in these settings, though under-utilized. Programmatic research should explore integrated ART and LARC delivery in consideration of the unique reproductive health challenges among HIV-infected African women on universal ART.

J Aizire, N Yende, T Nematadzira, ME Nyati, S Dadabhai, L Chinula, C Nakaye, M Naidoo, MG Fowler, T Taha, US-PEPFAR PROMOTE Cohort Study

Abstract 11898
Background: Safer conception strategies–ART for HIV-positive partners, PrEP for HIV-negative partners, timed condomless sex, self-insemination and male medical circumcision–empower couples affected by HIV trying to conceive to minimize HIV transmission risk to partners and potential children. We report outcomes from the Sakh”umndeni demonstration project, one of the first safer conception clinics in sub-Saharan Africa.
Methods: Adults trying to conceive and in relationships in which at least one partner was HIV-positive were enrolled into safer conception care at Witkoppen Clinic in Johannesburg, South Africa, between July 2013-July 2017. Patients were provided tailored safer conception care by a nurse. Time-to-first pregnancy was estimated using Kaplan-Meier curves; women who did not conceive were censored at date of termination or last follow-up visit.
Results: 526 individuals (334 women/192 men) from 334 partnerships participated. Couples were serodifferent (n=164, 49%), seroconcordant (n=147, 44%) or in relationships with one unknown status partner (n=23, 7%). Median ages of women and men were 34 [IQR:30-38] and 37 [IQR:33-42] respectively. At baseline, 64% of HIV-positive women and 45% of HIV-positive men were virally suppressed (< 50copies/ml). It took couples a median of 4.0 months [IQR:1.7-7.7] to be given the go-ahead to start trying to conceive. In total, 98 pregnancies among 88 women were observed. Pregnancy incidence was 47.9/100 person-years (95%CI:38.9,59.1). HIV-positive women were 52% less likely to conceive as HIV-negative women (IRR:0.48, 95%CI:0.28,0.87). Median time-to-pregnancy was 0.8 years for HIV-negative and 2.1 years for HIV-positive women (Figure). At time of pregnancy, most HIV-positive women were virally suppressed (63/75 [84%] < 50 copies/ml and 74/75 [99%] < 1000 copies/ml]. Of the 98 pregnancies, 66 (67%) delivered a baby, 24 (25%) had a miscarriage or ectopic pregnancy, 5 (5%) were still pregnant and 3 (3%) unknown. No horizontal or vertical HIV transmissions were observed.
Conclusions: HIV-positive women were less likely to conceive than HIV-negative women and risk of miscarriage was high. Prolonged attempted conception highlights the need for approaches to reduce onward transmission risks, particularly as viral suppression among patients trying to conceive on ART cannot be assumed. Safer conception strategies can help couples successfully conceive an HIV-free child without jeopardizing their own or partner”s health.

S Schwartz, J Bassett, M Mudavanhu, N Yende, R Phofa, L Mutunga, I Sanne, A Van Rie

Aidsmap material
AIDS 2018 abstract 7362
AIDS 2018 abstract 11898
International Guidance

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