HIV-positive Ugandan women who receive highly active antiretroviral therapy (HAART) are more likely to use contraceptives than their counterparts who do not receive such therapy, according to a clinic-based study in Mbarara.¹ Overall, 85% of sexually active study participants reported having used contraceptives in the past three months, and the vast majority of contraceptive users (84%) had used a barrier method. Among women treated with HAART, the odds of contraceptive use in general, and of barrier method use in particular, were more than twice those among women who were not receiving HAART (odds ratios, 2.6 and 3.6, respectively).

Uganda was an early adopter of antiretroviral therapy, and free HAART became accessible to the majority of the population in 2005. Almost half of HIV-infected Ugandans are reproductive-aged women, the researchers note, and although the total fertility rate is high and contraceptive use is low in the general population, data on contraceptive use among women receiving HAART is lacking. Some evidence suggests that women who use HAART are more likely than nonusers to want children, but may also be more likely to use condoms.

To assess the relationship between antiretroviral therapy and contraceptive use in this population, the investigators interviewed 484 HIV-positive female patients aged 18–50 at the HIV clinic of a regional referral hospital in Mbarara from November 2005 to June 2006. Women were classified as HAART users if they had taken at least one antiretroviral medication for nine months or more. In addition to providing their medical history and social and demographic information, the women answered questions about their sexual and reproductive behavior, contraceptive use and fertility desires. Respondents' HIV status and treatment history were obtained from the interviews and confirmed from medical records. Women who were pregnant were excluded from the sample.

On average, the respondents (219 HAART users and 265 nonusers) were 34 years old and had three children; only 14% reported wanting more children. Most women belonged to the Kiga or Nkole tribes (81%) and were Christian (88%). About two-thirds had a primary school education or less (68%), were not married (61%) and had a monthly household income of no more than US$50 (66%). Some 63% of women had a relatively advanced HIV infection (stage 3 or 4 on the World Health Organization scale), and 55% said they had abstained from sex in the past three months.

Among women who had been sexually active in the three months preceding the interview, 85% reported having used at least one contraceptive method during that time. Most contraceptive users (84%) had used a male condom or other barrier contraceptive, while 28% had used a hormonal method, most often the injectable. Ten percent reported that they had been sterilized or had used other methods, such as withdrawal. Dual use was common: Barrier methods were relied on by many users of hormonal contraceptives (57%), sterilization (40%) and traditional or "other" methods (60%).

Multivariate logistic regression analyses revealed that two variables were associated with use of any contraceptive method and with barrier contraceptive use. The odds of contraceptive use were elevated more than twofold among women who were receiving HAART (odds ratio, 2.6), and nearly threefold among those who did not want any more children (2.8). Similarly, HAART users and women who did not want more children had elevated odds of having used barrier methods (3.6 and 2.7, respectively).

Limitations of the study include the use of cross-sectional data from a single hospital. Moreover, universal HAART access is a recent phenomenon, the investigators note, and rates of contraceptive use may be different among women who have been using HAART for many years. In addition, women receiving this treatment had free access to condoms and counseling at the clinic, which may have led them to answer questions in a socially desirable manner. Still, the researchers point out that the high prevalence of dual method use, and the fact that Ugandans often use condoms to protect against HIV rather than pregnancy, indicate the need for integrated HIV and reproductive health services that help HIV-positive women "achieve their fertility goals" and "support their right to be sexually active."—S. Ramashwar

REFERENCE

1. Andia I et al., Highly active antiretroviral therapy and increased use of contraceptives among HIV-positive women during expanding access to antiretroviral therapy in Mbarara, Uganda, American Journal of Public Health, 2009, 99(2):340–347.