Does service integration improve the sexual and reproductive healthcare of women living with HIV?

Introduction

The integration of sexual and reproductive health (SRH) services with genitourinary medicine (GUM) clinics provides multiple specialist services under one roof and encourages expansion of clinician expertise. While it is difficult to obtain robust evidence on the definite benefits of integration, it is widely thought that for many patient groups, including women living with HIV, integration equates to more comprehensive and holistic care.

A recent review revealed an expanding evidence base for integration in the developing world, but commented that the observed effect was modest under typical settings where intervention implementation was often weak. ¹ In the UK, where health system obstacles are far fewer, one could expect integration to be a more easily implemented intervention with subsequent improvement in outcome measures. Few data have been published on the SRH care of HIV-positive women attending integrated sexual health centres in the developed world.

In NHS Lothian (Edinburgh, Scotland), GUM and SRH services relocated from separate sites to a purpose-built integrated centre in June 2011. Pre-integration GUM staff underwent training in contraception counselling and provision and cervical cytology sampling. All medical staff attained the Faculty of Sexual and Reproductive Health’s (FSRH) letter of competence (LOC) for contraceptive implant fitting. Subsequently, all doctors in training have achieved the FSRH LOC in intra-uterine device fitting. There remains a system for senior GUM and SRH physician cover in each integrated ‘general’ clinic, should gaps in training and expertise be apparent, and multiple specialist SRH services run on-site allowing efficient onwards referral should this be indicated.

In a cohort of women living with an infection that can be vertically transmitted, pre-conception counselling should be encouraged to allow informed decisions about treatment options and mode of delivery. Given the increased risk of cervical cancer in women living with HIV, guidelines recommend annual cervical screening. ²

This study used contraception provision, unplanned pregnancy rates and uptake of annual cervical cytology as indicators of comprehensive sexual and reproductive healthcare in a cohort of women attending for their routine HIV care, both before and after service integration, in order to assess improvements in care provided. As a service improvement study, ethical approval was not deemed necessary, and was not sought.

Methods

Paper case notes were examined for entries from the five years preceding integration (June 2007–May 2011). The Scotland-wide National Sexual Health (NaSH) system was introduced as the principle data recording system in April 2011, and was used for the repeat study cycle in 2014 (June 2011–May 2014).

In Scotland, over 90% of abortions take place within the NHS, and data were gathered from local records. The Scottish Cervical Call-Recall System (SCCRS) provided data on cervical cytology, in women eligible for cytology according to the Scottish National Guidelines. ³

It is now widely recognised that rates of pregnancy with typical condom use are high enough to warrant discussion of additional contraceptive methods should women wish to avoid or space pregnancies. ² For this reason, data were not collected on partner status or on condom use among these women, but the focus of this study was on use of additional contraception and uptake of long acting reversible contraceptive (LARC) methods.

Pregnancies were categorised as unplanned (UP) pregnancies if one or more of the following criteria were met: (1) documentation that the pregnancy was UP, (2) no documented HIV-specific pre-conception counselling, (3) documented discussion of contraception options to prevent pregnancy, (4) contraceptive failure or (5) pregnancy resulting in termination without a medical reason.

Results

The cohort attending the service regularly remained largely unchanged. A total of 107 women were still engaged in care post-integration, 14 had left and 36 were new to the service.

Contraception

Criteria for requiring pre-conception counselling or contraceptive discussion and provision were: being sexually active, of child-bearing age, not documented as planning a pregnancy, and not known to be infertile or have had a hysterectomy. Pre-integration, 68 women fitted these criteria, and 74 post-integration.

24.9% of these women pre-integration and 39.3% post-integration were using a contraceptive method whose efficacy was not compromised by anti-retroviral (ARV) drug–drug interactions (p = 0.0762) (Table 1). The proportion of women using LARC improved from 16.1% to 29.8% (non-significant p = 0.066).

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Table 1.

Use of effective contraceptive methods by fertile, sexually active women.

Contraceptive method	Pre- integration (n = 68)	Percentage	Post- integration (n = 74)	Percentage
IUD	0	0	6	8.1
IUS	9	13.2	15	20.3
Depo	4	5.9	6	8.1
Nexplanon a	2	2.9	1	1.4
COC a	2	2.9	0	0
POP a	0	0	1	1.4
Total	17	24.9	29	39.3

a

Women using these methods were either ARV-naïve, or on ARV regimens which did not result in reduced efficacy of the contraceptive method. IUD, intrauterine device; IUS, intrauterine system; COC, combined oral contraceptive pill; POP, progestogen-only pill.

Discussion

Following integration of services, there was an increased uptake of LARC in this cohort of women. LARC is now widely recognised to be superior to more traditional contraceptive methods at preventing pregnancies in all cohorts, as well as affording additional non-contraceptive benefits to many women. ⁴

Overall, however, there was no significant improvement in contraceptive use in a cohort which remained largely unchanged over the eight years of this study period. Ultimately, contraceptive uptake relies on many factors, including method acceptability and patient choice. ⁵ There is limited comparative research on interventions to improve contraceptive uptake in HIV-positive women, a cohort in whom complex social and cultural factors often influence health-related behaviours and engagement in care. ⁶

NATSAL 2013 reported that only 50% of pregnancies in the UK are planned, ⁷ while local data estimates an UP pregnancy rate of 30%. ⁸ The rates of UP pregnancy in this small cohort did drop following integration from 0.059 to 0.041 UP pregnancies per woman per year, although the proportion of all pregnancies which were unplanned rose and remain above the rates quoted in the general population. While an interesting finding, the accuracy and relevance of these observations may be contested; the definitions of UP pregnancy utilised in this study could be questionable, data may be missing and free-text notes may lack accuracy and be less than comprehensive. Decisions regarding pregnancy continuation or termination may not be clear-cut to the woman and may change repeatedly over short periods of time. It is also possible that patients may not have disclosed the desire for pregnancy, or indeed the occurrence of unplanned pregnancy to their HIV physician. However, despite these limitations, in a cohort of women who have an infection which can be vertically transmitted, and who regularly see clinicians trained in contraception, it is disappointing that UP pregnancy remains high.

The proportion of women who have had a smear test in the last year improved significantly following integration, reflecting diversification in the skills of all clinical staff, and affording women the chance to have cytology performed opportunistically at any clinic visit.

Further work is required to improve contraceptive uptake and prevention of unplanned pregnancies in this cohort of women. Inclusion of SRH factors in a mandatory data set to be completed in all patients may help drive further improvements in contraceptive uptake and annual cytology recording. Clinicians should be encouraged to routinely ask about pregnancy desires and plans in order to highlight outstanding contraceptive needs or to allow timely pre-conception counselling. A joint clinic utilising on-site expertise is one potential way of improving the SRH of these women, both in terms of contraception provision and prevention of unplanned pregnancies, but also in terms of non-contraceptive benefits of some methods. Such a clinic is likely to be of additional benefit in the future as our cohort ages and greater numbers of women require specialist menopause care.

Ultimately, we aim with this study to highlight the complexities of caring for women living with HIV and to acknowledge the many factors influencing a woman’s decisions regarding contraceptive use and pregnancy planning or avoidance. We recommend that services offer frequent opportunities for women to discuss their fertility as well as other sexual and reproductive health care needs.