Abstract
The objective of this study was to examine contraception use and family planning discussions (FPD) in female people living with HIV (PLWH). A retrospective cohort study was conducted. Female PLWH were included if they were 18–44 years and received care in 2019 at an HIV clinic. 74 patients met inclusion; mean age was 35 years, 53% were white. All patients were prescribed antiretroviral therapy. 48.6% of patients had documented FPD. 64.9% of patients were using contraception; sterilization was most common (41.7%). Only five patients had a contraindication to hormonal contraception. No differences in contraception use were observed based on age, race, HIV viral load, number of visits, or past pregnancies. However, patients with documented FPD were more likely to use contraception (OR 4.55; 95% CI 1.35-15.29). Routine FPD and contraception use in female PLWH were low. Rates of sterilization were high in female PLWH. Providing quality family planning services is critical to increase contraception use and selection of the most appropriate contraception form.
Introduction
In 2018, there were approximately 61 million women between the ages of 15–44 years in the United States (US). 1 However, only 60% reported using some form of contraception method. 1 In the US the oral contraceptive pill is the most commonly used form of contraception, followed by female sterilization. 2 Current contraceptive use is lower among black women and women aged 15–24 years compared with women aged 35–44 years. In the general population, language proficiency and comprehension of information received about the health system has been shown to influence the utilization of reproductive services. 3
As of 2018, there were approximately 245,000 women in the United States with HIV, with Black and Hispanic/Latino patients disproportionately affected. 4 Additionally, there were 7000 new HIV diagnoses in women; 4000 of these women were considered to be of reproductive age (15-44 years). 4 Approximately 70% of female patients with HIV (PLWH) are sexually active but use of effective contraception is variable and unintended pregnancy is frequently reported (>50%). 5
It was previously demonstrated that marital status and level of education in female PLWH were significant factors in contraceptive use. 6 Those patients with higher education and/or in monogamous relationships use contraception more frequently. 6 Male condoms have been reported to be the most regularly used type of contraception in female PLWH, but condom use has been shown to be variable. 7 In addition, male condoms have a significant higher user and method failure rate compared to longer-acting contraception methods. 6 Oral, injectable, implants, and intrauterine devices are all acceptable contraceptive choices for female PLWH without medical contraindications. The World Health Organization recognizes that informed choice of the wide range of contraceptive methods is an essential element of optimal and quality family planning care.. 8 The objective of this study was to examine contraception use and FPD in female people living with HIV (PLWH) receiving primary care at an HIV outpatient clinic.
Materials and Methods
This study was a retrospective chart review evaluating contraceptive use in adult women of childbearing age with HIV. The study protocol was approved by the institutional review board. Patients were included if they were female (natal sex), between the ages of 18–44 years, had a diagnosis of HIV, and received care at the outpatient HIV clinic between January 1, 2019 through December 31, 2019. Study data was collected from the patients’ electronic medical records (EMR). This included demographics, medications, laboratories, sexual history, number of prior pregnancies, contraception use, FPD, and contraindications to contraception. Contraindications were defined as category 4 conditions by the US Medical Eligibility Criteria for contraceptive use. 9 Hormonal type contraception included depot medroxyprogesterone acetate, combined hormonal oral contraceptives, progestin-only pill, hormonal implant, patch, or ring, and levonorgestrel-releasing intrauterine device. The Lexicomp® Interactions drug interaction software was utilized to identify potentially serious drug interactions (ie, category D and X).
Descriptive statistics were used to describe the baseline characteristics and demographics of the study population. Contraceptive use in adult female PLWH of childbearing age was reported dichotomously (contraception use/no contraception use). Categorical variables were analyzed utilizing the chi-square test, and continuous variables were analyzed using Student‘s t-test. Logistic regression was used to determine predictors of contraception use. Statistical significance was defined by a p < 0.05. All statistical tests were performed using IBM SPSS Statistics Version 28.
Ethical Approval and Informed Consent
The study protocol was approved by the ethics institutional review board through the Human Research Protections Office at the University of New Mexico Health Sciences (IRB study #20-271). Due to the retrospective nature of this project, the study met requirements for an expedited review. No patient consent was required for the retrospective chart review. All data was de-identified during data collection.
Results
In 2019 the clinic saw 1117 PLWH; women accounted for 13.5% of the clinic population. Of the 151 female PLWH seen in 2019, a total of 74 met the study inclusion criteria. The mean age of the study population was 35 years; 53% of patient were white and 82% were English-speaking. Eighty-four percent of female PLWH had an undetectable viral load (<50 copies/mL). The majority (81.1%) of patients were prescribed an integrase strand transfer inhibitor-based regimen. Table 1 describes the baseline characteristics of the patient population.
Patient Characteristics (n = 74).
SD = standard deviation
*NNRTI-, PI-, INSTI-based treatments include only combinations of these anchor drug classes with 2 NRTIs. The group “other” includes other drug classes combinations such as: PI + INSTI without or with 2 NRTIs or 1 NRTI; PI + INSTI + NNRTI without or with 2 NRTIs; PI + NNRTI with 1 or 2 NRTI(s); PI + 1 NRTI; INSTI + 1 NRTI.
Overall, 71.6% of study patients reported being sexually active. However, only 46 patients (62.2%) were currently using some form of contraception. In patients with detectable HIV viral loads (n = 20), 35% of patients were not using any form of contraception. The most common forms of current contraception reported were sterilization/removal of reproductive organs (41.7%; n = 20) and condom use (16.7%; n = 8) (Figure 1). FPD with a provider within the last year were only documented for 48.6% of patients. Family planning disscussions were only documented in three of the 12 patients (25%) with detectable viral loads. Multivariate analyses found that only documented FPD were associated with contraceptive use (Figure 2).
Current contraceptive methods used by patients (n = 74)*. *Three patients reported use of both condoms and another form of contraception. IUD = intrauterine device.
Multivariate analysis of contraceptive use in women with HIV.
The contraceptive type (ie, hormonal vs non-hormonal) used was dependent on age. For women with HIV < 35 years of age, 71.4% used hormonal contraception compared to only 20.0% of patients
Contraindications to hormonal contraception were identified in three patients, which included vascular disease or elevated blood pressure (systolic
Discussion
The results of this study demonstrated that contraceptive use in our population of female PLWH is low, despite access to free condoms and hormonal contraception. Although the overall use of contraception is similar to that reported in the general population, a difference was seen in the types of contraceptive methods used. Sterilization was used most frequently in our population of female PLWH and was twice the rate reported in the general US population. Our results in female PLWH are similar to those previously reported by Stanwood and colleagues, 10 where sterilization was reported in 47% of female PLWH. In this study a larger percentage of female PLWH also reported regret after being sterilized, compared to that previously reported in the general population.10, 11 Effective reversible hormonal alternatives were rarely used in our population, despite few contraindications or drug interactions with antiretrovirals. Condoms were also a popular contraceptive method in our cohort, but are less effective than other contraceptive options. 12 Condom use was also previously reported as the most common form of contraception in the Swiss HIV Cohort Study, resulting in unintended pregnancies. 13
Patients from this study rely on the HIV-specialty clinic for most of their health care and primary care needs, including gynecological exams. It is unlikely that the female patients in this study were receiving these services elsewhere. For female PLWH, care should encompass family planning services. Contraceptive care may be managed like a chronic condition, in which patients receive regular follow-up to assess their reproductive life plans and contraceptive options, as this may change over time.
Stigma, misinformation, and concerns about privacy and contraceptive safety in female PLWH, by both patients and health care providers, appear to be barriers to contraceptive use, as well as contraceptive type.14–16 In one study that included black female PLWH, family members were identified as reproductive decision influencers, resulting in the use of less effective methods (eg, condoms) after their HIV diagnosis. 17 This reinforces the importance of health care providers delivering reliable information on the many contraceptive choices available to patients.
Our study demonstrated that FPD with providers were associated with increased contraception use. It is important to note, however, that FPD were not associated with the type of contraception used. This suggests that providers did not influence patient choice about the type of contraception used, but rather encouraged the use of contraception in general for female PLWH. It has been demonstrated previously that minority and marginalized populations may have concerns about contraceptive coercion. 18 This is an important consideration for providing contraceptive care within the framework of reproductive justice, which includes the right to bodily autonomy and individual decision-making about contraception choice and childbearing.
Our state has a large Hispanic population (49.3%), making our study unique. 19 Although rates of hormonal contraception use were lower in Hispanic and non-English speaking patients, differences were not statistically significant, likely due to the size of the study cohort. Access to reproductive health care is variable in the US, and vulnerable minority groups are affected by barriers to care even with publicly funded contraceptive services. 20 It is also important that FPD extend beyond options of barrier methods in female PLWH. 21
Hormonal contraceptive methods have been shown to be highly effective in reducing pregnancy risk even in female PLWH receiving ART, 22 despite concerns about drug-drug interactions. Although interactions can occur with some antiretrovirals,23–25 most of the commonly used antiretrovirals today do not have major interactions with hormonal contraceptives. Very few patients in our study were receiving efavirenz- or booster-containing regimens, which can result in drug-drug interactions with hormonal contraception.
In the US, as demonstrated in our study, females account for a low percentage of the HIV population and oftentimes women‘s health issues are not prioritized. This is supported by our finding that less than 50% of female PLWH of childbearing age had a family planning discussion with their clinic provider, despite multiple opportunities (mean clinic visits 4.8). These are potential missed opportunities to provide these services.
Our study did have limitations. Retrospective chart reviews rely on documentation of all patient care discussions. However, some patient care discussions may not have been captured through documentation, In addition retrospective chart reviews may not capture all medications (such as emergency contraception), or sexual activity/number of partners. There are also a number of reasons why a patient may not be using contraception, which may not be captured on a chart review. We did not assess adverse events from prior contraception use. Our study did not collect information on income or education level, which could impact contraception use.
Conclusions
Routine FPD and contraception use in female PLWH were low. Rates of sterilization were high in female PLWH. Like all women of childbearing age, it is critical that female PWLH be offered routine family planning services in order to prevent and/or appropriately plan and space pregnancies, as well as decrease risk for mother to child transmission. Providing quality family planning services may increase contraception use and also ensure selection of the most appropriate form of contraception in female PLWH.
Footnotes
Author Disclosure Statement
B. Jakeman serves as an infectious diseases drug information clinical consultant for Wolters Kluwer, Lexicomp®. The authors have no other potential conflicts of interest to disclose.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article
Ethics Approval
The study protocol was approved by the University of New Mexico Human Research Protections Office institutional review board.
Reproduction Permissions
NA. This material has not been published anywhere else in any form.
