Meeting the Sexual and Reproductive Health Needs of Women Living With HIV

A three-armed randomized controlled trial at a VCT clinic in Lusaka, Zambia with 251 couples found a threefold higher contraceptive initiation rate where family planning education and offer of contraceptives were available on site rather than by referral to an outside clinic. All couples received a presentation on family planning methods and the advantages of dual method use, along with a free, unlimited supply of condoms. HIV discordant and concordant couples are advised to use condoms with every act of intercourse, with this information given during initial post-test counseling and repeated at each subsequent visit. Trained nurses help couples overcome barriers to condom use. The control group was referred to the Lusaka Planned Parenthood Association of Zambia for family planning methods, with all fees paid by the research project. Women in the intervention group who desired Norplant or surgical sterilization were referred to University Teaching Hospital, with transport and service fees paid. Self-reported condom use was assessed. Approximately half of the couples eventually wanted to have children. Self-reported condom use remained consistent at between 58 to 63%. Improving access to non-barrier contraceptives among couples already using condoms for HIV prevention increased dual-method use. Within three months of the intervention, 156 out of 169 couples had initiated nonbarrier contraception if family planning was provided on site, but only 27 out of 82 couples initiated nonbarrier contraception if they had to travel to a different facility for contraception. The majority of couples (92%) were HIV discordant.

A three-arm randomized control trial in South Africa with two intervention groups and one comparison group which integrated routine discussion of HIV risk and prevention, dual method use and increased counseling and testing in family planning services resulted in a statistically significant improvement in dual method use from 5 to 10% at baseline to 35 to 50% at endline. Pre- intervention data was collected through 369 client exit interviews and 374 client provider observations in 2004; three day training took place with 56 providers and four day training was conducted with 73 providers in 2005 and the same data collection methods were repeated in 2005. Six focus group discussions were held with clients and six focus group discussions were held with providers.

A study from 1999-2004 in Haiti with GHESKIO analyzed 348 HIV-positive mothers. Rapid HIV-testing and syphilis screening were performed on all pregnant women. After testing, all HIV-positive, pregnant women were informed of their status, counseled and referred to an ANC clinic. GHESKIO integrated VCT, STI screening, family planning services and tuberculosis screening and treatment into one central HIV clinic. At 18 months, 73.9% of mothers in the study were also using family planning services compared to 23% of women in the general population using contraceptives. “Although our clinic staff encouraged women to bring in their partners for testing, 86% were unable to do so due to power disparities and/or lack of interest or resistance from partners” . The study also found limited participation due to fear of abandonment, violence and partners’ reaction (Deschamps et al., 2009).

A pre-post study from 2004 to 2008 of serodiscordant couples in Kenya found that a multiprong family planning intervention lead to high rates of both condom use and contraceptive use. Among 213 serodiscordant couples in the intervention group, nonbarrier contraceptive use increased from 31.5% to 64.7% among HIV-positive women and from 28.6% to 46.7% among HIV-negative women. At the intervention site, approximately 90% of sex acts were reported to be protected by condoms. At other Kenyan sites which did not have the intervention, which had a total of 1,216 couples, contraceptive use changes from 15.6% to 22.3% for HIV-positive women and decreased from 13.6% to 12.7% among HIV-negative women. Pregnancy incidence among HIV-positive women in the intervention site, which declined from 21.1 to 11 per 100 woman years was approximately half that at other Kenyan sites during the intervention period which increased from 16.8 to 21.9 women years. The intervention consisted of: training clinical and counseling staff on contraceptive methods with job aids to use with clients; provision of free contraceptive methods; appointment cards; ongoing training for staff; ongoing contraceptive supplies; discussions with couples on contraceptives; involving male partners in discussions on contraception; and discussions of unintended pregnancies .⁸

⁸ Whether this study was coercive is an issue of concern. The authors state: “Finally, our clinical trial protocol required discontinuation of the study drug for HIV-1-seropositive women who became pregnant, which may have been an incentive for study staff to focus family planning messages more strongly towards HIV-1-seropositive women.” (Ngure et al., 2009: S94).

A study in Uganda in 2005 found that clients expressed a desire for a wider range of services at HIV/AIDS centers. They also noted that FP services are only offered when requested by the client or as a result of a provider’s assessment of client needs. The limited range of available family planning options and stockouts increases vulnerability to unintended pregnancies. Furthermore, reliance on the provider’s assessment or the client’s initiative to demand family planning services may be unproductive when the provider fails to make the correct assessment of the family planning needs or the client does not feel comfortable initiating a discussion about family planning needs to a provider whose preferred option for the client is abstinence.

A cross sectional survey of 484 women who were HIV-positive and attending an HIV clinic in Uganda, 45% of whom were receiving HAART, found that women receiving HAART were more than twice as likely to use contraceptive methods and more than three times as likely to use barrier contraceptive methods than were women not receiving HAART. Of those 184 women who were sexually active and receiving HAART, 84% used barrier contraceptive methods, primarily the male condom. Almost 30% used hormonal contraceptive methods, with injections as the most common hormonal methods and 5% were sterilized. Women on HAART reported a high degree of dual contraception: 57% used hormonal contraceptive methods and barrier contraceptive methods. Among sexually active women, contraceptive use was 85%, a much higher contraceptive prevalence rate than in the general female population (23%). Clinic visits for those on HAART is monthly and for those HIV-positive patients not on HAART, every three months. Median HAART use was 15 months.

A 2007 study with 493 HIV-positive women in Uganda found that easy access to family planning services was significantly associated with contraceptive use among HIV-positive women accessing HAART services.

A review of family planning records from 2005 until 2007 of 600 HIV- negative women and 150 HIV-positive women in Malawi found that providing on- site family planning services to women participating in HIV-related research studies was well accepted with high uptake: At the initial visit 79% chose Depo-Provera; 17% chose contraceptive pills, 3% chose Norplant and 1% used condom use only. In follow-up visits, 3% were referred for sterilization and less than 5% changed their initial contraceptive method.

A study in 2005 of 227 women attending a hospital based antiretroviral program in South Africa found that one-third reported the combined use of a condom and a non-barrier contraceptive at last sexual intercourse. Women initiating ART are also counseled on effective contraception, provided through referral to a nearby primary care clinic. Of 227 women, 86% discussed condom use with their providers and 89% discussed contraceptive use However, less than 10% knew of the existence of emergency contraception and only 13% knew that abortion is a legal and free public health service.

A systematic review of evidence from 26 studies on the safety of hormonal and intrauterine methods of contraception for women with HIV/AIDS found that hormonal and intrauterine methods of contraception was generally well tolerated by women with HIV. Eight observational studies reported no increased risk of HIV disease progression with hormonal or intrauterine contraceptive use, whereas one randomized controlled trial found increased risks of declining CD4 cell count and death for hormonal contraceptive users compared with intrauterine device users. Women with HIV who used hormonal contraception had increased risk of acquiring STIs compared to women not using hormonal contraception, similar to the risk reported among HIV-negative women. One study found no association between hormonal or intrauterine contraceptive use and increased risk of HIV transmission to uninfected partners, whereas findings from nine studies examining contraceptive use and viral shedding from the genital tract (a proxy for infectivity) were inconsistent.

A multi-country cohort analysis comparing the incidence of HIV disease progression among anti-retroviral therapy-naïve women with and without exposure to hormonal contraception at 13 sites in Africa and Asia found no association between hormonal contraceptive use and HIV disease progression. Between August 2002 and December 2007, the MTCT-Plus programs enrolled 7846 women. 4109 (52%) women met the eligibility criteria for this analysis and contributed 5911 person-years of follow-up. At baseline, 3064 (75%) women reported using either no contraception or a nonhormonal method, whereas 823 (20%) reported using implants/injectables and 222 (5%) reported using oral contraceptive pills. The disease progression outcome was met by 944 (29%) women. Neither implants/injectables nor oral contraceptive pills were associated with disease progression.

A study of 4,200 HIV-negative women in South Africa ages 35 to 49 years of age found that during 5,010 person years of follow-up, 111 women acquired HIV. Of the 4,200 women, 21% used hormonal contraception, of which 14% used DMPA and 5% norethindrone enanthate. After adjusting for sexual risk behaviors and STIs, the incidence of HIV was similar among women using combined oral contraceptives, DMPA and norethindrone enanthate compared to women not using any hormonal contraceptives. “The conflicting evidence regarding the potential role of hormonal contraception in increasing women’s risk of HIV infection would appear to demand further epidemiological investigation. However, any true association is likely to be small…In the case of hormonal contraception and HIV infection, it is unclear whether more definitive evidence is likely to emerge from observational epidemiological studies…”.

A study with 13 years of follow-up in Uganda which assessed the association between hormonal contraceptive use on time from HIV seroconversion to death from 1994 to 2006 with 625 women found that hormonal contraception was not associated with an increased risk of death in HIV-positive women and “thus does not support the concern that hormonal contraception accelerates time-to-death among HIV-infected women”.

An observational prospective cohort study of 498 HIV-positive women in Kenya and Zimbabwe with CD4 counts equal to or greater than 500 who used a contraceptive method of their choice and were followed up every six months for four years was not associated with HIV disease progression. Of the 363 women who used their contraceptive method consistently for a mean of two years, 135 (37%) used DMPA; 85 (23%) used oral contraceptives and 143 (39%) used non- hormonal methods. DMPA users and oral contraceptive users had a similar change in CD4 count in comparison to women using non-hormonal contraception methods; change in HIV viral load was not significantly different; and progression to WHO clinic stage III or IV was also similar.

Information on HIV status correlated with DMPA use among women ages 15 to 24 years of age for 874 women in Kenya, 867 women in Lesotho, 931 women in Malawi and 1,877 women in Zimbabwe found that users of DMPA had consistently higher HIV seroprevalence, with differences from nonusers significant for Lesotho and Zimbabwe and highly significant for the merged data set. However, “even if women shifted from DMPA to the pill, the net effect on HIV prevalence would be small and unlikely to change the course of the HIV epidemic”.

A study in the United States with 70 women, with 16 women who were not on HAART, who were followed for 12 weeks, found no significant changes in CD4 counts of HIV RNA levels occurred with DMPA use. No evidence of ovulation was detected and no pregnancies occurred. “Data suggest that DMPA can be used safely by HIV-positive women on the ARV studied [nucleoside; nelfinavir; efavirenz; nevirapine].

Based on results of five studies , the use of oral contraceptives may be associated with an increased risk of HIV acquisition among sex workers; however, among other women, no increased risk of HIV was observed during use of oral contraceptives (Leclerc et al., 2008 cited in Heikinheimo and Lahteenmaki et al., 2009).

“Among women from the general population, combined oral contraceptives and DMPA use does not appear to significantly increase HIV acquisition risk; evidence from studies conducted among high risk groups of women is more mixed… Additional research is urgently needed….” The assessment was based on a review of 13 prospective studies.

A review of peer-reviewed literature for prospective studies published between 1996 and August 2008 found that data suggest that neither oral contraceptives nor DMPA increase HIV risk among women in the general population. Data are equivocal for sex workers. Data suggested no increased risk among copper IUD users. Women’s contraceptive preferences would make randomized controlled trials unethical. “Care should be taken…to avoid inducing unwarranted concern about risks associated with contraceptive use”.

Use of injectable contraception may increase risk of HIV acquisition for sex workers but not for other women.

An open label pharmacokinetic study of drug interactions among 54 HIV- positive women treated with DMPA in the USA while on different antiretroviral therapies – nelfinavir, efavirenz or nevirapine – found that suppression of ovulation was maintained, contraception was effective and there were no significant changes in median CD4 cell count at week 12 compared to baseline. DMPA, also known as Depo-Provera, is one the more frequently used contraceptive methods globally and is often used by women living with HIV.

“Biological and epidemiological studies suggest that hormonal contraceptive use could influence susceptibility to HIV-1, as well as infectivity and disease progression for those who become infected. However, not all studies have shown this relationship and many questions remain”.

A randomized trial of 599 HIV-positive women to receive either IUD or hormonal contraception in Zambia (no year given) found that women who received hormonal contraception were more likely to experience a CD4 count decline to less than 200 cells/UL than were women who received the IUD. Over 642 woman- years of follow-up, one woman who received the IUD experienced Pelvic Inflammatory Disease (PID). Ten women expelled their IUDs; of these four were partial expulsions that required medical attention and six were complete expulsions. Only one woman who had experienced expulsion elected to have the IUD reinserted. Overall 184 patients (31%) discontinued their originally allocated form of contraception over a 24-month follow-up. Women assigned to hormonal contraception were more likely to become pregnant than were women who were assigned to the IUD (4.09 pregnancies per 100 women years vs. .38 pregnancies per 100 woman years). No cases of PID occurred among participants who received hormonal contraception. Women who received hormonal contraception were less likely to discontinue than were women who received the IUD.

A review performed by an independent expert group using 1,000 references related to IUDs found that: there are no known drug interactions between IUDs and HAART; there appears to be no effect of IUDs on HIV-1 viral shedding; there appears to be no increase in overall complications or infections with IUDs; and there is no increase risk of transmission to HIV-negative partners by HIV-positive IUD users.

A meta-analytic review based on electronic databases from 1988 to 2004, with twelve trials in the USA that used randomization, statistical analysis and assessment of HIV-related behavioral or biologic outcomes at least three months after the intervention found that interventions for people living with HIV are effective in reducing unprotected sex and acquisition of sexually transmitted diseases. Only one study was with HIV-positive women only. All the interventions provided information with nine interventions providing skill building through live demonstrations, role plays or practice, such as correct use of condoms, coping or interpersonal skills such as communication about safer sex or disclosing serostatus. Interventions were delivered by health care providers, counselors or trained HIV-positive peers. Effective interventions were delivered on a one-to-one basis by providers or counselors with at least ten intervention sessions for at least three months. Reduced rates of unprotected sex were reported at 12 months post-interventions. No studies which met the meta-analytic criteria were found for developing country contexts. “Although it is unclear the extent to which our meta-analytic findings (based on the experience in the US) can be generalized to resource- poor settings and other populations, the lessons learned may provide insights… As antiretroviral therapy programmes are expanded worldwide, effective prevention strategies should be integrated within routine medical care and services provided for PLWH”.

A meta-analysis of 14 articles with 3,234 people (the majority in the USA) found that sexual risk reduction strategies that included HIV-positive participants; used a randomized controlled design; and measured condom use reduced sexual risk by increasing condom use especially if interventions included skills-building and motivated participants. “Perhaps the most surprising finding of this work is that more than two decades into the epidemic, there have been so few intervention randomized controlled trials that focus on people living with HIV”.

An intervention of four focus group sessions for 180 women in Zambia with skills training on HIV prevention and transmission, communication, conflict resolution and sexual negotiation resulted in female participants reporting increased condom use, with 94% of the women reporting using condoms all of the time. Sexual risk behavior was assessed at the start of the project and after 12 months..

A review of published research in the United States from 1998 to 2008 of “prevention for positives” found a few studies with interventions that increased condom use between HIV-positive people and their sexual partners. In one study, providers were trained to deliver a standardized intervention resulting in a significant decline in unprotected anal or vaginal intercourse from 42% to 23% at 12-month follow-up among 767 patients at HIV clinics . In another study, 15 ninety-minute individually delivered intervention sessions resulted in a significant 36% reduction in the number of unprotected sex acts among 794 patients, 68% male, 52% Black (Healthy Living Project Team, 2007 cited in Gilliam and Straub, 2009). Another randomized controlled study with 233 men and 99 women, 48% high school graduates provided five group sessions, gender and sexual orientation specific on disclosure and reduction in transmission risk behaviors resulted in significant reductions in unprotected vaginal and anal intercourse in the previous three months at six month follow-up (Kalichman et al., 2005 cited in Gilliam and Straub, 2009). Another study found significant reductions in unsafe sex in 214 participants through emphasizing the negative consequences of unsafe sex for the HIV-positive person, such as “if you don’t use clean syringes, you could get hepatitis” (Richardson et al., 2004 cited in Gillaim and Straub, 2009). A study with HIV- positive women who received four four-hour interactive group sessions and a social network intervention, compared to a health promotion intervention had significantly lower self-reported vaginal intercourse at 12-month follow-up (Wingood et al., 2004 cited in Gilliam and Straub, 2009). Increased frequency of counseling about safe sex in several studies was correlated with having specific written procedures. Addressing provider attitudes and providing training to providers is also critical (Gilliam and Straub, 2009).

A 2003 study in South Africa interviewed 215 HIV-positive individuals (192 women) and found that HIV status disclosure lead to safer sexual behavior and greater social support. After disclosure 82% asked their partners to get tested, 81% decided to be monogamous, 64% used condoms every time, 56% reduced their number of sexual partners and 20% abstained from sex. One-third of HIV- positive individuals did not disclose their status to their sexual partner. Families provided 25% and doctors provided 20% of social support. The study measured social support by the patients’ perception as increased, maintained or decreased depending on to whom they disclosed.

A study by TASO in Uganda found that support that resulted in sero- disclosure resulted in increased condom use. A total of 3,219 counseling records of sexually active clients, 65% female, accessing care in 2007 were analyzed using Epi Info. 3,129 or 40% of sexually active clients disclosed their HIV-positive serostatus to their sexual partners. Of these, 1,173 or 90.8% reported consistent condom use. Of those who disclosed their serostatus, 5% did not use condoms as compared to 19.3% of clients who had not disclosed their HIV-positive serostatus.

394 participants recruited through the Caribbean regional network of people living with HIV/AIDS (CRN+) found that 54% of respondents reported that they did not use a condom at last sex, with no difference by sex. Bivariate analysis showed that condom use was positively associated with disclosure of HIV-positive serostatus and partner being HIV-negative, as well as being married.

A program for cervical cancer for both HIV-positive and negative women in Lusaka, Zambia has screened over 20,000 women in 15 primary care clinics and has linked cervical cancer prevention services with HIV care and treatment services. Due to lack of resources to establish a patient recall system, emphasis was on high population coverage rather than frequency of exams. Cervical cancer using visual inspection with acetic acid (VIA) provided on- the-spot results, which was then linked with same visit cryotherapy. Community randomized trials have documented the safety, acceptability and effectiveness of single visit “see and treat” methodology based on VIA and same visit cryotherapy of eligible lesions . Peer educators as health promotion advocates and patient navigators reduced loss to follow- up. Community women were trained on conducting community-based cervical health promotion talk. Women who wanted more information were directed to the cervical cancer prevention clinics. Women who attended cervical cancer prevention clinics who had not been tested for HIV were counseled on HPV and HIV testing. HIV-positive women were escorted to nearby HIV care treatment clinics for further evaluation. To minimize stigma, screening clinics were co- located in government-operated public health clinics near to but not directly within the HIV clinic (Mwanahamuntu et al., 2008).

A 2007 overview states that cervical cancer screening of HIV-positive women in low-resource countries could be integrated with ARV treatments, which have established the regular observation, infrastructure and services to support cervical cancer screenings. The overview explains that a new, rapid HPV test is underway and may be the best option considering the difficulties associated with Pap smears, visual inspection and HPV tests in low-resource countries. Pap smears require high standards of implementation, which work in high-resource countries, but may be deficient in low-resource settings. Visual inspection relies heavily upon the training of the health provider, though it is a low-cost option giving immediate results.