Meeting the Sexual and Reproductive Health Needs of Women Living With HIV
- Promoting family planning counseling and voluntary contraceptive use as part of routine HIV services (and vice versa) can increase contraceptive use, including dual method use, thus averting unintended pregnancies and transmission of infection among women living with HIV.
- A wide range of contraceptive method choices are safe and effective for women living with HIV, including hormonal contraception and IUDs. However, further research is awaited on hormonal contraception and HIV.
- Providing information and skills-building support to people living with HIV can reduce self-reported unprotected sex.
- Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use.
- Cervical cancer screening and treatment integrated into HIV care reduces morbidity and mortality in women living with HIV.
- Promoting condom use for contraception may make condom use more acceptable and easier to negotiate.
- Early postpartum visits can result in increased condom use, contraceptive use, HIV testing and treatment.
1. Promoting family planning counseling and voluntary contraceptive use as part of routine HIV services (and vice versa) can increase contraceptive use, including dual method use, thus averting unintended pregnancies and transmission of infection among women living with HIV. [See also Structuring Health Services to Meet Women’s Needs]
A systematic review of studies from 1990 to 2007 that linked sexual and reproductive health and HIV found positive effects for key outcomes, such as HIV incidence, STI incidence, condom use, contraceptive use, and uptake of HIV testing. Studies took place in Africa, India, UK, Thailand, China and Haiti. HIV interventions included prevention, education and condoms; testing; PMTCT; clinic care for people living with HIV and other service for HIV. SRH interventions included family planning, maternal/child health care; STIs prevention and management; gender-based violence prevention and management; management of cancer, fistula and menopause. "Overall, the majority of studies showed improvements in all outcomes measured. Linking SRH and HIV was considered beneficial” (Kennedy et al., 2010a: 7).
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 were 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 helped 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 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 use of other contraceptives. 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 (Ngure et al., 2009). Note: It is possible that the outcome of this study may be due, in part, to the study design. The authors state: “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). While the study design may have been strong regarding the risk of teratogensis with the study drugs, the need to ensure voluntarism of contraceptive use in studies is paramount and should be included in study protocols and training of 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” (Deschamps et al., 2009: 26). The study also found limited participation due to fear of abandonment, violence and partners’ reaction.
A survey in South Africa of both 214 HIV-negative and 171 HIV-positive women found that when on-site, no-cost family planning services were made available to HIV-positive women accessing antiretroviral therapy, women were significantly more likely to use contraception. 80% of HAART users as compared to 69% of HIV-negative women reported contraceptive use.
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 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.
A project in India offered provider-initiated family planning services during HIV counseling. In 2011, 2,892 female sex workers were screened for unmet contraceptive needs, of whom, 45% were identified as having an unmet contraceptive need. Of these, 96% were provided counseling on a range of contraceptive choices and 84% chose condoms, 8% were referred for oral contraceptives; 1% for injectable, 3% for sterilization, and 3% for IUDs.
2. A wide range of contraceptive method choices are safe and effective for women living with HIV, including hormonal contraception and IUDs. However, further research is awaited on hormonal contraception and HIV. [See Overview for the role of hormonal contraception in HIV acquisition and transmission]
A study between 2001 and 2009 with 303 HIV-positive women with 1,408 person-years in Uganda and Zimbabwe found that hormonal contraceptive use was not associated with more rapid HIV disease progression. Beginning in 2003, HAART was offered to women with CD4 counts of less than 200 or WHO clinical stage 3 or 4. HIV testing, CD4 counts and clinical examinations were conducted every 12 weeks, with estimated infection date usually within a six-week window of actual infection. Of the 202 HIV-positive women, 37% developed AIDS. AIDS incidence was 6.6 per for those using DMPA; 9.3 for those using oral contraceptives and 8.8 per hundred person years for those not using hormonal contraception. No association was found between hormonal contraceptive use during the year before AIDS and HIV progression. No association was found between hormonal contraceptive use at the time HIV infection was acquired and subsequent disease progression. Women were followed from the time HIV was acquired to AIDS, up to nine years. Hormonal contraception was provided and documented. AIDS was defined as two successive CD4 counts under 200 cells or WHO advanced Stage 3 or 4 disease.
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 that neither implants, injectables or oral contraceptives were associated with disease progression. Between August 2002 and December 2007, the MTCT-Plus programs enrolled 7846 women of whom 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 non-hormonal 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.
A study with 13 years of follow-up in Uganda, assessing the association between hormonal contraceptive use and time from HIV seroconversion to death from 1994 to 2006 with 625 women found that hormonal contraception was not associated with faster progression to death in HIV-positive women (Polis et al., 2010) (Gray IIIb). A further analysis of 285 women in Uganda who seroconverted and reported using hormonal contraception before HIV seroconversion found that hormonal contraception before HIV seroconversion was not associated with elevated viral load setpoint. Higher viral load setpoints were associated with more rapid progression to death.
A prospective study with 2,236 women from 7 countries in Africa living with HIV with baseline CD4 counts of more than 250 found that hormonal contraception did not accelerate disease progression and was instead associated with a reduced risk of HIV disease progression to death or a CD4 count of under 200.
3. Providing information and skills-building support to people living with HIV can reduce self-reported unprotected sex.
A meta-analytic review based on electronic databases from 1988 to 2004, with twelve trials in the United States 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 resource limited settings. “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” (Crepaz et al., 2006: 154).
A meta-analysis of 14 articles with 3,234 people (the majority in the United States) 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” (Johnson et al., 2006: 28).
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 (Gardner et al., 2008 cited in Gilliam and Straub, 2009). 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). 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.
4. Providing antiretroviral treatment to people living with HIV can increase HIV prevention behaviors, including condom use. [See Staying Healthy and Reducing Transmission]
5. Cervical cancer screening and treatment integrated into HIV care reduces morbidity and mortality in women living with HIV. [See also Prevention for Young People for a discussion of access to the HPV vaccine for young women]
A randomized trial in South Africa conducted with 6,553 women, of whom 956 were HIV positive, found that screening and treatment using HPV DNA testing significantly reduced high grade pre-cancerous cervical lesion cancer (cervical intraepithelial neoplasia grade 2 or higher) by 80% and this reduction was sustained by 36 months among both HIV-positive and HIV-negative women. The benefit of using visual inspection using acetic acid (VIA) only reached statistical significance in HIV-positive women. For every 100 women screened with DNA tested and treatment could prevent 11.9 high grade cervical cancer (CIN+2) in HIV positive women and 3.1 CIN2+ in HIV negative women. With VIA test and treat programs could prevent 7.4 cases in HIV-positive women and 1.1 cases in HIV-negative women. HIV-positive women were evenly distributed between those who had DNA testing, those who had VIA and those in the control. DNA testing and VIA requires less infrastructure and lab equipment than Pap smears. The screen and treat approach eliminates the requirement to confirm a diagnosis of cervical cancer prior to treatment, reducing the need for repeat visits. Complications from cryotherapy were minor and did not differ between women who were HIV-positive and women who were HIV-negative. The control group had their evaluation or treatment delayed for six months. After six months, women received colposcopy and biopsy to determine if higher grade cervical cancer was present (CIN+2) by a physician blinded to the clinical information; a subset underwent additional colposcopy and biopsy at 12, 24 and 36 months. Biopsies were processed at Columbia University, NY, USA. There was one serious complication in one HIV-positive participant who needed a blood transfusion. Both HIV-positive and HIV-negative women reported similar symptoms from cryotherapy: vaginal discharge, abdominal pain and bleeding.
Modeling of a cohort of HIV-positive women in Cameroon found, based on data on prevalence, progression and regression of cervical cancer lesions, as well as mortality rates from HIV and cervical cancer, that compared to no HAART and no screening, an additional cervical cancer death would occur for every 47 women put on HAART when indicated but not screened for cervical cancer. Screening for cervical cancer once at HAART initiation would prevent one case of cancer for every 262 women screened. Screening once at age 35 was projected to prevent one cancer death per 202 women screened for cervical cancer. With an estimated 200,000 women in Cameroon who are living with HIV, screening women once at HAART initiation would prevent 763 deaths due to cervical cancer with screening for cervical cancer once at age 35 would prevent 990 deaths. “The ethical and practical complexities of potentially denying care to patients and following women for their lifetime respectively make it unfeasible to conduct a study” rather than modeling the data (Atashili et al., 2011: 5).
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 (Sankaranarayanan et al., 2009; Goldie et al., 2005; Denny et al., 2005 cited in Mwanahamuntu et al., 2009). 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.
6. Promoting condom use for contraception may make condom use more acceptable and easier to negotiate. [See Male and Female Condom Use]