Neglect of Attention to Reproductive Health in Women With HIV Infection

Contraceptive Use and Unintended Pregnancies in the Swiss HIV Cohort Study

K Aebi-Popp; V Mercanti; C Voide; J Nemeth; A Cusini; B Jakopp; D Nicca; M Rasi; A Bruno; A Calmy; B Martinez de Tejada

Disclosures

HIV Medicine. 2018;19(5):339-346. 

In This Article

Abstract and Introduction

Abstract

Objectives Women with HIV infection are mainly of reproductive age and need safe, effective and affordable contraception to avoid unintended pregnancies. The aim of this study was to evaluate contraceptive use and unintended pregnancies in this population in Switzerland.

Methods A self–report anonymous questionnaire on contraceptive methods, adherence to them, and unintended pregnancies was completed by women included in the Swiss HIV Cohort Study (SHCS) between November 2013 and June 2014. Sociodemographic characteristics and information related to combined antiretroviral therapy and HIV disease status were obtained from the SHCS database.

Results Of 462 women included, 164 (35.5%) reported not using any contraception. Among these, 65 (39.6%) reported being sexually active, although 29 (44.6%) were not planning a pregnancy. Of 298 women using contraception, the following methods were reported: condoms, 219 (73.5%); oral hormonal contraception, 32 (10.7%); and intrauterine devices, 28 (9.4%). Among all women on contraception, 32 (10.7%) reported using more than one contraceptive method and 48 (16%) had an unintended pregnancy while on contraception (18, condoms; 16, oral contraception; four, other methods). Of these, 68.1% terminated the pregnancy and almost half (43.7%) continued using the same contraceptive method after the event.

Conclusions Family planning needs in HIV–positive women are not fully addressed because male condoms remained the predominant reported contraceptive method, with a high rate of unintended pregnancies. It is of utmost importance to provide effective contraception such as long–acting reversible contraceptives for women living with HIV.

Introduction

Approximately 34 million people world–wide are living with HIV–1. Among these, half are women, who are mostly of reproductive age.[1] Family planning is an important topic, and it is now more frequent that women with HIV infection plan their pregnancies than previously as a result of the low rates of vertical transmission of HIV from mothers to their newborns. However, the promotion of effective and safe contraception is critical to avoid unwanted pregnancies and associated adverse outcomes, as well as to avoid HIV vertical transmission world–wide. For example, the World Health Organization recommends the use of long–acting, reversible contraceptive methods for family planning in combination with the use of condoms ("dual contraception") for women living with HIV in order to prevent onward transmission of HIV and other sexually transmitted diseases.[2]

In 2008, the "Swiss Statement" was an important milestone and offered the opportunity to omit condom use in discordant partnerships with virally suppressed HIV–positive persons on combined antiretroviral therapy (cART) without any other coinfections.[3] Nevertheless, given the new evidence for HIV treatment as prevention, effective contraceptive methods are warranted for couples who are no longer using condoms. Most contraceptive options can be safely and effectively used by HIV–positive women either as short–acting methods (oral contraceptive pill and injectables) or as long–acting reversible contraception, such as subdermal implants and copper or hormonal intrauterine devices (IUDs).[4] Hormonal contraception can contain combined hormones (progestin and oestrogen) delivered as a daily pill, vaginal ring or transdermal patch, or progestin only (oral pill, injectable, subcutaneous implant or an IUD).

However, there is concern that drug–drug interactions between hormonal contraception and ART may lead to reduced effectiveness of the contraception. HIV–positive women using combined hormonal contraception while on efavirenz (EFV)–, nevirapine (NVP)– or ritonavir–containing ART should be informed about the possibility of decreased contraceptive efficacy and therefore advised to use high–dose hormonal contraceptive pills. They should also be counselled on the use of the dual contraceptive method, including the correct and consistent use of male or female condoms.[5–9] Importantly, combined hormonal contraception is generally contraindicated in women over 40 years, smokers, and those who are obese or with arterial hypertension, especially with regard to an increased cardiovascular risk.[10] Therefore, the choice of contraceptive method(s) is very individualized and there are few data from Europe concerning women living with HIV, as the commonly used types of contraceptives differ from those in resource–poor countries.[11,12]

The Swiss HIV Cohort Study (SHCS) is an ongoing, nationwide, multicentre, clinic–based observational study with continuous enrolment and semi–annual study visits. Until the end of the year 2014, 2494 HIV–positive women were included and followed, mainly of reproductive age (54%) and on ART (93%).[13] However, the methods of contraception used by these women are not systematically described as this information is not included in the SHCS database. We aimed to assess the rates of contraceptive use and the types of methods used according to the type of cART, dual contraception use, and the number of unintended pregnancies.

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