IJG-07909; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

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CLINICAL ARTICLE

Contraceptive use among HIV-positive women in Enugu, southeast Nigeria Euzebus C. Ezugwu ⁎, Peter O. Nkwo, Polycap U. Agu, Emmanuel O. Ugwu, Augustine O. Asogwa Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria

a r t i c l e

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Article history: Received 28 August 2013 Received in revised form 17 December 2013 Accepted 13 March 2014 Keywords: Contraception Enugu Family planning HIV-positive women Nigeria

a b s t r a c t Objective: To determine the prevalence and pattern of, and factors associated with, contraceptive usage among HIV-positive women in Enugu, southeastern Nigeria. Methods: In a questionnaire-based cross-sectional study, 400 consecutive HIV-positive, sexually active women receiving care at the adult HIV clinics of 2 tertiary health institutions in Enugu were interviewed using pre-tested questionnaires between March and August 2012. Descriptive and inferential statistical analysis was carried out via Epi Info. Results: The rate of contraceptive use was 73.1%; 26.9% (n = 91) of women were not using modern contraceptives. Male condoms were the most frequent contraception used (78.1%, n = 193), but 48.2% of women reported inconsistent use. The proportion of women using a dual-contraceptive method was 25.1%; none used the female condom. Having a regular sexual partner was significantly associated with use of modern contraception (odds ratio, 73.00; 95% confidence interval, 34.13–156.13; P b 0.001). Misconception and fear of adverse effects were the most common reasons for not using contraception. Conclusion: A considerable proportion of HIV-positive women in Enugu who did not desire to achieve pregnancy in the following 2 years (26.9%) had an unmet need for contraception. The use of contraception prevents unintended pregnancy and subsequent mother-to-child transmission of HIV and should be promoted in the region. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction HIV infection and AIDS represent a global public health problem with greatest burden in Sub-Saharan Africa. This region contributes 12% of the global population with HIV infection; however, more than 70% of new HIV infection in occurs there [1,2]. Women constitute the majority (60%) of adults living with HIV in Sub-Saharan Africa [1–3]. The region also has the highest burden of pediatric HIV infection: most cases (90%) of pediatric HIV/AIDS result from transmission from the mother to the child during pregnancy, labor, delivery, or breastfeeding [3]. Nigeria, the most populous nation in Sub-Saharan Africa, has the second largest burden of HIV in Africa and the third largest burden in the world after India and South Africa; in addition, more women are affected than men [4,5]. The prevalence of HIV seropositivity among prenatal women in Enugu state is 5.1% [6], which is higher than the overall national prevalence among prenatal women of 4.1% [5]. According to a recent global HIV progress report, one-third (60 000) of all new HIV

⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129, Enugu state, Nigeria. Tel.: + 234 8037020295. E-mail address: [email protected] (E.C. Ezugwu).

infections among children in the 21 priority countries in Sub-Saharan Africa in 2012 occurred in Nigeria [7], and mother-to-child transmission (MTCT) accounted for a considerable proportion of new infections among children [4]. Owing to the relatively high unmet need for family planning in Nigeria (20%) [8], some of the neonates delivered by HIV-infected mothers might result from unintended pregnancy. HIV-infected women who do not wish to initiate pregnancy require effective contraception both to prevent unwanted pregnancy and for protection against sexually transmitted infection (STI) and HIV super-infection [9–11]. This approach—referred to as dual protection—involves simultaneous protection against unintended pregnancy and STI and/or HIV. Although the barrier method of contraception alone (condom) offers dual protection [11], it is associated with a high 1-year cumulative incidence of unintended pregnancy [12]. Consequently, in regions with high unintended pregnancy rates including Nigeria, the use of condoms together with another effective modern contraception method is often promoted for optimal sexual and reproductive health of women living with HIV [12]. Use of contraception for the prevention of unintended pregnancy among HIV infected women is also recommended by the WHO in its 4-pronged approach for comprehensive prevention of MTCT of HIV [13]. Although addressing the contraceptive needs of women of childbearing age living with HIV is a cost-effective strategy for preventing

http://dx.doi.org/10.1016/j.ijgo.2013.12.014 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Ezugwu EC, et al, Contraceptive use among HIV-positive women in Enugu, southeast Nigeria, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2013.12.014

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E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx

unintended pregnancy and HIV transmission to unborn children [3,14], this evidence-based approach is often neglected during the care of this vulnerable group of women [11]. Thus, despite the effectiveness of modern contraception as a strategy for preventing MTCT, contraceptive use among HIV-positive women in Nigeria, particularly those in the southeastern region of the country, calls for a critical appraisal. This is in view of the fact that women in the region are generally disempowered about sex [15], because most of them do not have the power to negotiate for safe sex. A recent study from the region showed that many married women (43.7%) are unaware of their right to contraception; the decision to use contraception or not is usually taken by the man (61.9%), making contraception inaccessible without the support of the husband [16]. The prevalence of and variables associated with contraceptive usage among HIV-positive women in the region deserve careful evaluation because these factors may have a direct implication on the frequency of unintended pregnancy and on the overall success of preventing MTCT of HIV in the region. Furthermore, this information might be relevant for policy-makers, HIV treatment and control experts, the maternal and child health units of health institutions, and the ministry of health for effective planning and strategic intervention. The aim of the present study therefore was to determine the prevalence and pattern of, and factors associated with, contraceptive usage among HIV-positive women in Enugu, southeastern Nigeria. 2. Materials and methods In a questionnaire-based cross-sectional study, contraceptive usage was assessed among HIV-positive, sexually active women aged 18–45 years who were receiving care at adult HIV clinics in Enugu, southeast Nigeria, over a 6-month period from March 1 to August 31, 2012. Prior to commencement of the study, ethical approval was obtained from the institutional ethical review boards of the participating institutions, and all participants provided informed written consent. The study was conducted at 2 tertiary health institutions in Enugu, the capital city of Enugu state: University of Nigeria Teaching Hospital, and Enugu State University Teaching Hospital. Although both institutions are referral centers, they also provide primary and secondary healthcare services. They have well-established adult and pediatric HIV/AIDS clinics, in addition to MTCT prevention clinics. Both tertiary health institutions provide healthcare services to approximately 6 million people of Enugu state; the neighboring states of Abia, Ebonyi, Imo, and Anambra; and some parts of Benue and Kogi state. On the basis of a rate of contraceptive use of 70% reported in a previous study in Jos, Nigeria [17], a confidence level of 95%, and error margin and non-response rates of 5% and 10%, respectively, it was calculated that 400 study participants would be adequate for the study. Therefore, 200 women were recruited consecutively from the adult HIV clinic of each institution. The inclusion criteria were age 18–45 years, HIV-positive status for at least 1 year before the study, sexual activity in the past 3 months, and capacity to give consent. Pregnant women and other women who were not at risk of pregnancy—for example, postmenopausal women and women who had had a hysterectomy—were excluded from the study. Using a pretested questionnaire, trained medical interns conducted a face-to-face interview with the participants to obtain the following information: the patient’s sociodemographic characteristics, desire for pregnancy, and contraceptive use including the method used at the time of the study and the source of the contraception method. The questionnaires were cross-checked to ensure completeness. Data were entered into Epi Info version 3.3.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA) and frequency tables were generated for relevant variables. Proportions were compared via Pearson χ2 test or Fisher exact test as appropriate, and relationships

were expressed via the odds ratio (OR) and confidence interval (CI). A P value of less than 0.05 was considered statistically significant. 3. Results In total, 400 HIV-positive women participated in the study. The age range was 18–45 years (mean age, 31.4 ± 5.8 years). Most respondents were married (62.3%). In total, 65% of the respondents lived in Enugu metropolis, and most were Christians (99.8%) of Roman Catholic (68%) and Protestant (18%) denominations. The sociodemographics of the participants are shown in Table 1. Overall, 338 (85%) participants had no desire to achieve pregnancy in the following 2 years. The prevalence of contraceptive use among this group of women was 73.1%. Male condom was the most frequent type of contraception used (78.1%, n = 193), either alone (53%) or in combination with another effective method (25.1%). However, almost half (48.2%) of the HIV-positive women in the study whose partners used condoms reported inconsistent use. Sixty-two participants (25.1%) used a dual-contraceptive method. None of the participants reported the use of female condoms (Table 2). Injectable contraceptive was the third most frequent method used (12.1%). Only a few women used long-acting reversible contraceptives, including the intrauterine device (IUD) (4.8%) and implants (4.8%). Although most women obtained their contraception from the hospital (80.2%), one-fifth (19.8%) procured contraceptives, especially the male condom, from a pharmacy shop. Approximately 27% (n = 91) of the HIV-positive women who did not desire to achieve pregnancy within 2 years despite being sexually active were not on any form of contraception for either child spacing or for limiting number of children. Approximately 18% (n = 16) of them stated that they had not received counseling on family planning. Misconception coupled with fear of adverse effects (49.4%) was the most common reason for not using contraception. Having a regular sexual partner was strongly associated with use of modern contraception (OR, 73.00; 95% CI, 34.13–156.13; P b 0.0001). However, parity, educational status, religion, and use of antiretroviral drugs were not significantly associated with modern contraception use (P N 0.05) (Table 3). Table 1 Sociodemographic characteristics of the study respondents. Characteristics Age distribution, y ≤19 20–29 30–39 40–45 Marital status Married Single widowed Separated Divorced Educational level Non-literate Primary Secondary Tertiary Religion Catholic Protestant Anglican Muslim Residence Enugu city Outside Enugu city Occupation Employed Unemployed

Number (percentage) of women (n = 400) 2 (0.5) 158 (39.5) 172 (43.0) 68 (17.0) 250 (62.5) 86 (21.5) 44 (11.0) 10 (2.5) 10 (2.5) 2 (0.5) 84 (21.0) 180 (45.0) 134 (33.5) 272 (68.0) 72 (18.0) 52 (13.7) 1 (0.3) 136 (34.0) 264 (66.0) 250 (62.5) 150 (37.5)

Please cite this article as: Ezugwu EC, et al, Contraceptive use among HIV-positive women in Enugu, southeast Nigeria, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2013.12.014

E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx Table 2 Reproductive intention, and contraceptive use and source among respondents. Question

Number of respondents

Desire for a child within 2 y Yes No Currently using modern contraception Yes No Method of contraception used Male condom alone Injectables Dual method (condom + another method) Implants IUD Source of contraception UNTH ESUTH Retail shop Private hospital PHC For non-users: have you had counseling on family planning? Yes No Reason for not using contraceptive by non-users Misconception and fear of adverse effects Partner does not like it Decreased sexual pleasure Difficulty accessing

400

Number (percentage) of respondents 62 (15.5) 338 (84.5)

338 247 (73.1) 91 (26.9) 247 131 (53.0) 30 (12.2) 62 (25.1) 12 (4.9) 12 (4.9) 247 74 (30.0) 69 (27.9) 49 (19.8) 40 (16.2) 15 (6.1) 91 75 (82.4) 16 (17.6) 91 45 (49.5) 27 (29.7) 14 (15.4) 5 (5.5)

Abbreviations: ESUTH, Enugu State University Teaching Hospital; IUD, intrauterine device; PHC, primary healthcare center; UNTH, University of Nigeria Teaching Hospital.

4. Discussion The present study demonstrated that the prevalence of contraceptive use among HIV-positive, non-pregnant women who did not desire pregnancy in Enugu was 73.1%, which is similar to the level of 70% reported in Jos, Nigeria [17], but lower than the level of 85% reported in Soweto, South Africa [18]. Although the contraceptive prevalence of 73.1% seems high, 26.9% (n = 91) of the HIV-positive women who did not desire pregnancy within 2 years were not using any form of modern contraceptive. This is slightly lower than the level of 30% reported in Jos [17], but higher than that of 5%, 12.4%, and 16% reported in India [9], Brazil [19], and Soweto [18], respectively. Being sexually active, this group of women is at risk of unintended pregnancy that might militate against the fight

Table 3 Factors associated with contraceptive usage among 338 HIV-positive women not desiring pregnancy within 2 years. Characteristic

Parity 0–1 N2 Educational status Primary Post-primary Religion Catholic Non-Catholic Regular sexual partner Yes No Antiretroviral use Yes No

Number of women using contraceptives

Number of women not using contraceptives

χ2

62 185

31 60

2.250

0.13

49 198

19 72

0.003

0.95

143 104

55 36

0.088

0.77

234 13

18 73

193

184 63

68 23

0.001

P value

b0.001

0.92

3

for preventing new pediatric HIV infections. The high burden of unmet need for contraception recorded in the present study must be urgently addressed because any unintended pregnancies among HIV-positive women must be prevented to achieve the desired reduction and possible elimination of MCTC of HIV in the Sub-Saharan region. Among the subgroup of HIV-positive women in Enugu who were using modern contraceptives, male condom (78.1%) was the most commonly used contraception among, similar to reports from Jos [17], India [9], and Soweto [18]. Male condoms were used either alone by their male partners (53%), or as part of the dual-contraceptive method (25.1%). Nowhere in the world is the consistent and correct use of condom more important than in Sub-Saharan Africa in preventing STI infection including HIV [20]. The effective and consistent use of condom alone has the potential to offer dual protection, thus reducing the burden of unwanted pregnancy and HIV infection in the sub-region [11]; unfortunately, almost half of the HIV-positive women in the present study whose partners used condoms reported inconsistent use. The effectiveness of condoms is dependent on correct and consistent usage [11]: inconsistent use undoubtedly increases the risk of STI, transmission of HIV to a sexual partner among serodiscordant couples, and HIV super-infection. Furthermore, in the absence of another effective contraception method, unintended pregnancy might result [11]. Only approximately 25% of the HIV-positive women in the study used condoms with another effective contraceptive (dual-contraceptive method) compared with 50% in Jos [17], 33% in Soweto [18], and 27% in Brazil [19]. However, this is much higher than that reported among HIV-positive men and women in Uganda (3.5%) [21] and in India (23%) [9]. Considering that Nigeria is responsible for approximately 32% of the gap in achieving the global target of eradicating MTCT of HIV [4], all efforts should be made to promote the availability and accessibility of contraception to HIV-positive women. The dual-contraceptive method should be encouraged with emphasis on the consistent and proper use of condoms to effectively prevent unintended pregnancy and STI including HIV super-infection. Regrettably, no participant reported use of the female condom. Although the female condom has a higher risk of unintended pregnancy rate compared with the male condom [22,23], it has the advantage of being under the control of the woman and should be encouraged in combination with a modern contraceptive for dual protection. The non-use of female condom observed in the present study might be due to the scarcity, and in some places the non-availability, of the female condom in most health facilities in southeastern Nigeria. Female condoms should be made readily available in all health facilities, especially for HIV-positive women. There seems to be limited use of non-condom contraceptives among HIV-positive women in Enugu. The use of long-acting reversible contraceptives LARC (IUD and implant) reported in the present study was relatively low (4.8% each) despite the safety and effectiveness of these methods [23]. This finding may be due to low awareness of the safety of long-acting reversible contraceptives among HIV-positive women [18] and their health provider. Further studies are necessary to confirm this assumption; however, Morse et al. [24] have reported that the clinician’s perception that the IUD and implant are inappropriate for HIVpositive women, despite evidence to the contrary, might affect usage. Chakrapani et al. [9] reported 3 main barriers to the use of noncondom contraceptives, either alone or in combination with condoms, among individuals living with HIV: a lack of discussion about forms of contraceptives other than condoms; a lack of acceptability owing to misconception and overestimation of adverse effects; and a lack of involvement of the husband in family planning counseling. Among non-users of modern contraceptives in the present study, the common reasons for non-usage were misconception, exaggerated fear of adverse effects, and disapproval of the husband. In many Sub-Saharan Africa countries, where women are reportedly denied the right to contraception as seen in Enugu [16], couple counseling should be encouraged because it might promote the support and cooperation

Please cite this article as: Ezugwu EC, et al, Contraceptive use among HIV-positive women in Enugu, southeast Nigeria, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2013.12.014

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of the male partner. Notably, having a regular sexual partner was associated with the use of modern contraception in the present study. Couple counseling might reduce the burden of contraception on the women. In addition, there is a need for proper counseling and education of couples to erase fears and misconceptions of modern contraception. Importantly, there should be training or retraining of HIV counselors and clinicians in Sub-Saharan Africa on the WHO eligibility criteria for the different contraception methods. This will help to equip HIV counselors and clinicians with the evidence-based information needed to address such misconception among HIV-positive women. These women should be offered correct information to allay their fears and correct any misconception. The limitation of the present study includes the possibility that some biases might have occurred in the choice of some of the responses obtained from the respondents because the questionnaires were administered via an interviewer. However, the effects of any bias on the study’s estimates are likely to be minimal and non-directional. In conclusion, a significant proportion of HIV-positive women in Enugu who did not desire to achieve pregnancy in the following 2 years despite being sexually active did not use contraception. This high burden of unmet need for contraception must be addressed in order to prevent unintended pregnancies among HIV-positive women and consequently MTCT of HIV. This approach could reduce the unacceptable high rate of pediatric HIV infection in Nigeria and in SubSaharan Africa in general, and can be achieved by promoting family planning services and making modern contraceptives easily accessible and affordable to HIV-positive women desirous of either child spacing or limiting their family size. Furthermore, the dual-contraceptive method should be encouraged among HIV-positive women with emphasis on consistent and effective use of the condom. Conflict of interest

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Please cite this article as: Ezugwu EC, et al, Contraceptive use among HIV-positive women in Enugu, southeast Nigeria, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2013.12.014

Contraceptive use among HIV-positive women in Enugu, southeast Nigeria.

To determine the prevalence and pattern of, and factors associated with, contraceptive usage among HIV-positive women in Enugu, southeastern Nigeria...
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