Reproductive Plans And Utilization of Contraceptives Among Women Living With HIV

1.1. Background of Study

The reproductive health care of women living with human immunodeficiency virus (WLHIV) has never been adequately met despite intention of public health policies to provide universal access to reproductive health care service.1 HIV has a serious effect on the reproductive health of women, not only its transmission sexually but annual occurrence of infection in women.2 In Nigeria, HIV prevalence among currently married and never-married women is 3.4%. Being under 15 years of age at first sex, and having engaged in transactional sex were found to be the strongest HIV risk factors among women.3 Nigeria has over 80% cases of HIV transmission through heterosexual intercourse.4 Inability to make sexual decisions, and forced abortion experience has been reported by WLHIV Nigeria.5 About 2 million (90%) of childhood HIV in sub-Saharan Africa is through mother to child transmission, this signifies high levels of fertility and low modern contraceptive use among HIV positive women in Sub-Saharan Africa.2

Fertility is a vital transition in sub-Sahara African, fertility rate in this region is higher than other region of the world.4 Nigeria account for 70% of sexually active WLHIV, fertility rate of 5.5 million per children among WLHIV and (15%) low contraceptive uptake.4 Reproductive family health as related to preventing unintended pregnancy and supporting planned pregnancy is an area that is especially relevant to HIV-infected women.6 According to the World Health Organization’s (WHO’s) Medical Eligibility Criteria for Contraceptive use, most contraceptive methods are safe and effective for WLHIV, both with asymptomatic HIV and AIDS.6 Modern contraceptives should be made readily available and accessible to women living with HIV to help eliminate mother-to-child transmission of HIV and subsequent new pediatric HIV infections.6 Various studies have demonstrated that there is need for more information on safer contraception methods among WLHIV.7 About 2 million (90%) of childhood HIV in sub-Saharan Africa is through mother to child transmission, this signifies high levels of fertility and low modern contraceptive use among HIV positive women in Sub-Saharan Africa.2

However, integrated HIV and family planning (FP) service model developed enable linkage with antiretroviral therapy (ART) services for eligible clients. Globally, there is unmet need of family planning services among at least 25 per cent of all HIV married women.8 In sub-Saharan Africa, eight male condoms are available per year for each sexually active individual, there is low access to condom among young people.2 Evidence suggests that in Sub Saharan Africa (Nigeria and Zambia) WLHIV utilize contraception at higher rate to prevent unplanned pregnancy than women not living with HIV.9 In contrast, there is significant low uptake of family planning services, majority of WLHIV were conversant with at least one method of family planning.10 Utilization of contraceptives is significantly predicted by women’s knowledge of their HIV-positive status.11 In Nigeria, it was reported that 39.8% utilization of condom among WLHIV with cohabiting partner.12 However, Adenuga, et al reported increased level of contraceptive uptake and satisfaction among WLHIV.12

Availability and accessibility of highly active antiretroviral therapy (HAART) to treat HIV infection results in increase reproductive opportunity for women living with HIV. It is every woman’s right to conceive, yet there are various problems related to pregnancy, especially amongst WLHIV. Evidence show that these women have different reproductive desires with majority desirous of childbearing.13 Despite the impact of provision of antiretroviral treatment for people living with HIV and AIDS to improve pregnancy outcome, transmission of (HIV from mother to child is still high. 13 There is a significant association between fertility intention and ART use among WLHIV in Ethiopia. 14

Unintended/unwanted pregnancy continues to be a burden in Sub-Saharan Africa, with an estimated 14 million cases occurring each year.8 Similarly, researchers noted high rate of unplanned pregnancy among women living with HIV in South Africa.15 In contrast, Akelo, et al.16 noted that majority of women living with HIV on ART in South Africa and Kenya planned their pregnancy. Unplanned pregnancies involve higher HIV risk and could undermine efforts to eliminate new infections.17 Ezugwu et al18 noted that substantial number of women living with HIV declared their pregnancies to be unplanned. Unplanned pregnancies among women living with HIV are targeted through availability and accessibility of Family Planning Services.19

The researchers observed that WLHIV can also plan their reproductive lives to avoid unwanted pregnancy and enjoy parenthood like their counterparts who are not infected by the virus. Hence, this study intended to bridge this gap of limited information on contraceptives option and helps provide necessary information for informing reproductive practice and care of WLHIV.

1.2. Objectives and Hypotheses

The objective of the study was to assess the reproductive plans and utilization of contraceptives among WLHIV in selected teaching hospitals in South West, Nigeria. Specifically, we aimed to: (1) assess the knowledge of contraceptive options available to WLHIV; and (2) examine the reproductive plans and desire for children among WLHIV; (3) examine utilization of contraceptives among WLHIV; and (4) assess the family support received by WLHIV in our study. We hypothesized that (1) would be no significant association between knowledge of contraceptive options and contraceptives utilization among WLHIV; (2) there would be no significant association between knowledge level of contraceptive options and desire for children among WLHIV; and (3) there would be no significant association between number of living children and reproductive desire to have more children among WLHIV.

2.1. Study Variables

The quantitative data was collected using a validated structured questionnaire developed by Haynes et al.18 The questionnaire was used to assess women’s reproductive desire and focus group discussion guide to identify the factors influencing contraceptive utilization and reproductive desire. The adapted questionnaire was translated into local Yoruba language (for those who would find it easier to complete in Yoruba language) and back translated into English language to retain the original meaning of the questions. The reliability of the quantitative instrument was determined by test–retest of instrument stability. This was done by administering questionnaire to 5% of study sample that met inclusion and exclusion criteria. The data were analyzed using Cronbach’s alpha reliability coefficient which was 0.7, hence reliability of the instrument was confirmed to be high. Three research assistants, who were nursing students, were trained and they performed all data collection.

Sample size of 427 was determined by using the simple estimation formula by Adeunga et al.,12 including 20% non-response rate.

Table A Proportionate allocation of study Sample

Centre	Estimated Population	Sample Size selected
LUTH	250
UCH	300
Total	550	426

Qualitative method: The number of WLHIV that gave consent and participated in the focus group discussion was 10 respondents for each hospital.

2.2. Statistical Analysis

Statistical Package for Social Science windows version 22 (SPSS Inc., Chicago, Illinois) was used to obtain the mean and standard deviation of mean ages of enrolled women using simple descriptive analysis. Basic descriptive statistics (frequencies, proportions, means, and standard deviations [SD]) were calculated for all of the items of the questionnaire. Chi-square test was also used in bivariate analysis to determine the association between various socio-demographic factors and contraceptive use while P-value ≤ 0.05 was considered to be statistically significant

2.3. Ethical Approval

This study was conducted in accordance with research ethics. Ethical approval was obtained from Ethics Review Committees at the College of Medicine, University of Lagos, Idi-Araba, (CMUL/HREC/02/18/333) and University College Hospital, University of Ibadan (UI/UCH/EC/17/0569). The purpose of the study was explained to the participants and they were informed of their right to withdraw from the study any time. Women unable to read or write had the consent read and explained to them in their local dialects. All participants provided informed consent. Confidentiality of information given by the subjects was maintained and anonymity ensured. The research assistants were also trained to ensure confidentiality.

3.1. Socio-demographic Characteristics

A total of 427 questionnaires were administered but 400 of them were completely filled giving a response rate of 93.67%. Most of respondents 99 (24.75%) were within 35-39 years and are currently married. Two hundred and six (51.15%) of the enrolled women had tertiary education and 198 (49.5%) identified as Christians. The mean age of participants was 37.42±7.51. Table 1 presents the results of social demographic variables of enrolled women.

3.2. Knowledge on Contraceptive Options

Ten questions were asked on contraceptive options and each correct answer was assigned a score of 1. Respondents were categorized based on their scores as having good knowledge (score of 5-10 points), and poor knowledge (score of 4 and below). Table 2 presents the cumulative level of knowledge. There was a significant association between knowledge level of contraceptive options and utilization of contraceptives (p=0.007).

3.3. Reproductive Plans

Respondents were asked if they have been sexually exposed or not sexually exposed since diagnosis of HIV. They were classified as being sexually exposed if they answered “yes.” Respondents were asked if they had decided to have more children, the outcome of previous pregnancy, whether they were alive, miscarried or dead, if they had planned the pregnancy, and whether they had used contraceptives. The reproductive desire of the participants showed that more than half of the respondents or 286 (56.5%) had desire for children, with desire for 1-2 children (24.25%) and reasons for desire reported (Table 3). A good number of the women living with HIV had children ranging from one to five children. Among the women who had children, 31.49% (n = 97) had planned their last pregnancy, whereas 68.51% (n = 211) had an unplanned pregnancy (Table 3). Majority of the women (74%) were currently in a sexual relationship and had regular sexual partners, whereas 51.47% of them had changed their partners after HIV diagnosis. In all, 90.25% of the women did not disclose their HIV status to their sexual partners.

3.4. Utilization of Contraceptives

The number of contraceptives used by the respondents and reason for usage were highlighted. Approximately 248 (62%) respondents had used contraceptive some years back while 210 (52.5%) respondents were currently using contraceptives (Table 4). Figure 1 reflects the different methods of contraceptives utilized by WLHIV in the study.

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Figure 1

Types of contraceptives currently used by study participants

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3.5. Receipt of Family Support

The support received from family members by women living with HIV was explored using the Family APGAR function test. The Family APGAR was designed in 1978 by Smilksteinin to explore the family functionality of study participants. The APGAR acronym refers to the five components of family function: adaptability (adaptability), cooperation (partnership), development (growth), affection (affection) and response capacity (resolution).20 It was used to assess family support among the participants. Majority of respondents 226 (56.5%) disclosed functional family support, while minority of the women 58 (14.5%) described severely dysfunctional family support (Table 5).

3.6. Tests of Research Hypotheses

A significant association was found between knowledge level of contraceptive options and utilization of contraceptives (Table 6). This affirms that the knowledge level of contraceptive options of WLHIV was related to actual utilization of contraceptives (X² = 7.21, df = 1, p =.007).

The results shown in Table 7 indicated a significant association between level of education and utilization of contraceptives among women living with HIV (X2 = 21.02, df = 3, p =.001). Therefore, level of education was associated with the extent to which WLHIV utilize contraceptives. Table 8 shows a significant association between the respondents’ desires to have babies and their knowledge level of contraceptive options that prevent and reduce the risk of vertical transmission of HIV infection (X²= 13.717; P = 0.03).

4.1. Limitations of the Study

The conduct of this study was limited by the study design, where a participant’s response may not be their true opinion so there is likely to have been social desirability bias. Women living with HIV may under-report their reproductive plan as a result of perceived negative social approval from the community. Moreover, the WLHIV may have been psychologically affected by the types of questions that were asked and this may explain why some opted to withdraw from the interviews. Also, this study being a cross-sectional study rather than a longitudinal study could be a limitation to the study. A longitudinal study among WLHIV is recommended to understand the reproductive pattern as well as the effect of good knowledge of contraceptives on reproductive plan of WLHIV. Further research should be carried out on occupation, spousal’s level of education and psychological factors that affect contraceptive utilization and reproductive plans among women living with HIV in the society.