High levels of unmet need for family planning in people with HIV - couples unaware of conception and contraception options

In Kenya, Tanzania and Namibia, just 46% of HIV-positive women and 28% of HIV-positive men have discussed family planning with a healthcare provider, delegates were told at the International AIDS Society conference (IAS 2011) in Rome last week. In these and other African settings, few couples employ dual protection methods (using condoms alongside another contraceptive method), while there is low awareness of strategies which allow a serodiscordant couple to conceive while limiting the risk of sexual HIV transmission.

A number of posters quantified the unmet needs for contraception in various African countries, whilst studies from South Africa and Kenya explored men and women’s feelings about having a child, HIV transmission risk and interventions for safer conception. Treatment-as-prevention and pre-exposure prophylaxis were well accepted, whereas there was scepticism about sperm washing.

The largest quantitative study on unmet needs was conducted in 18 different clinics in Kenya, Tanzania and Namibia, recruiting 1992 women and 1483 men. Participants were living with HIV, sexually active and under the age of 50. The average (median) age of participants was 37, with an average of two children each.

Only a minority of participants reported that they had discussed family planning with a healthcare provider at their HIV clinic. The number who had done so varied from women to men, and from country to country. Overall, 46% of women had had this discussion (68% in Kenya, 40% in Namibia and 32% in Tanzania). The number of men who had had family planning discussions was much lower, at 28% (41% in Kenya, 23% in Namibia and 21% in Tanzania).

Pregnancy was more often desired by men than women. Among men with HIV, 20% hoped for a pregnancy in the next six months, whereas among women with HIV, 14% did. Moreover, 25% of women with HIV believed that their husband or main sexual partner wanted her to become pregnant.

Turning now to those individuals who were not hoping for a pregnancy in the coming months, only a minority were using dual protection, which is widely recommended. Dual protection combines condom use (protective against transmission of HIV and sexually transmitted infections) with another contraceptive method whose effectiveness is not reliant on it being used at the time of sex – for example pills, injections, implants and intrauterine devices.

Only 30% of women who didn’t want to get pregnant reported dual protection. In contrast, 12% used no method at all; 14% reported using a method such as pills or injections; and 44% reported only using condoms.

However, there is such an emphasis on condom use in HIV services that there is a risk that participants exaggerated their use of condoms, in order to tell the researchers what they thought they wanted to hear. The investigators warn that if this is the case, the unmet family planning need is actually greater than they estimate.

Among the men not hoping to get their partner pregnant, 18% reported dual protection; 7% a method such as pills or injections; and 73% condom use only. Again, condom use may be over-reported.

There were variations between countries – for example, Tanzanians were the least likely to report having dual protection.

The researchers conclude that in this group of people with HIV wishing to delay or avoid pregnancy, seven out of ten women and eight out of ten men are not using dual protection and so have unmet family planning needs. It is likely that the limitations of the family planning information provided by healthcare workers is one cause of the low uptake of effective methods.

Qualitative data

To explore attitudes and feelings about conception, researchers in Durban, South Africa, conducted in-depth interviews with 30 women and 20 men living with HIV whose primary partner was either HIV-negative or of unknown status.

As in the previous study, men often had a stronger desire than women to have a child, and women with HIV often felt pressure from their partners to have children. One man explained why he wanted to have a child:

“I think because children are a gift from God. They leave a legacy of the family and they extend and expand your surname so that it won’t die when you die, your legacy won’t perish.”

One woman with HIV said:

“At times he would pretend he was using the condom when he was not. I told him that we should stop thinking about having a baby because I am sick, but he had hope that he will get a child.”

Given the crucial role of men in decisions around pregnancy, the researchers recommend that male partners must be involved in interventions to promote safer conception.

But only a few pregnancies were explicitly planned. One woman said:

“I did want to have a child but I had not really planned which year it would be, but I wanted one… I was the one who wanted a child and I’m the only one who knew that. When I told him [partner] that I was pregnant, he did not have a problem with that.”

Moreover, in these couples, there was considerable confusion over serodiscordancy. Participants found various explanations for why one partner was apparently HIV-negative while the other was HIV-positive. Test results were not always trusted.

“Maybe the virus is hidden but it is there.”

“He then asked me how it happens that he is negative and I am positive and I told him about the window period.”

“I think it’s God’s will that she did not get the virus from me.”

A number of respondents and partners were fatalistic about eventual HIV transmission within the couple. This led to riskier behaviour.

Moreover, some HIV-negative male partners were prepared to risk HIV infection in order to conceive.

“He was the one who took that decision that he wanted another child. I was afraid. I told him that what we are doing is not right because he might get infected. And if he is HIV-positive, he will blame me. He said that if it supposed to happen, then it will happen.”

A few respondents took viral load into account in their decision making.

“After finding out that my viral load was very low, even undetectable, he decided that let’s take a chance and try and see what is going to happen.”

However the majority of respondents were not aware of strategies such as delaying conception until viral load is undetectable and self-insemination.

To further explore strategies for safer conception, another group of researchers interviewed Kenyans who were involved in serodiscordant relationships. They interviewed both the HIV-positive and HIV-negative partners, with the aim of better understanding which techniques would be acceptable to participants.

Some participants were aware of the technique of confining unprotected intercourse to the female partner’s fertile window, and one couple had had a baby with this technique (but had not had tested their child for HIV).

But there was scepticism about sperm washing, with one HIV-positive man commenting:

“It will be so much expensive, the poor people won’t afford it. The psychological part of it – the community – people will view you as getting a child in a scientific way… in such a situation, I think you have to take some legal action because you are not sure that the child who is going to be born is yours. The psychological part of it might haunt you.”

On the other hand, the idea of pre-exposure prophylaxis (PrEP) was well received, with its ease of administration being seen as a major advantage.

“That would be good if there is a pill that can be taken to prevent infection. It would be good.”

Moreover, most respondents responded positively to the idea of antiretroviral treatment of the partner living with HIV, in order to reduce the risk of transmission, although some raised questions about the burden of side-effects when initiating therapy at a high CD4 count.

A recent UK study has also found some ambivalence amongst couples about sperm washing, while the preventative use of antiretroviral therapy was well accepted.

The authors of the Kenyan study conclude that couples attempting conception are highly motivated to consider interventions to reduce their transmission risk. With adequate education, they may be open to the use of HIV treatment, PrEP and timed intercourse.