A number of antitroviral treatment (ART) programmes supported by the US have observed a large number of unexpected pregnancies in women on ART, according to reports made at the 2006 PEPFAR Implementers meeting held in June in Durban, South Africa. According to one report, the results were disastrous for some women on ART in Uganda, who did not want any more children. As a result, teams have concluded that PEPFAR may need to invest more in supporting family planning services in these countries.
Reproductive behaviour on ART in Uganda
This was illustrated most dramatically by a study by researchers from the US Centers for Disease Control (CDC) in Uganda. The team conducted the study to determine what the total impact of ART over a few years would be on reproductive attitudes and behaviours in over 700 women offered ART in rural Uganda.
What they found was disturbing: at least 85 pregnancies occurred in these women; 97% of these women did not want to have more children, and 99% of them were not planning to have more children at that time (these patterns were similar among women who did not get pregnant). 79% of those who knew said that their partners did not want more children either.
Many of the women were shocked by their pregnancies since they had not been fertile for years prior to going on ART.
Background
In addition to reducing the likelihood of transmission, ART can restore fertility in women. Although aware of this fact, when setting up ART programmes in its target countries, PEPFAR believed that local services could handle family planning for people under their care, especially those taking ART. But to their dismay, the existing family planning services were weak in many countries and/or people simply do not use them.
The consequences of unwanted pregnancies in Uganda
While ART might reduce the likelihood of transmission to the infant, the serious difficulty that an unwanted pregnancy poses a woman — who until quite recently may have been at death’s door — should not be underestimated. Although her health may be improved for now, or quite possibly years, the future is still filled with uncertainty, and aside from the burden that having an additional child might put on the family, there is no guarantee that the child won’t fall ill or be orphaned while still quite young. Many such orphans lead a short and miserable existence.
And what is such a woman to do? Abortion is illegal in Uganda and women (and practitioners) can be jailed for performing it. Of course, that doesn’t stop women from seeking out the procedure anyway.
A recent paper by Singh et al in International Family Planning Perspectives noted: “Each year, an estimated 297,000 induced abortions are performed in Uganda, and nearly 85,000 women are treated for complications. Abortions occur at a rate of 54 per 1,000 women aged 15-49 and account for one in five pregnancies.” The paper states that since the people performing the abortions usually are not trained in the procedure and often use unsafe methods, “the death rate from abortion-related complications is very high."
So this is an ongoing problem in Uganda, which according to Singh and colleagues is partly due to a widespread fear that contraceptives cause side effects, and the fact that people have little access to them.
Indeed, the CDC researchers also found that the family planning referral sites were not functional due to poor management, lacked basic commodities and trained staff.
Unwanted pregnancies in South Africa
But even in South Africa, where family planning services are available, unwanted pregnancies in women on ART were still reported — and these were on efavirenz based regimens. Becoming pregnant while on efavirenz-based regimens is discouraged because the drug could potentially cause birth defects.
According to one presentation, the Perinatal HIV Research Unit at Wits University has placed more than seven hundred women on efavirenz-based ART since August 2004. 53 (8%) of the women were diagnosed as pregnant while in the programme, and only ten of these pregnancies had been planned. Women who elected to continue their pregnancies were switched to other treatment regimens. However, in South Africa, abortion is legalb and 19 women (35%) chose to terminate their pregnancy.
Strengthening family planning services
For a variety of reasons, it would be much better to avoid these pregnancies in the first place, so the CDC in Uganda has decided that they need to provide much stronger counselling and education about the impact of ART on fertility. In addition, it may make sense for PEPFAR to directly support family planning services for people with HIV.
According to researchers from Family Health International in Tanzania, these family planning services might best be provided in-house at their HIV care and treatment clinics (CTC). In a survey among their patients, they found that about one third of patients on ART want to have children at some point in the future but very few use contraception. These patients said that they would prefer to have family planning and sexuality counselling offered through their CTC, rather than to be referred elsewhere. Initially, the CTC counsellor were unfamiliar and uncomfortable with providing these services, so they are receiving further training in family planning and sexuality.
Gray RH et al. Increased risk of incident HIV during pregnancy in Rakai, Uganda: a prospective study. Lancet 366(9492):1182-8, 2005.
Homsy et al. Determinants of pregnancy among women receiving HAART in rural Uganda. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 98.
Mohohlo M et al. Pregnancy-related events in an antiretroviral treatment program. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 113.
Mpangile G et al. Sexual and child-bearing needs of people on ART: The forgotten agenda. The 2006 HIV/AIDS Implementers Meeting of the President’s Emergency Plan for AIDS Relief, Durban, South Africa, abstract 116.