Only a fifth of pregnancies among women living with HIV in the United States are planned, research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes shows. The majority of women were ambivalent about their pregnancy and planned pregnancies were associated with patient-initiated discussions about conception and pregnancy.
“Our findings suggest that family planning – including discussions of effective contraception, pregnancy intentions and safer contraception methods – alongside HIV prevention education – is needed in this population…in the primary HIV care setting,” comment the authors. “Our goal should be to maximize the number of planned pregnancies.”
Improvements in HIV treatment and care mean that the risk of vertical (mother-to-child) transmission of HIV can be reduced to below 1%. Moreover, use of antiretroviral therapy can minimise the risk of sexual transmission of HIV in couples wishing to conceive.
The number of pregnancies among women living with HIV in the US increased by 30% between 2000 and 2006. However, relatively little is known about pregnancy planning among women in the US. Investigators from the HIV and Obstetrics Pregnancy Education Study (HOPES) therefore designed a cross-sectional study involving women with HIV who received care at twelve sites in 2012.
All the women knew they were living with HIV before becoming pregnant and were aged 18 or over.
They completed the London Measure of Unplanned Pregnancy (LMUP), a validated questionnaire designed to assess the pregnancy intentions of women who are already pregnant. The LMUP categorises pregnancies as unplanned, ambivalent pregnancy or planned. The women were also asked about their engagement with HIV care in the year before they became pregnant and if they had had any discussions with a healthcare provider about conception and pregnancy.
A total of 172 women were recruited to the study. Their median age was 28 years and 78% were black. The majority (86%) reported that they had seen a healthcare provider in the year before their pregnancy, including 77% who had seen an HIV specialist and 47% who had received interdisciplinary care (combination of HIV care, primary care and/or obstetrics and gynaecology). Most (81%) were taking antiretroviral therapy in the year before conceiving.
Approximately half (45%) of participants reported that they had initiated a conversation with a healthcare provider about their interest in pregnancy and 60% said that a healthcare provider had raised this subject with them. Conversations with healthcare staff about conception and birth control were reported by 81% of women and 97% said they had been informed about condom use to prevent the transmission of HIV and sexually transmitted infections.
Analysis of the LMUP scores showed that 19% of participants had planned their pregnancy, 58% were ambivalent and 23% had an unplanned pregnancy. Over half (52%) indicated that they had not intended to become pregnant and a similar proportion (54%) stated that when they became pregnant they did not want the baby.
Factors associated with a reduced risk of an unplanned or ambivalent pregnancy included a previous pregnancy since diagnosis with HIV (aRR = 0.67; 95% CI, 0.47-0.94, p = 0.02).
“We speculate that this may be related to increased knowledge regarding the low risk of transmission of HIV during pregnancy from past experience and, therefore, less ambivalence or fear regarding planning for a future pregnancy,” comment the authors.
Having seen a healthcare provider (aRR = 0.60; 95% CI, 0.46-0.77, p < 0.001) and having a patient-initiated pregnancy discussion (aRR = 0.63; 95% CI, 0.46-0.77, p < 0.001) also significantly reduced the risk of unwanted or ambivalent pregnancies.
The investigators conclude that interventions that increase the engagement of women living with HIV with health care and the incorporation of pregnancy discussions and counselling into routine HIV care may decrease rates of unplanned or ambivalent pregnancies among women with HIV.
Rahangdale L et al. Pregnancy intentions among women living with HIV in the United States. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI0000000000000014, 2013.