HIV-positive women choose different forms of contraception depending on their partner’s HIV status, according to a French study published in the June 1st edition of the Journal of Acquired Immune Deficiency Syndromes. Whereas women with HIV-negative partners tend to use condoms, the use of oral contraceptives and intrauterine devices (IUDs) is more common among women with HIV-positive partners.
The study’s authors argue that their observations are due to HIV-positive women with HIV-negative partners choosing a contraceptive method that is better suited to prevent HIV transmission. Conversely, women in seroconcordant relationships tend to choose methods to avoid pregnancy, and are seemingly less concerned about the transmission of sexually transmitted infections or new strains of HIV.
“Although they are associated with a high degree of protection against HIV transmission, [condoms] provide less protection against pregnancy,” state the authors. “Oral contraceptives, IUDs and sterilisation are highly effective means of contraception. However, they do not prevent HIV transmission.”
The investigators recruited 575 HIV-positive women from the gynaecology outpatient departments of two Paris hospitals between June 1993 and December 2001 for their prospective observational study. The women were aged between 19 and 49 (median 32) and had not undergone hysterectomy or been through the menopause.
At baseline, the women were asked to complete a questionnaire about their demographic, sexual and medical history. They were then questioned every six months about their sexual relationships and use of contraception. Rates of sterilisation were not recorded, since tubal ligation and vasectomy were not authorised in France until July 2001.
Overall, there were 429 reports of relationships with HIV-negative partners and 190 with HIV-positive partners, with some women reporting more than one partner over the eight-year study. Use of contraceptives was reported in 91% of the visits of women with an HIV-negative partner, and 69% of those with an HIV-positive partner (p = 0.0001).
Consistent use of condoms was more common in serodiscordant couples than those in which both partners were HIV-positive (odds ratio [OR] = 6.1; p < 0.001). Conversely, use of oral contraceptives or IUDs was less common among positive women with an HIV-negative partner (OR = 0.8; p < 0.001). No data are available on the rate of HIV transmission to the women’s partners, or on which women became pregnant during the study.
Of the women with an HIV-negative partner reporting contraceptive use, condom use alone was reported at 84% of visits, whereas oral contraceptive or IUD use alone was reported at 4%. Condoms used together with either oral contraceptives or IUDs, which gives the best protection against both HIV transmission and pregnancy, was reported at only 12% of visits.
In women with an HIV-positive partner reporting contraceptive use, condom use alone was reported at 57% of visits, oral contraceptive or IUD use alone at 31%, and dual methods at 12%.
Following the introduction of HAART, the use of oral contraceptives and IUDs decreased in women with an HIV-negative partner after 1998 (p = 0.02). However, it remained stable in those with an HIV-positive partner. Consistent condom use also remained stable in both groups over time.
The authors suggest that the reduction in use of contraceptive methods better suited to avoidance of pregnancy in serodiscordant couples may reflect a desire for pregnancy in the light of improved survival and quality of life in the HAART era. In contrast, the advent of HAART has not led to reductions in condom use, despite falls in viral load.
However, it is difficult to imagine that couples intending to become pregnant would persist with the use of condoms. It seems more likely that an increased desire for pregnancy would be reflected in an overall decrease in contraceptive use over time. These data are not available in this study.
Although the patients' perceptions regarding the relative efficacy of condoms and other contraceptive methods in preventing HIV transmission and pregnancy are not reported, a more rational explanation of these findings may be that serodiscordant couples tend to use condoms more frequently to avoid the transmission of HIV and other infections, whereas those in which both partners are HIV-positive are less concerned about this.
Despite their interesting findings, the authors acknowledge that “the results of the study should… be interpreted with caution since the data were collected as self-reports about contraceptive use, sexual behaviour and the partner’s serostatus.” This may have led to the high rates of consistent condom use reported in the study.
“The use of a contraceptive method and condoms is a critical issue when discussing interventions in HIV-infected women at risk for transmitting HIV,” conclude the authors. “Our data emphasise that contraception counselling should take into account the partner’s serostatus.”
Further information on this website
Pregnancy & Contraception - factsheet
HIV & women - patient information booklet
Reference
Heard I et al. Contraceptive use in HIV-positive women. J Acquir Immune Defic 36: 714-720, 2004.