Contraceptive use and method preference among HIV positive women in Addis Ababa, Ethiopia: a cross sectional survey

A cross sectional survey was carried out at selected public health facilities (hospitals & health center) of Addis Ababa between June and October, 2012. Non-pregnant women aged 18–49 years, reported having sexual relationship six months prior to the data collection period were eligible to participate in this study.

Sample size was computed using two-proportion formula with the assumption of proportion of contraceptive use among HIV positive women receiving HAART and HAART naïve being 86% and 82%, respectively [12], with a minimum detectable odds ratio of 2 at 5% level of significance power of 90% with a design effect of 2 and 5% addition for non-response rate a total sample size of 1924. However, the number of women who satisfy the eligibility criteria at the records of the health facilities was 1418 (770 HAART users and 648 HAART- naïve).

Study participants were selected using multi-stage sampling technique. Initially, five hospitals and seven health centers were selected by lottery methods, and then the total sample size was proportionally allocated to the selected facilities according to the client load in each institution. Finally individual study subjects were selected using a systematic random sampling technique from the records of each selected facility.

Data were collected using interviewer administered structured questionnaires adopted from previous similar study [12]. The questionnaire has been translated in to the local language (Amharic) by experts in both languages and back translated to English by another person to ensure consistency and accuracy. Data collectors were all female nurses recruited based on their previous experience in data collection, those who had previous training on ART and/or HIV counseling and fluency of the local language. Moreover, training was given for five consecutive days on interview techniques, sampling and ethical issues, emphasizing the importance of safety of participants and interviewers, minimization of under reporting and maintaining confidentiality. A pre-test of the questionnaire was conducted in selected ART units which were not included in the main study. The data collection process was closely supervised by the principal investigator.

The primary outcome variable was self-reported contraceptive use for the previous six months prior to the data collection period. In this study contraceptive use was defined the use of any method including injectables (Depot), implants (implanol or jadelle), oral contraceptive pill (OCP), intra uterine contraceptive device (lUCD), male/female condom, diaphragm, permanent methods such as tubal ligation and hysterectomy. Dual contraceptive method was defined as use of primarily the male condom with hormonal or other contraceptive methods like IUCD. Consistent condom use was defined as the use of condoms always or frequently in all vaginal sexual relationships with casual and/or steady partners. Women who used condoms sometimes or rarely were regarded as inconsistent condom users.

Independent variables in this study included were age, education, employment, monthly household income, sexual partnership status, HIV sero-status of partner/husband, number of living children, HIV test of children, disclosure of HIV status to partner/husband and discussion with partner/husband or health workers about contraception. Medical record review was also conducted to confirm HAART history and obtain clinical data including World Health Organization stage of disease and CD4 cell count.

Antiretroviral therapy (ART) is treatment of people infected with human immunodeficiency virus (HIV) using anti-HIV drugs [36]. The standard treatment consists of a combination of at least three drugs (often called “highly active antiretroviral therapy” or HAART) that suppress HIV replication [37]. Highly active anti retroviral therapy (HAART) use defined as use of one of three antiretroviral medications either Efaveranze (EFV) or Neverapin (NVP) based [5, 12, 38] first line drugs or use of combination drugs with protease inhibitors(PIs) backbone of second line drugs [38]. We considered women to be HAART users if they had been receiving HAART for at least one month and HAART-naïve if they had never taken HAART, prior to the data collection period.

The pre coded responses were double entered in EPI Info version 3.5.2 software, for checking its consistency then was exported to SPSS for window version 20 for statistical analysis. Uses, preference and reasons for selection of contraceptive methods are presented using descriptive statistics. Variables found to be significant at bivariate level, (P < 0.05), were selected and included in to multiple logistic regression models. Then multiple logistic regression analyses were used to calculate Odds ratio with 95% confidence interval to estimate association and to control the potential confounding variables. Strength and direction of the association between contraceptive use and potential socio-demographic, reproductive health and clinical factors were presented using odds ratios relative to the reference category and 95% confidence levels.

The research was approved for scientific and ethical integrity by the Institutional Review Board (IRB) of College of Health Sciences, Addis Ababa University. Written permission was obtained from health bureau of the Addis Ababa city government. Consent was obtained from medical directors and respective unit heads at each health institutions. Verbal consent was also obtained from individual clients. In order to make informed decision sufficient information was given to each participant. Confidentiality was strictly maintained for each piece of information and the interview was conducted in strict private place. At the end of the interview general information, referral and follow up linkages were made for those who need.

Of the total 1418 women who participated in this study, 423 (29.8%) were in the age range of 30–34 years, with mean (standard deviation) of 31.1(±5.5). The study participants were predominantly Orthodox Christians 1109(78.2%) and Amhara 849(59.9%) by religion and ethnicity, respectively. Occupationally, 373 (26.3%) participants had their own private business and 292(20.6%) were housewives. Concerning educational status of the participants, 538 (37.9%) have completed grade 1–8, 466(32.9) grade 9–12 and 133(9.4%) with higher education. Four hundred nineteen (29.5) earn monthly income of less than 1000 Ethiopian birr and 390 (27.5%) women were with no monthly income. Concerning marital status, about 62% of the participants are currently married/cohabited and 242(17.1%) were single (Table 1).

About 55%(422/769) of HAART users and 45% (347/769)HAART naïve women had recent CD4 counts of 350 cell/mm3 and 42% (363/863) and 58% (500/863) HAART users and HAART naïve, respectively were in WHO stage of disease I or II. About 70.3% (997/1418) of the study participants reported ever had sexual partner in their life time. Of these women who had partners, 81.8% (816/997) reported that their partners were tested for HIV, and 73.8% (602/816) are positive for HIV. Of the total study participants, 463(32.7%) women reported having one child, 321(22.6%) two children and 428(30.2%) no children. About 59% (507/859) and 41% (352/859) HAART users and HAART naïve women, respectively, had disclosed HIV status to partner/husband. Furthermore, 66.6%(664/997) women reported they had open discussion with partner/husband (Table 2).

Overall contraceptive use was 71% (75% (579/770) and 65% (422/648) among HAART users and 42% HAART- naïve women, respectively). Four hundred five (28.8%) reported did not use contraceptive methods six months prior to the data collection period while contraceptive status was not known for 9 (0.6%) women (Table 3). In general male condom is the most preferred contraceptive method 45.7% (468/1001) followed by injectables 30.5% (306/1001) (Table 3).

The primary reason given for contraceptive use was for protection against STIs in 28% (281/1001) followed by prevention of unwanted pregnancy in 21% (208/1001), among women using any method. Other reasons mentioned were convenient to use 18% (180/1001), easy to use 14% (138/1001), does not interfere with sexual activity 8% (82/1001), advise of health workers 5% (50/1001), and the like (Figure 1).

Using the logistic regression model, a number of socio-demographic, HAART use, sexual history, disclosure behavior and clinical factors were identified as significant predictors of the association of contraceptive use (Table 4).

The results showed that HAART use has influence on women’s decision to use contraceptives compared to HAART naïve women, the odds of contraceptive use among HAART users was significantly higher, adjusted for other potential confounders (AOR 1.60, 95% CI; 1.30 to 2.12). Similarly, women who had sexual partners currently were more likely to use contraceptives than women with no partners (AOR 2.32, 95% CI 1.60 to 3.40). On the other hand, married/cohabited (AOR 0.41, 95% CI 0.21 to 0.80) and widowed women (AOR 0.31, 95% CI 0.12 to 0.84) respectively, had less likely to use contraceptive methods compared to that of single women.

Disclosure of HIV status, especially, with sexual partner has significant association with contraceptive use, women who disclosed their HIV status to partner were about two times more likely to use contraceptive than women who did not (AOR 2.23, 95% CI 1.21 to 4.12). Furthermore, women who reported open discussion with their partner/husband were about two times more likely to use contraceptives than those who reported no discussion (AOR 2.0, 95% CI; 1.60 to 2.60).

Contraceptive use also increased by the number of living children women have. The odds of contraceptive use for women who have one child (AOR 1.7, 95% CI 1.03 to 2.40), two children (AOR 2.6; 95% CI 1.7 to 4.02) and three or more children (AOR 3.3, 95% CI 1.90 to 5.60), respectively, were higher than women with no children. Similarly, the odds of contraceptive use was higher for women whose children are tested for HIV than women who did not (AOR, 1.6; 95% CI; 1.01 to 2.40).