Background
Approximately 450,000 adults were living with HIV/AIDS in Thailand in 2013 [
1] and more than half of them were 18–49 years old. Thailand provides universal access to antiretroviral treatment (ART) under the national AIDS program and ART use has increased life expectancy and improved the quality of life of people living with HIV and AIDS (PLHIV) [
2]. Longer life expectancy and an improved quality of life may increase the number of PLHIV who desire to become pregnant and have children [
3]. A study in Canada showed that the proportion of HIV-infected women who desired children and intended to become pregnant increased once they were receiving ART [
4].
Studies have shown that many PLHIV do not have access to family planning services [
5‐
9]. Women with unintended pregnancies are more likely to have poor pregnancy outcomes (e.g., abortions, preterm birth, low birth weight) than women who plan their pregnancies [
10]. HIV-infected women are also at risk of transmitting HIV to their infants and sexual partners. Thus, providing family planning services to PLHIV can improve the health of HIV-infected women and their children and reduce the risk of mother-to-child HIV transmission (MTCT).
The correct and consistent use of contraceptive methods is important to prevent unintended pregnancies and transmission of sexually transmitted infections (STIs) [
11]. However, contraceptive methods vary in their effectiveness during routine use (i.e., including both incorrect and inconsistent use) and during perfect use (correct and consistent use) [
12]. In PLHIV, the concurrent use of hormonal contraceptives and antiretroviral medications (the non-nucleoside reverse transcriptase inhibitors and protease inhibitors) can be associated with drug-drug interactions that may alter the contraceptive or antiretroviral effects of these medications [
13]. In addition, contraceptives that are most effective at preventing pregnancy under routine use (e.g, hormonal contraceptives) provide no protection against HIV/STIs. Though condoms can prevent transmission of HIV and other STIs [
5], inconsistent and incorrect condom use is common [
12]. Studies report 14 to 21 % of people who use condoms alone become pregnant during the first year of routine condom use [
12,
14]. As a result, the World Health Organization (WHO) recommends that PLHIV use dual contraceptive methods or dual protection to prevent unintended pregnancies and STIs [
15]. Dual contraceptive method use is defined as the use of a barrier contraceptive (i.e., condoms), which can reduce transmission of many STIs, plus another effective family planning method that can prevent pregnancy as recommended by the World Health Organization (e.g., sterilization, hormonal methods, intrauterine devices, hormonal pills) [
16,
17]. There are limited data on dual contraceptive use and the intention to become pregnant among PLHIV in Thailand. We assessed the intention of PLHIV to become pregnant and have children in the future and their use of dual contraceptive methods at six hospitals in Thailand.
Results
Baseline participant characteristics
From January 2008 to March 2009, 1,570 HIV-infected heterosexual men and women were recruited for the study. We excluded 137 women because they were pregnant and 45 female PLHIV who were 50 years or older from the analysis. Of the 1,388 PLHIV selected for data analysis, 737 (53.1 %) were male, their median age was 37 years (Interquartile range [IQR] 33–43 years) and 776 (55.9 %) were married or living with their partner. Participants had known their HIV status a median of 5 years (IQR 2–8 years). Most PLHIV (99.7 %) were taking ART and their median CD4 count was 343 (IQR 201–502) cells/mm
3 and, among the 719 (51.8 %) who had viral load results, median viral load was <50 (IQR 40–50) copies/mL. Participant demographics characteristics are shown in Table
1.
Table 1
Baseline characteristics of participants in the assessment of family planning practices at 6 hospitals in Thailand, 2008-2009
Hospital | | | |
Vajira (BKK) | 202 (14.6) | 102 (13.8) | 100 (15.4) |
Taksin (BKK) | 165 (11.9) | 99 (13.4) | 66 (10.1) |
Rajavithi (BKK) | 93 (6.7) | 29 (3.9) | 64 (9.8) |
Siriraj (BKK) | 250 (18.0) | 110 (14.9) | 140 (21.5) |
Bamrasnaradura Infectious Diseases Institute (Nonthaburi) | 588 (42.4) | 343 (46.5) | 245 (37.6) |
Viangpapao (Chiang Rai) | 90 (6.5) | 54 (7.3) | 36 (5.5) |
Age | | | |
Median age in years (IQR) | 37 (33, 43) | 39 (34, 45) | 35 (32, 40) |
18–29 years old | 164 (11.8) | 69 (9.4) | 95 (14.6) |
30–39 years old | 677 (48.8) | 310 (42.1) | 367 (56.4) |
40–49 years old | 447 (32.2) | 258 (35.0) | 189 (29.0) |
> 50 years old | 100 (7.2) | 100 (13.6) | 0 (0.0) |
Education group | | | |
≤ Primary school | 533 (38.4) | 257 (34.9) | 276 (42.4) |
> Primary school | 853 (61.5) | 478 (64.9) | 375 (57.6) |
Missing | 2 (0.1) | 2 (0.3) | 0 (0.0) |
Marital status | | | |
Single | 301 (21.7) | 253 (34.3) | 48 (7.4) |
Married with and/or Live in partner | 776 (55.9) | 372 (50.5) | 404 (62.1) |
Divorced or Separated | 311 (22.4) | 112 (15.2) | 199 (30.5) |
Years since HIV diagnosis | | | |
Median (IQR) | 5 (2, 8) | 5 (2, 7) | 5 (2, 9) |
< 1 year | 120 (8.7) | 61 (8.4) | 59 (9.1) |
1 to less than 5 years | 529 (38.5) | 298 (40.9) | 231 (35.8) |
≥ 5 years | 726 (52.8) | 370 (50.8) | 356 (55.1) |
Missing | 13 | 8 | 5 |
On ART | | | |
Yes | 1,157 (99.7) | 649 (99.7) | 508 (99.8) |
No | 3 (0.3) | 2 (0.3) | 1 (0.2) |
Missing | 228 | 86 | 142 |
CD4 count at baselinea | | | |
Median (IQR) cells/mmb | 343 (201–502) | 326 (181–475) | 376 (225–530) |
Viral loadc | | | |
Median (IQR) copies/mL | 50 (40–50) | 50 (40–50) | 50 (40–50) |
Received short messages relating to family planning at enrollment (PLHIV may receive messages from many staff) |
From doctor | 927 (66.8) | 514 (69.7) | 413 (63.4) |
From nurse | 455 (32.8) | 258 (35.0) | 197 (30.3) |
From counselor | 1,042 (75.1) | 571 (77.5) | 471 (72.4) |
Have steady partner | | | |
No | 490 (35.3) | 290 (39.3) | 200 (30.7) |
Yes | 898 (64.7) | 447 (60.7) | 451 (69.3) |
Among PLHIV with steady partner (n = 898) | | | |
Intention to become pregnant in the future | | | |
Yes | 36 (4.0) | 13 (2.9) | 23 (5.1) |
No | 862 (96.0) | 434 (97.1) | 428 (94.9) |
Disclosed HIV status to steady partner | 765 (85.2) | 385 (86.1) | 380 (84.3) |
Steady partner HIV status | | | |
Positive | 385 (42.9) | 183 (40.9) | 201 (44.6) |
Negative | 288 (32.1) | 161 (36.0) | 127 (28.2) |
Unknown | 225 (25.1) | 103 (23.0) | 123 (27.3) |
Among PLHIV with steady partner who had sex during the previous 3 months and had not had sterilization (n = 558) | 558 | 291 | 267 |
Intention to become pregnant in the future | | | |
Yes | 34 (6.1) | 13 (4.5) | 21 (7.9) |
No | 524 (93.9) | 278 (95.5) | 246 (92.1) |
Among 862 PLHIV not planning to become pregnant in the future |
Had sex during the previous 3 months | 709 (82.3) | 352 (81.1) | 357 (83.4) |
Contraceptive used during the past 3 monthsb | 683 (96.3) | 341 (96.9) | 342 (95.8) |
If contraceptive used (n = 683), methods used | | | |
Single method used | 481 (70.4) | 257 (75.4) | 224 (65.5) |
Oral pills | 12 (2.5) | 4 (1.6) | 8 (3.6) |
Hormonal injection | 4 (0.8) | 0 (0.0) | 4 (1.8) |
Hormonal implantation | 6 (1.2) | 0 (0.0) | 6 (1.2) |
Sterilization | 37 (7.7) | 10 (3.9) | 27 (12.0) |
Condom | 422 (87.7) | 243 (94.6) | 179 (79.9) |
Intrauterine device | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Two or more methods usedd | 202 (29.6) | 84 (24.5) | 118 (34.2) |
Condom and sterilization | 141 (69.8) | 63 (75.0) | 78 (66.1) |
Condom and oral pills | 36 (17.8) | 13 (15.5) | 23 (19.5) |
Condom and hormonal implantation | 16 (7.9) | 3 (3.6) | 16 (13.6) |
Condom and hormonal injection | 10 (5.0) | 5 (6.0) | 5 (4.2) |
Condom and oral pills and hormonal injection | 1 (0.5) | 0 (0.0) | 1 (0.8) |
Of the 1,388 PLHIV who participated in the interview at baseline, 966 (69.6 %) participated in the interview at 12 months (4th visit). Among the 422 PLHIV who did not participate in the interview at 12 months, 324 (76.8 %) were not interviewed because hospital staff were not available to conduct the interview according to the project schedule and 98 (23.2 %) declined to participate in the interview or were lost to follow-up for more than 180 days after an appointment.
HIV disclosure to partner, partner HIV status, and pregnancy intent
At enrollment, 898 (64.7 %) PLHIV had a steady partner, 765 (85.2 %) had disclosed their HIV status to their partner, and 105 (34.7 %) of partners were HIV-infected.
Among the 898 participants who had a steady partner, 36 (4.0 %) reported they intended to become pregnant in the future. Excluding PLHIV and partners who had been sterilized, 34 (6.1 %) reported they intended to become pregnant in the future.
Current contraceptive practices
Among 709 PLHIV who had no intention to become pregnant in the future and reported having sex during the previous 3 months, 683 (96.3 %) reported using at least one contraceptive method during the previous 3 months (Table
1). Only 202 (29.6 %) reported using two or more contraceptive methods (dual methods) and, in this group, 141 (69.8 %) used male or female sterilization and condoms. None of PLHIV in this study reported using intrauterine devices. Contraceptive methods used by participants are shown in Table
1.
Changes in pregnancy intention and sexual behavior after receiving family planning short messages
Of the 898 PLHIV who had a partner, 623 (69.4 %) PLHIV came for follow-up at 12 months. Of these, 29 (4.7 %) reported at baseline that they intended to become pregnant, but 25 (86.2 %) changed their minds and reported they did not plan to have children at the 12 month visit. Only three of the 862 (0.3 %) PLHIV who did not plan to have children at baseline changed their minds and reported that they planned to become pregnant in the future at the 12 month visit. None of the PLHIV or their partners was pregnant at 12 months.
Factors associated with dual contraceptive use at baseline
Factors associated with dual contraceptive use during the previous 3 months before baseline in multivariable analysis, included being female (adjusted Odds Ratio [aOR] 1.4; 95 % confidence interval [CI] 1.02–2.1), receiving care at Viangpapao Hospital (aOR 2.6; 95 % CI 1.3–5.0) or Rajavithi Hospital (aOR 2.6; 95 % CI 1.2–5.2), and being aware of their HIV status for 1 to 5 years (aOR 2.5; 95 % CI 1.1–5.5) or more than 5 years (aOR 2.6; 95 % CI 1.2–5.6) (Table
2).
Table 2
Factors associated with dual contraceptive use at baseline among PLHIV in the assessment of family planning practices at 6 hospitals in Thailand, 2008 − 2009
Sex | | | | | | |
Female | 118 (34.5) | 224 (65.5) | 1.6 (1.1–2.2) | <0.01 | 1.4 (1.02–2.1) | 0.04 |
Male | 84 (24.6) | 257 (75.4) | 1.0 | | 1.0 | |
Age | | | | | | |
< 29 years | 24 (24.5) | 74 (75.5) | 0.7 (0.3–1.8) | 0.66 | | |
30–39 years | 110 (31.3) | 241 (68.7) | 1.0 (0.5–2.3) | 0.94 | | |
40–49 years | 58 (28.9) | 143 (71.1) | 0.9 (0.4–2.1) | 0.97 | | |
> =50 years | 10 (30.3) | 23 (69.7) | 1.0 | | | |
Educationa | | | | | | |
< =Primary school | 82 (31.1) | 182 (68.9) | 1.1 (0.8–1.6) | 0.57 | | |
> Primary school | 120 (28.7) | 298 (71.3) | 1.0 | | | |
Marital status | | | | | | |
Single | 2 (3.8) | 51 (96.2) | 0.3 (0.1–1.7) | 0.17 | 0.3 (0.1–1.9) | 0.22 |
Married/Live in partner | 196 (32.9) | 400 (67.1) | 3.7 (1.3–10.6) | 0.02 | 2.7 (0.9–8.2) | 0.08 |
Divorce/Separated | 4 (11.8) | 30 (88.2) | 1.0 | | 1.0 | |
Time since HIV diagnosisa | | | | | |
≥ 5 years | 103 (30.5) | 235 (69.5) | 2.4 (1.2–4.9) | 0.01 | 2.6 (1.2–5.6) | 0.02 |
1 to less than 5 years | 86 (31.3) | 189 (68.7) | 2.5 (1.2–5.1) | 0.01 | 2.5 (1.1–5.5) | 0.02 |
< 1 year | 10 (15.4) | 55 (84.6) | 1.0 | | 1.0 | |
Disclosure of HIV status to steady partner | | | |
Yes | 190 (31.8) | 407 (68.2) | 2.9 (1.5–5.4) | <0.01 | 1.7 (0.8–1.7) | 0.14 |
No / No partner | 12 (13.9) | 74 (86.0) | 1.0 | | 1.0 | |
Steady partner HIV status | | | |
Positive | 105 (34.6) | 198 (65.4) | 1.5 (1.1–2.1) | 0.01 | 1.2 (0.8–3.4) | 0.32 |
Negative/unknown | 97 (25.5) | 283 (74.5) | 1.0 | | 1.0 | |
Hospital | | | | | | |
Viangpapao | 22 (51.2) | 21 (48.8) | 3.5 (1.8–6.8) | <0.01 | 2.6 (1.3–5.0) | <0.01 |
Rajvithi | 22 (43.1) | 29 (56.9) | 2.5 (1.4–4.7) | <0.01 | 2.6 (1.2–5.2) | 0.01 |
Siriraj | 29 (24.6) | 89 (75.4) | 1.1 (0.7–1.8) | 0.72 | 0.8 (0.5–1.4) | 0.55 |
BMA (Vajira&Taksin) | 59 (35.5) | 107 (64.5) | 1.8 (1.2–2.8) | <0.01 | 1.5 (1.0–2.3) | 0.08 |
Bamrasnaradura | 70 (23.0) | 235 (77.0) | 1.0 | | 1.0 | |
CD4a | | | | | | |
< 200 | 43 (33.1) | 87 (66.9) | 1.2 (0.8–1.8) | 0.43 | | |
> =200 | 133 (29.0) | 326 (71.0) | 1.0 | | | |
Ever received ART | | | | | | |
Yes | 169 (30.9) | 378 (69.1) | 1.4 (0.9–2.1) | 0.16 | | |
Never | 33 (24.3) | 103 (75.7) | 1.0 | | | |
Factors associated with changing from a single contraceptive method at baseline to dual methods at 12 months
Of the 481 participants who reported using a single method of contraception during the previous 3 months at baseline, 317 (65.9 %) were re-interviewed 12 months later and 66 (20.8 %) had changed to use dual contraceptive methods. In the multivariable analysis, participants receiving care in Rajavithi (
p = 0.03) and Siriraj (
p = 0.02) Hospitals were more likely to change to dual methods than participants receiving care at the other sites (Table
3).
Table 3
Factors associated with changing from a single method of contraception at baseline to dual methods 12 months later among participants in the assessment of family planning practices at 6 hospitals in Thailand, 2008–2009
Sexa (no.,%) | | | | | | |
Female | 36 (19.0) | 154 (81.0) | 1.2 (0.8–1.9) | 0.37 | | |
Male | 30 (23.8) | 96 (76.2) | 1.0 | | | |
Age (no.,%) | | | | | | |
< 29 years | 12 (24.0) | 38 (76.0) | 1.1 (0.4–3.4) | 0.87 | | |
30–39 years | 30 (18.7) | 130 (81.3) | 0.9 (0.3–2.5) | 0.91 | | |
40–49 years | 21 (22.6) | 72 (77.4) | 1.0 (0.4–3.1) | 0.80 | | |
> =50 years | 3 (21.4) | 11 (78.6) | 1.0 | | | |
Educationa (no.,%) | | | | | | |
< =Primary school | 28 (20.6) | 108 (79.4) | 1.0 (0.6–1.5) | 1.0 | | |
> Primary school | 38 (21.2) | 141 (78.8) | 1.0 | | | |
Marital status (no.,%) | | | | | | |
Single | 0 (0.0) | 27 (100.0) | N/A | 0.34 | | |
Married/Live in partner | 65 (23.5) | 211 (76.5) | 3.3 (0.5–22.0) | 0.20 | | |
Divorce/Separated | 1 (7.1) | 13 (92.9) | 1.0 | | | |
Disclosure of HIV status to steady partner (no.,%) |
Yes | 55 (20.2) | 217 (79.8) | 0.8 (0.5–1.4) | 0.65 | | |
No / No partner | 11 (24.4) | 34 (75.6) | 1.0 | | | |
Steady partner HIV status (no.,%) |
Positive | 29 (20.6) | 112 (79.4) | 1.0 (0.6–1.5) | 1.0 | | |
Negative/unknown | 37 (21.0) | 139 (79.0) | 1.0 | | | |
Hospital (no.,%) | | | | | | |
Viangpapao | 4 (20.0) | 16 (80.0) | 1.5 (0.5–4.3) | 0.48 | 1.5 (0.5–4.3) | 0.43 |
Rajvithi | 11 (47.8) | 12 (52.2) | 3.7 (1.9–7.2) | <0.001 | 2.5 (1.1–5.7) | 0.03 |
Siriraj | 26 (32.1) | 55 (67.9) | 2.5 (1.3–4.5) | <0.01 | 2.2 (1.1–4.2) | 0.02 |
BMA (Vajira&Taksin) | 13 (12.9) | 88 (87.1) | 1.0 (0.5–2.0) | 1.0 | 1.0 (0.5–2.1) | 0.98 |
Bamrasnaradura | 12 (13.0) | 80 (87.0) | 1.0 | | 1.0 | |
Time since HIV diagnosis at enrollmenta (no.,%) | | | | |
≥ 5 years | 25 (16.9) | 123 (83.1) | 0.4 (0.2–0.8) | 0.01 | 0.5 (0.2–1.0) | 0.051 |
1–4 years | 28 (20.4) | 109 (79.6) | 0.5 (0.3–0.9) | 0.05 | 0.6 (0.3–1.1) | 0.12 |
< 1 year | 12 (38.7) | 19 (61.3) | 1.0 | | 1.0 | |
CD4a (no.,%) | | | | | | |
< 200 | 7 (20.6) | 27 (79.4) | 1.0 (0.5–2.1) | 0.10 | | |
> =200 | 54 (19.8) | 219 (80.2) | 1.0 | | | |
Ever received ARVa (no.,%) | | | | | |
Yes | 45 (17.2) | 217 (82.8) | 0.5 (0.3–0.7) | <0.01 | 0.8 (0.4–1.6) | 0.61 |
No | 20 (37.0) | 34 (63.0) | 1.0 | | 1.0 | |
Received short messages relating to family planning from nurse at enrollment (no.,%) |
No | 25 (28.7) | 62 (71.3) | 1.6 (1.0–2.5) | .05 | 1.5 (0.9–2.4) | 0.15 |
Yes | 41 (17.8) | 189 (82.2) | 1.0 | | 1.0 | |
Received short messages relating to family planning from doctor at enrollment (no.,%) |
No | 41 (21.8) | 147 (78.2) | 1.1 (0.7–1.7) | 0.70 | | |
Yes | 25 (19.4) | 104 (80.6) | 1.0 | | | |
Received short messages relating to family planning from counselor at enrollment (no.,%) |
No | 42 (21.2) | 156 (78.8) | 1.0 (0.7–1.6) | 0.94 | | |
Yes | 24 (20.2) | 95 (79.8) | 1.0 | | | |
Discussion
Most (96.3 %) PLHIV who reported having sex with their steady partner in our study used at least one contraceptive method but less than one-third used dual methods. The most common single method used was condoms (87.7 %). Because of inconsistent and incorrect condom use, condom use alone is associated with pregnancy rates as high as 18 % [
15]. Therefore, dual contraceptive protection is strongly recommended to protect against HIV/AIDS and other STIs [
13]. WHO urges healthcare providers to educate PLHIV on the benefits of dual protection use and to provide PLHIV access to contraceptives.
In this study, the most common combination of contraceptives used was condoms and sterilization (69.8 %). Our analyses indicate that female PLHIV and PLHIV who were aware of their HIV status for more than one year were more likely to use dual methods. This may be because PLHIV who were aware of their HIV status for more than one year were more likely to have received family planning messages and referral services as part of HIV service package. Women reported dual contraceptive use more frequently than men (
p = 0.04). Women can independently initiate contraceptive choices, while men are not always aware of the partner’s contraceptive method and may not be aware of all contraceptives used (e.g., their partners’ oral or hormonal contraceptive use). A study in Chiang Mai, a Northern province of Thailand [
22], showed that the rate of contraceptive use in postpartum HIV-uninfected women was high (97.6 %) and most used modern contraceptive methods; males reported condom use only 7.7 % of the time [
22]. In contrast, a study of HIV-infected women in Chiang Mai found that 87 % of their partners used condoms [
17,
23‐
25] and 18–56 % of the women used dual contraceptive methods; consistent with the findings of our study. Studies from India and Zambia have also reported that condoms and sterilization were the most common dual methods used among PLHIV in those countries [
24,
25].
Studies have shown that integration of family planning services into HIV care is feasible and increases the use of contraceptives among HIV-infected women, and improves a variety of health and behavioral outcomes [
12,
26]. In our study, the use of dual contraceptive methods varied by site (e.g., rate of dual methods was higher in Viengpapao Hospital and Rajavithi Hospital than Siriraj Hospital, Vajira Hospital, Taksin Hospital, and Bamrasnaradura Infectious Diseases Institute). None of the six sites provided one stop service of family planning service and HIV care. After we implemented short messages on family planning and referral services, one-fifth (20.8 %) of PLHIV who did not use dual contraceptive methods at baseline changed to dual methods at 12 months. This was particularly clear at Rajavithi and Siriraj Hospital, where there were project coordinators who helped facilitate referrals and link PLHIV to family planning services, whereas other hospitals implemented the services using routine staff and the routine referral system. Many HIV clinics in Thailand do not integrate family planning services with HIV care as a one stop service. Thus, having a staff person or a case manager who helps facilitate referrals and link PLHIV to family planning services can increase the likelihood PLHIV will access family planning services. Additional research on models that integrate family planning services in HIV clinics providing a one stop service would be helpful.
More than 80 % of reproductive age PLHIV who had a steady partner in our study reported having sex, but few (4.0 %) expressed a desire to have children. In contrast to studies in Europe and North America that report high fertility desire (69–75 %) and fertility intention (58 %) among reproductive age HIV-infected women [
4,
26], our study found that only three HIV-infected women (0.3 %) who initially said they did not intend to become pregnant in the future because of their HIV diagnosis, changed their minds at 12 months. PLHIV in our study may not intend to become pregnant because more than half had not disclosed their HIV status to their partners and they may be concerned about discussing pregnancy and family planning with their partners. Furthermore, half of female PLHIV in our study were older than 35 years and may not want to become pregnant [
27]. Other potential concerns among health care providers and PLHIV in Thailand include that PLHIV may transmit HIV to their infants, the misperception that HIV is an untreatable disease, and social discrimination that often occurs when others learn that one is infected [
28,
29].
With access to ART free of charge under the Thai National HIV Treatment Program, HIV has become a manageable chronic disease. The Thailand National Prevention of Mother-to-Child HIV Transmission (PMTCT) Policy 2010 recommended using a lopinavir/ritonavir-based regimen for PMTCT [
30] and the MTCT rate in Thailand was 2.3 % in 2012 [
1]. Current evidence-based information and education should be provided to PLHIV and health care providers to help reduce stigma and discrimination.
The Thailand National HIV Treatment and Care Guidelines 2014 recommend that health care providers discuss pregnancy and childbearing intentions with all PLHIV, recommend effective and appropriate contraceptive methods (dual methods) to reduce the likelihood of unintended pregnancy and STI, provide reproductive options for HIV-concordant and serodiscordant couples who want to conceive (e.g., provide ART to the HIV-infected partner to have maximum viral suppression before attempting conception, provide assisted reproductive technology options, and consider administration of antiretroviral pre-exposure prophylaxis [PrEP] for HIV-uninfected partners) [
31].
Our study had several limitations. Data were limited to PLHIV seen at five tertiary care hospitals in Bangkok, and one community hospital in the Chiang Rai province and PLHIV were on ART for average of 5 years; therefore, the results may not be generalizable to other settings in Thailand, to PLHIV who are not on ART, or to PLHIV who do not access to HIV prevention messages. Assessment of contraceptive methods used by men was challenging because some did not know their partners contraceptive method, resulting in an underestimate of contraception use in this study. Similarly, assessment of the intention to become pregnant of partners, particularly those who did not disclosed their HIV status, might be inaccurate. This model was implemented and integrated into routine hospital service during our evaluation, likely contributing to the 30 % of the PLHIV who did not participate in the interview at 12 months. This may have led to over or under estimates of some of the findings. About half of female PLHIV in our study were older than 35 years. Hence, the data in this survey may not accurately reflect the pregnancy intentions of younger reproductive age female PLHIV.
Acknowledgements
We acknowledge the staff of the HIV and OB/GYN clinics of the 6 participating hospitals for their contribution to this project. We thank the Thailand MOPH, Bureau of AIDS, TB, and STIs for the development of the Prevention with Positives services. This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC under the terms of 3U19GH000004-03.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
WM and RL participated in study design, project implementation, statistical analysis, interpretation of data, and drafting and revision of the manuscript. BK, AR, SJ, SA, UH, BB participated in study design, project implementation, and data collection. SP performed data analysis. MM participated in study design, statistical analysis, interpretation of data, and revision of the manuscript. All authors reviewed and approved the final version of the manuscript.