Myer L, Rebe K, Morroni C. Missed opportunities to address reproductive health care needs among HIV-infected women in antiviral therapy programs. Trop Med Int Health 2007 Dec;12(12):1484-9.
To investigate the delivery of reproductive health care services to HIV-infected women in an antiretroviral therapy (ART) program.
Cross-sectional survey with semi-structured interviews to investigate reproductive health issues and services the women received. Thirty- to 45-minute interviews were conducted in the participant's native language (93% isiXhosa) in a private room on the hospital grounds.
A large hospital-based ART service near Cape Town, South Africa.
From August to November 2005, 242 consecutive women attending the ART outpatient clinic were asked to participate, and 227 (93%) consented to be interviewed. Eligible women were at least 18 years of age and had been receiving outpatient ART for at least 4 weeks. Participants did not receive remuneration.
There was no intervention in this study.
Primary outcome measures were participants' demographic and reproductive characteristics, sexual behaviors, incidence of physical and verbal partner abuse, self-report of sexually transmitted diseases (STDs), reproductive health care needs, and knowledge of reproductive health care options and services received at the ART programme and through other sources of health care. Primary measures of the women's knowledge of options were awareness of emergency contraception and knowledge that termination of pregnancy was legal and available free of charge
Demographic and Reproductive Characteristics -The median age of participants was 32 years; 54% had completed secondary education and 76% had at least one child. Their median time on ART was 11 months (interquartile range, 4-15). 67% of women younger than 30 years said that they were currently in a relationship, compared with 45% of women over the age of 40 (p=0.05).
Sexual and Reproductive Health Behaviors. Seventy-five percent of women had been sexually active in the previous year, and 93% who were in a relationship, compared with 47% who were not, were sexually active. Level of sexual activity was not associated with duration of ART. Nineteen percent reported having a new sexual partner since their HIV diagnosis, a percentage that was relatively consistent across age strata. Eighteen percent of women reported being treated for a STD since their HIV diagnosis: 29% among women 18-29 years old, 13% among those 30-39 years old, and 14% among women older than 40 years (p=0.02). Eleven percent of women reported having ever been forced to have sex against their will. One participant (<1%) reported engaging in any form of transactional sex.
Condom use decreased with a woman's age. Overall, 69% of women reported condom use at last sex: 85% among women 18-29 years old, 62% among women 30-39 years old, and 60% among women older than 40 years (p<0.01). Among sexually active women, those in a relationship compared with women who were not were more than 10 times as likely to report consistent condom use (p<0.001). Forty percent of women reported consistent condom use during sex in the last 6 months. Thirty-two percent of women had had unprotected sex at least once since finding out that they were infected with HIV. Forty-five percent of women reported use of any non-barrier method at last sex, primarily injectable contraception (31%) with frequency varying inversely by age. Only 1% of women used oral contraception. The prevalence of sterilization was 13%: 4% among women 18-29 years old, 14% among those 30-39 years old, and 26% among women older than 40 years (p=0.01). Seven percent of women had heard of emergency contraception, and 13% knew that termination of pregnancy was a free and legal health service. Forty-five percent had had a Papanicolau test since HIV diagnosis. Twelve percent of women had experienced some form of partner violence since they were diagnosed with HIV, with 10% reporting physical abuse and 5% reporting verbal abuse. Among women reporting physical violence, 17% said that it related to their HIV infection.
Reproductive health issues discussed with health workers since time of HIV diagnosis. A high percentage of women had discussed contraceptive use (89%) and condom use specifically (86%) with health care providers, ranging from 95% among women 18-29 to 69% among women older than 40 years (p<0.001). Five percent of women had discussed emergency contraception with providers, and 4% had discussed abortion/termination of pregnancy. Sixty-five percent of participants had discussed cervical cancer/Papanicolau testing. This percentage ranged from 53% among women 18-29 years old, to 68% among those 30-39 years old, and 77% among women older than 40 years (p=0.03). No women had discussed partner violence with a health care provider since learning of their HIV status.
Although most women had discussed the use of condoms and other forms of contraception with a health care provider since their HIV diagnosis, very few knew about emergency contraception or termination of pregnancy, and even fewer had discussed the topics. No woman had discussed issues of partner violence. The use of both condoms and hormonal contraceptives decreased with age, while the prevalence of sterilization increased with age. The study suggests that HIV-infected women enrolled into ART programmes in Cape Town, South Africa have significant unmet reproductive health care needs. Although issues related to condom and contraceptive use are relatively well addressed, reproductive health services related to unintended pregnancy and partner violence are neglected. The authors propose that basic reproductive health care services should become an integral part of all HIV care and treatment services in sub-Saharan Africa.
This study was of fair quality. The study is focused on a single public-sector ART service, and the generalizability of findings to other settings will vary according to the population being served and the nature of local health care services. Additionally, the cross-sectional nature of the study does not allow for the detection of any trends or comparisons. Lastly, the authors do not discuss the representativeness of the sample. However, of the 270 female patients receiving ART in the program, 242 met the eligibility criteria and 93% agreed to participate, making it probable that the sample is representative of this particular clinic.
Few HIV care and treatment programmes fully integrate aspects of reproductive health care. These programs often focus on condom and contraceptive use, with little attention given to other aspects of reproductive health.(1) HIV infection increases the risk of pregnancy-related morbidity and mortality, cervical cancer and a range of vaginal and cervical infections.(2,3) Although about half of the women in the study had received a Papanicolau test, the recommendation in South Africa is that all women be tested annually. Additionally, the social stigma associated with HIV infection, coupled with women's relative disempowerment in many countries, can lead to violent abuse of HIV-infected women by their partners.(4) Quantifying reproductive health care needs among women enrolled in ART programmes is necessary to determine what should be routine care for women receiving ART.(5)
The authors suggest that these data delineate the large unmet need for reproductive health services among HIV-infected women receiving ART in this setting. The integration of a broad range of reproductive health services into ART programmes requires urgent attention from researchers and policy-makers. Greater attention to the integration of reproductive health care is required in the design of ART and operation of services in sub-Saharan Africa.
- Shelton JD, Peterson EA. The imperative for family planning in ART therapy in Africa. Lancet 2004;364(9449):1916-8.
- Levine AM. Evaluation and management of HIV-infected women. Ann Intern Med 2002;126(3):228-42.
- Cejtin HE. Gynecologic issues in the HIV-infected woman. Obstet Gyne Clin North Am 2003;30(4):711-29.
- Ojikutu BO, Stone VE. Women, inequality, and the burden of HIV. NEJM 2005;352(7):649-52.
- The Futures Group (2006). Meeting the Reproductive Health Needs of HIV-Positive Women: Using Evidence to Advocate for Change. United States Agency for International Development, Washington, D.C.