Reproductive health of HIV-positive women in Switzerland being neglected, says study

Michael Carter
Published: 06 February 2018

HIV-positive women in Switzerland are mainly relying on male condoms for contraception, investigators report in HIV Medicine. Two-thirds of reproductive age women reported using contraception, with three-quarters of these individuals putting their trust in male condoms. Unwanted pregnancies were not uncommon among women using contraception.

“Male condoms remained the most frequently used contraceptive method, whereas the use of long-acting reversible contraceptives was very uncommon,” note the researchers. “One in six women using contraceptives experienced an unwanted pregnancy, with 42% occurring while using a combined hormonal pill.”

The investigators suggest that HIV clinicians need to do more to encourage effective contraceptive use by women with HIV, especially in the light of growing awareness that people with HIV with undetectable viral load do not transmit HIV. If couples stop using the male condom, women need information about which contraceptive options are suitable for them.

The majority of HIV-positive women are of reproductive age, and it is now possible for many of these women to have a baby without any significant risk of mother-to-child HIV transmission. However, promotion and use of safe and effective contraception is important to prevent unwanted pregnancies. The World Health Organization recommends dual contraception, involving the use of long-acting, reversible contraception and male condoms.

Most forms of contraception can be used safely and effectively by women with HIV. However, there is concern that interactions between some antiretroviral drugs and hormonal contraceptives could reduce the effectiveness of the latter. In particular, non-nucleoside reverse transcriptase inhibitors and boosted protease inhibitors reduce the effectiveness of hormonal contraception at standard doses.This means that contraceptive choices should be individualised.

Little is known about contraceptive use by HIV-positive women in Europe. Investigators from the respected Swiss HIV Cohort Study designed a cross-sectional study involving 462 women. All received routine care between 2013 and 2014. The participants were all of reproductive age (18 to 46 years) and completed questionnaires about their use of contraception, relationship status and unwanted pregnancy. Demographic, HIV- and antiretroviral-related data were obtained from study databases.

Participants had a median age of 40 years and had been living with diagnosed HIV infection for a median of ten year. Most (87%) had been infected with HIV through heterosexual intercourse and 44% were black. The vast majority (78%) reported a regular and/or occasional partner. Almost all the women (94%) were on combination antiretroviral therapy (cART). Median CD4 cell count was normal (644 cells/mm3) and 89% of participants had an undetectable viral load (below 20 copies/ml).

Approximately two-thirds (65%) of women reported the use of contraception, but only a quarter used methods other than male condoms. Hormonal pills were taken by 32 women, whereas 17 had a hormonal IUD, eleven had a copper IUD, six had a hormonal implant, five used injectables, two used a vaginal ring and one used a contraceptive patch. Eleven per cent used two or more forms of contraception.

Condom use was slightly higher among cART-naïve women (who may have needed them to prevent HIV transmission) than women taking antiretrovirals (78 vs 70%). Two-thirds of women using condoms said this was to prevent pregnancy and sexually transmitted infections.

A hormonal contraceptive was used by 42 women, with approximately half taking a contraceptive with a potential interaction with antiretrovirals.

The investigators drew attention to potential barriers to obtaining effective contraception.

“In Switzerland, contraceptive counselling is partially integrated in HIV care, but women have to be referred to a gynaecologist for the prescription of hormonal and long-acting contraceptives, such as IUDs and injectablables,” comment the authors. “This may result in reduced access to effective contraception as women do not always engage in routine gynaecological care or they are lost to follow-up for some time, especially after having a baby.”

Overall, 36% of women reported not using contraception, and 40% of these individuals reported being sexually active. Almost half (44%) of these sexually active women said they did not want to conceive.

An unwanted pregnancy was reported by 48 individuals (11%) with most (39 of 48) reporting they were using contraception at the time. The contraceptive types used most commonly when the unintended pregnancy occurred were male condoms (47%) and oral contraception (42%). Two-thirds of women with an unwanted pregnancy opted for termination.

Lower educational attainment was associated with a significant increase in the risk of unwanted pregnancy (aOR = 13.8; 95% CI, 1.73-1110.2, p = 0.013), but taking HIV therapy was associated with a reduction in risk (aOR = 0.06; 95% CI, 0.03-0.15, p < 0.001).

“The use of effective contraception is challenging in HIV-positive women of reproductive age. HIV care physicians should be attentive both to women’s choices and to their needs for contraception,” conclude the authors. “In a new era, where condoms are no longer needed to prevent the onward transmission of HIV, it will be essential to provide safe and effective contraception for women living with HIV.”

References

Aebi-Popp K et al. Neglect of attention to reproductive health in women with HIV infection: contraceptive use and unintended pregnancies in the Swiss HIV Cohort Study. HIV Med, online edition. DOI: 10.1111/hiv.12582 (2018).

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