Unwanted or unplanned pregnancy is a significant risk for women with HIV within 18 months of starting antiretroviral therapy, and in Uganda few were being offered family planning methods in order to avoid pregnancy, researchers reported on Tuesday at the Fifteenth Conference on Retroviruses and Opportunistic Infections in Boston.
French researchers also reported on the impact of replacement, or formula, feeding on pregnancy rates among women who had taken part in two studies of prevention of mother to child transmission. Their research showed that after two years of follow-up, women who had opted for replacement feeding rather than breastfeeding with early weaning had no greater risk of falling pregnant despite the fact that breastfeeding reduces the likelihood of pregnancy as long as it is practiced.
Pregnancy in Uganda
Researchers in Uganda looked at the trends, predictors, and incidence of pregnancy in a cohort of women who were receiving ART in the Home Based AIDS Care (HBAC) study.
Antiretroviral therapy is known to restore fertility in HIV-positive women, but little is known about its effect on the desire to bear children, the incidence of pregnancy after starting treatment, or women’s family planning choices during antiretroviral treatment.
The study analysed the incidence of pregnancy and contraceptive choices in approximately 700 women commencing antiretroviral therapy between 2003 and 2006 in a rural district of Uganda served by the Home Based AIDS Care study, a programme providing a wide range of services at the community level that is funded by the US PEPFAR programme. The study was conducted by the US Centers for Disease Control.
The women were counselled on HIV prevention and family planning, but women who were interested in family planning services was referred to the nearest provider. Free condoms were available to study participants on request.
During the first year on ARV therapy, each woman was visited in her home quarterly and provided answers to an in-depth questionnaire regarding social and behavioural issues. Among other topics, women were asked about their sexual activity and desire for children. After the first year, the women were surveyed, again in their homes, every 6 to 12 months. Contraceptive information was collected after 18 months on treatment. Median follow-up time was just over two years.
The women in the study ranged from 18 to 49 years of age. Most of the women (93 to 97%) did not wish to add to their family, but over the course of the study, nearly 17% did become pregnant. In this study, incidence of pregnancy peaked 12 months after starting treatment, then declined slightly, but showed signs of returning to the previous peak level after 24 months. Pregnancy was usually unintended.
There were 140 pregnancies (of which 20 were repeat pregnancies within the study period), with 106 live births and 21 induced abortions.
Despite not desiring more children, fewer than 8% of the women used dual contraception by the second year and permanent or semi-permanent family planning methods were used by just 14% of the women. Only 4.3% were using a hormonal contraceptive at the end of the study period. Researchers found that the proportion of women reporting sexual activity increased over 24 months from less than 25% to nearly 33%.
Independent predictors of pregnancy were young age, being married or living with a partner, a body mass index over 18.5, and inconsistent condom use.
The investigators advise that patients on ART should be counselled regarding its effect on restoring health and fertility and that dual contraception methods should be stressed. Dr Jaco Homsy of US CDC said that family planning services should be an integral part of ART provision, and should target younger women and their partners with timely information.
Replacement feeding does not always result in a greater risk of unwanted pregnancy
A second study on pregnancy rates in HIV-positive women examined whether non-breastfeeding women were exposed to a greater risk of unwanted pregnancy. The report, from Cote d’Ivoire, West Africa, looked at the pattern of subsequent pregnancies among 724 women from the Ditrame-Plus project (ANRS 1201-1202).
Each of the women received short-course antiretrovirals at the time of delivery. Afterwards, 54% of the women chose to breastfeed their infants and 46% opted for replacement feeding.
Family planning services, including free contraception methods, were provided to all women. In each of the two the groups, a roughly equivalent number (~78%) chose to use contraception methods provided by the clinic – a very high uptake of contraception for sub-Saharan Africa.
Researchers wanted to see how many new pregnancies occurred in the two years following delivery and if the method of infant feeding made a difference in that number. Incidence of pregnancy was noted at 12 and 24 months, with time of conception gauged by the date of the last (reported) menstrual cycle and an ultrasound assessment of gestational age.
At 12 months, approximately 4% of the women in each group became pregnant again. Using a Cox model analysis, two factors that were independently associated with subsequent pregnancy were advanced clinical HIV disease (WHO state 3-4) and the death of the infant.
At 24 months, there were significantly more pregnancies in the group of breastfeeding women. In the two-year study period, 10% of the women who had used replacement feeding became pregnant again versus nearly 17% of the women in the breastfeeding group. Additional factors independently associated with pregnancy incidence were the follow-up clinic and number of living children. The study reported no difference in infant mortality during the follow-up period according to feeding mode.
In this trial, women chose whether they would use replacement feeding or breastfeeding. This raises the question of whether some women chose replacement feeding because they may have been in a weaker physical state or at a more advanced disease stage, both conditions that may have influenced fertility.
Valeriane Leroy said that with effective family planning services and access to contraception methods, replacement feeding does not have to result in more frequent subsequent pregnancies than in women who breastfeed, despite the protective hormonal effect of breastfeeding.
Viho I et al. Alternatives to prolonged breastfeeding and incidence of pregnancies among HIV-infected women: The ANRS 1201-1202 Ditrame Plus cohort in Abidjan, Côte d'Ivoire, 2001 to 2005. Fifteenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 73. 2008.
Homsy J et al. Incidence and determinants of pregnancy among women receiving ART in rural Uganda. Fifteenth Conference on Retroviruses and Opportunistic Infections, Boston, abstract 74. 2008.