Behavioral interventions for improving contraceptive use among women living with HIV

  • Review
  • Intervention

Authors


Abstract

Background

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to the increased availability of antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. This review examines behavioral interventions to improve contraceptive use, for family planning, among women who are HIV-positive.

Objectives

We systematically reviewed studies that examined behavioral interventions for HIV-positive women that were intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.

Search methods

Through October 2012, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, CINAHL, PsycINFO, ClinicalTrials.gov and ICTRP. For other relevant papers, we examined reference lists and unpublished project reports, and contacted investigators in the field.

Selection criteria

Studies evaluated a behavioral intervention for improving contraceptive use for contraception. The comparison could be another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive women versus HIV-negative women. We included nonrandomized (observational) studies as well as randomized trials.

Primary outcomes were pregnancy and contraception use, e.g., uptake of a new method, improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception in general or about a specific contraceptive method.

Data collection and analysis

Two authors independently extracted the data. One author entered the data into RevMan and a second verified accuracy. We examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale.

Given the need to control for confounding factors in observational studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs, we did not conduct meta-analysis.

Main results

The seven studies meeting our inclusion criteria had a total of 8882 women. All were conducted in Africa. Three studies compared a special intervention versus standard services. In one, the special intervention site showed greater use of non-condom contraceptives per visit (OR 6.40; 95% CI 5.37 to 7.62) and reported a lower pregnancy incidence. In another study, use of modern contraceptives was more likely for women at sites with enhanced versus basic integrated services (OR 2.48; 95% CI 1.31 to 4.72), but the groups did not differ significantly in change from baseline. In the third study, new use of modern contraceptives, excluding condoms, was less likely for women with integrated services versus those with routine care (OR 0.56; 95% CI 0.42 to 0.75), but new use of condoms was more likely (OR 1.73; 95% CI 1.52 to 1.98).

Four older studies compared HIV-positive women versus HIV-negative women. None showed any significant difference between the HIV-status groups in use of modern contraceptives except condoms. Two did not provide an intervention for the HIV-negative women. In the larger of the two studies, HIV-positive women were less likely to become pregnant (OR 0.55; 95% CI 0.43 to 0.69). HIV-positive women were more likely to discontinue their hormonal contraceptive (OR 2.52; 95% CI 1.53 to 4.14) but more likely to use condoms (OR 2.82; 95% CI 2.18 to 3.65) and spermicide (OR 2.36; 95% CI 1.69 to 3.30). Two studies provided the intervention to both HIV-status groups. One included many of the women from the study just mentioned, and also showed fewer pregnancies for HIV-positive women (OR 0.39; 95% CI 0.23 to 0.68). In the other study, the HIV-status groups were not significantly different for pregnancy or consistent condom use.

Authors' conclusions

Comparative research on contraceptive counseling for HIV-positive women has been limited. We found little innovation in the behavioral interventions. Our ability to make statements about overall results is hampered by varied study designs, interventions, and outcome assessments. The quality of evidence was moderate. Since some of these studies were conducted, improvements in HIV treatment have influenced the fertility intentions of HIV-positive people.

The family planning field needs better ways to help women choose an appropriate contraceptive and continue using that chosen method. Women with HIV may have special concerns regarding family planning. Research could focus on assessing the woman's needs and training providers to address those issues rather than delivering standardized information.

Plain language summary

Family planning programs for HIV-positive women

Counseling can help HIV-positive women meet their goals for family planning. It can also help prevent giving the virus to their infants. Due to better treatment, people with HIV are living longer. More HIV-positive women may want to have a child in the future. We examined behavioral programs to help women with HIV improve their use of family planning methods.

Through October 2012, we did computer searches for studies of family planning programs for HIV-positive women. We wrote to researchers to find other reports. The program could be compared with a different program, routine care, or no counseling. Studies could also compare HIV-positive women versus HIV-negative women. If available, we used adjusted results to help control for factors affecting the outcomes. Otherwise, we used the odds ratio. We assessed the research quality.

We found seven studies from Africa with a total of 8882 women. Three studies compared a special program versus standard services. One showed the special program site had more use of non-condom birth control and fewer pregnancies. In another, women at sites with enhanced services used modern family planning more than women at sites with basic services. The groups had similar change from baseline. In the third study, more women who had family planning services combined with HIV care used modern birth control (non-condom). More women with combined services used condoms than those with routine care.

Four older studies compared HIV-positive women versus HIV-negative women. The study groups did not differ much in use of modern birth control. Two studies did not provide family planning counseling for HIV-negative women. In the larger study, HIV-positive women were less likely to get pregnant. More HIV-positive women stopped using their hormonal birth control, but more used condoms and spermicide. Two studies provided counseling for both HIV groups. One showed fewer pregnancies for HIV-positive women. In the other, the HIV groups were similar for pregnancy and condom use.

Overall, these were moderate quality studies. Many did not adjust for factors affecting the outcomes, and many used self-reported data. The studies had different designs and reporting methods. Four studies were done many years ago. Improved HIV treatment has changed how HIV-positive women think about having children. However, we found little research on birth control counseling for these women. The field needs tested programs to help women choose and use a birth control method.