A survey of the sexual and reproductive health of HIV-positive women in Leicester

Abstract

This project reports results from a questionnaire survey of sexual practices, contraception use and pregnancy plans in HIV-positive women in Leicester, UK, in order to establish the need for a dedicated sexual and reproductive health (SRH) clinic. The majority (96%) of women were aware of the benefits of antiretroviral therapy (ART) in pregnancy and 39% were planning a future pregnancy. Most (74%) used condoms consistently but their use decreased with the addition of another contraceptive method. Condoms were mostly obtained from non-National Health Service (NHS) settings. Long-acting reversible contraception (LARC) use was higher in this group of women than the general population and mainly provided by family planning services. A dedicated SRH clinic was thought to be useful by 79% of women. Data also identified some limitations of the existing service and need to provide holistic and integrated care.

Keywords

HIV women contraception sexual health long-acting reversible contraception LARC preconceptual counselling UK

INTRODUCTION

Since 1997, the East Midlands has proportionally had the largest increase in new HIV cases diagnosed in the UK: an eight-fold increase (48 to 393).¹ During 2007, approximately 260 HIV-positive women accessed the genitourinary (GU) medicine service in Leicester, UK. Recent studies indicate that women living with HIV have similar reproductive patterns to those of HIV-negative women,^2,3 such as planning pregnancy and limiting their family among other gender-specific concerns.

The National Strategy for Sexual Health and HIV⁴ seeks to improve the sexual health of people living with HIV incorporating safer sex and condom use. Previously inadequate sexual and reproductive health (SRH) counselling from health professionals has been reported⁵ for women with HIV and dedicated, integrated and accessible SRH services, with a range of reproductive choices, have been recommended.⁶ A national guideline emphasizes the unique SRH requirements of people living with HIV.⁷ Gender-specific concerns include preconceptual counselling, pregnancy and contraception.

In Leicester, most SRH issues are currently dealt with as part of the routine HIV clinic. In view of the national recommendations and increasing numbers of women living with HIV, we conducted a survey to ascertain their sexual practices, contraceptive use and pregnancy plans. In addition, we wanted to establish the need for a dedicated SRH clinic within our service.

METHODS

During the period November 2007 to April 2008 an anonymous two-sided (one-page) questionnaire was offered to all women aged 18–50 years attending the HIV clinic. Background information of age, number of years since HIV diagnosis and whether receiving antiretroviral therapy (ART) were recorded. SRH details collected included previous pregnancies, future pregnancy plans, current sexual relationships, condom use and current contraception. Women were directly asked if a clinic for contraception and pregnancy advice purposes would be useful. Most questions had tick boxes for ease of response; free text was used for comments. Questionnaires were analysed using SPSS version 15 (SPSS Inc, Chicago, IL, USA).

RESULTS

During the survey period, 156 HIV-positive women accessed the service and 114 women returned the questionnaires, giving a response rate of 73%. The mean age of respondents was 34.4 years (range 18–50, SD 6.66) and the average number of years since diagnosis was 3.6 years (range 0–13, SD 2.41) with 79.8% (91/114) currently on ART. Most women, 76.3% (87/114), were in a sexual relationship and 87.4% (76/87) were aware of their partner's HIV status.

Past and future pregnancies

Previous pregnancies had occurred in 62.3% (71/114) of women: of these, 53.5% (38/71) were planned and 52.1% (37/71) were aware of their HIV status at the time (22 negative and 49 positive). The majority (81.6%; 40/49) of women who were HIV-positive in their previous pregnancy had received ART. A future pregnancy was planned by 38.6% (44/114), and 95.5% (42/44) of them were aware of mother-to-baby transmission risks with 93.2% (41/44) aware that ART reduced this transmission. There was no significant difference (using an unpaired t-test) in mean age of women who were planning a pregnancy compared with those who were not.

Condom and contraceptive use

Almost two-thirds of women 63.2% (72/114) stated that they were currently sexually active. Condom use overall was variable with 73.6% (53/72) always using, 19.4% (14/72) using sometimes and 6.9% (5/72) never using condoms. When male or female condoms were the only contraceptive method, 83.7% (41/49) always used them; this became less likely when another method of contraception was added, with only 59.1% (13/22) always using condoms, but this was not statistically significant (chi-square test). Long-acting reversible contraception (LARC) methods were used by 25% (18/72) of sexually active women. Table 1 shows method of contraception with consistency of condom use and whether on ART.

Table 1

Method of contraception, condom use and antiretroviral therapy (ART) status

	N = 72		Condom use
Method of contraception	n	%	Always (n)	Sometimes (n)	Never (n)	Using ART
Male condom	46	64.8	38	8	0	35
Female condom	3	4.2	3	0	0	1
Pills	2	2.8	2	0	0	2
Implant	6	8.3	4	2	0	5
Injection	4	5.6	2	1	1	4
Hormone coil	3	4.2	3	0	0	2
Copper coil	5	6.9	2	3	0	1
Female sterilization	1	1.4	0	0	1	1
Male sterilization	1	1.4	0	0	1	1
None	1	1.4	0	0	1	1

Most 87.5% (63/72) sexually active women knew their partner's HIV status, and 73% (46/63) of them always used condoms. This was similar for the 9.7% (7/72) who did not know partners’ HIV status where 71.4% (5/7) always used condoms. The 2.8% (2/72) of sexually active women who had no regular partner 100% (2/2) always used condoms. Most condoms were obtained from a non-National Health Service (NHS) source despite being free of charge from NHS providers. Other contraceptive methods were provided mainly by family planning and general practice. Table 2 shows where contraception was obtained from – more than one location could be given.

Table 2

Locations where HIV-positive women are obtaining contraception

Method of contraception	General practice (n)	Family planning (n)	Genitourinary medicine clinic (n)	Shop/other (n)
Male condom, n = 46	5	11	4	25
Female condom, n = 3	1	1	0	1
Pills, n = 2	1	1	NA	NA
Implant, n = 6	2	4	NA	NA
Injection, n = 4	1	3	NA	NA
Hormone coil, n = 3	1	2	NA	NA
Copper coil, n = 5	3	2	NA	NA

NA = not applicable

Need for a dedicated SRH clinic

Women were directly asked their preference for a dedicated SRH clinic. Overall 68.4% (78/114) answered yes, 23.7% (27/114) said no and 7.9% (9/114) did not respond. Reasons cited for not wanting one were: not in a sexual relationship, family complete or not planning children. When only sexually active women are considered, 79.2% (57/72) said yes to a dedicated clinic being useful. Other comments included 15 compliments, three specific requests for more information about contraception and one criticism about the clinic telephone answer machine.

DISCUSSION

The survey provides us with information regarding the SRH needs of HIV-positive women accessing our service in Leicester. It highlights differing practices with regards to sexual activity and contraceptive use when compared with the general population. In spite of high levels of awareness of the benefits of ART in pregnancy, women remain at risk of unplanned pregnancy. Condom use is suboptimal and surprisingly this is not being accessed through the service. Contraceptive methods that interact with ART are being prescribed.

Contrary to previous studies reporting approximately 70% of HIV-positive women being sexually active,^2,8 a relatively high rate of sexual abstinence was noted in our group, with only 63.2% (72/114) of women admitting sexual activity. We believe that as a UK-based subpopulation group was studied, other factors such as ethnicity, immigration status and cultural elements may explain this difference. In 2006, 75% of women living in the UK with HIV were African born.¹ Geographical distance between partners, with one partner only having migrated could be a reason. A dedicated SRH would also ensure that women are prepared when sexual activity does recommence.

Almost all (99%; 71/72) sexually active women in our group admitted to using some mode of contraception, with 25% (18/72) of sexually active women and 15.8% (18/114) overall using LARC. This is higher than LARC usage in the general population, which was reported as 9% in 2006/2007,⁹ and nationally for HIV-positive women from the case-notes audit¹⁰ where LARC methods were used in 10%. A national clinical guideline¹¹ emphasizes the cost-effective role of LARC methods in reducing unplanned pregnancy and advocates the availability of LARC to all women of reproductive age in the UK.

The high usage of LARC in our group is encouraging as previous studies have shown a higher rate of sterilizations and under-usage of LARC in HIV-positive women.² Our data provide evidence that some effective contraceptive counselling is occurring. Nonetheless, some women on ART were prescribed contraception with known drug–drug interactions,¹² risking unplanned pregnancy, although this risk was reduced by consistent condom use alongside.

Our survey indicates that condom use was the only method of contraception in 43% (49/114), which is higher than that reported nationally for HIV-positive women (40%)¹⁰ and in the general population (22%).⁹ This probably indicates an awareness of the benefits of condoms for preventing HIV transmission as well as pregnancy. Knowledge of postexposure prophylaxis following sexual exposure reinforced on follow-up may also be a factor but was not ascertained in our survey. High failure rate of condoms and risks of unplanned pregnancy remain. It is possible that fears of side-effects from poly-pharmacy maybe a barrier to access in some cases, an area which could be explored further.

An interesting observation was that the majority of women are using their GP or family planning clinics for contraceptive advice and obtaining condoms from a non-NHS provider. The possibility of non-disclosure of HIV status exists (we have had 2 cases of contraceptive implant failure with ART where HIV status and medication was not disclosed to the contraceptive provider). Not accessing condoms from the GU medicine service or other NHS settings where they are provided free may be possibly due to stigma (deductive disclosure), lack of awareness of availability, or patients’ choice and a better range of condoms in shops. It may be that women wish to keep their HIV care separate from condom provision, an area that needs additional research.

Despite a 73% response rate, the overall number of women we surveyed is small and conclusions may not be generalized. Again, the responses may be biased with women reporting what they think professionals want to hear especially regarding condom use. A recent audit¹³ of a one-stop SRH clinic showed an improvement in all aspects of SRH care including cervical cytology and contraception following its introduction. Another audit¹⁴ demonstrated high acceptance of a one-stop contraception and medical gynaecology clinic and its effectiveness in providing high-quality care for HIV-positive women. Our survey highlights some important shortcomings in current service provision. Establishment of an SRH clinic could optimize counselling and minimize fears of disclosure. A large majority (80%) of our sexually active patients felt that a dedicated SRH clinic would be useful which would be a positive step towards optimizing integrated and holistic SRH care.

References

Health Protection Agency. HIV and AIDS in the United Kingdom quarterly update: data to the end of March 2006. Communicable Disease Report Weekly 2006;16

Stanwood

, Cohn

, Heiser

, Pugliese

. Contraception and fertility plans in a cohort of HIV-positive women in care. Contraception 2007;75:294–98

Ogilvie

, Palepu

, Remple

, Fertility intentions of women of reproductive age living with HIV in British Columbia, Canada. AIDS 2007;21(Suppl 1):S83–88

Department of Health. The National Strategy for Sexual Health and HIV. London: Department of Health, 2001

Duggan

, Walerius

, Purohit

, Reproductive issues in HIV-seropositive women: a survey regarding counseling, contraception, safer sex, and pregnancy choices. J Assoc Nurs AIDS Care 1999;10:84–92

Clark

, Dumestre

. Women and human immunodeficiency virus: unique management issues. Am J Med Sci 2004;328:17–25

Fakoya

, Lamba

, Mackie

, British HIV Association, BASHH and FSRH guidelines for the management of the sexual and reproductive health of people living with HIV infection 2008. HIV Med 2008;9:681–720

Mitchell

, Stephens

. Contraception choice for HIV positive women. Sex Transm Infect 2004;80:167–73

Lader

. Contraception and Sexual Health 2006/07. Newport: Office for National Statistics, 2007

10.

Carne

, McClean

, Bunting

, Wilkins

, Tucker

, Baguley

. UK national audit of sexual health care for people with HIV infection: case-notes audit. Int J STD AIDS 2007;18:639–42

11.

National Institute for Health and Clinical Excellence. Long Acting Reversible Contraception. London: RCOG Press, 2005

12.

Faculty of Sexual and Reproductive Healthcare. Drug interactions with hormonal contraception. J Fam Plann Reprod Health Care 2005;31:139–51

13.

Coyne

, Hawkins

, Desmond

. Sexual and reproductive health in HIV-positive women: a dedicated clinic improves service. Int J STD AIDS 2007;18:420–21

14.

Samuel

, Welch

, Tenant-Flowers

, Contraception and medical gynaecology for HIV-positive women in a one-stop clinic. Int J STD AIDS 2008;19:559–60