Unintended Pregnancy and Contraception among African women living with HIV: baseline analysis of the multi-country US PEPFAR PROMOTE cohort

Background: About 90% of unintended pregnancies are attributed to non-use of effective contraception – tubal ligation, or reversible effective contraception (REC) including injectables, oral pills, intra-uterine device (IUD), and implant. We assessed prevalence of unintended pregnancy and factors associated with using RECs, and Long-Acting-Reversible-Contraceptives (LARCs) – implants and IUDs, among women living with HIV (WLHIV) on antiretroviral therapy (ART). Methods: : Cross-sectional analysis of US-PEPFAR PROMOTE cohort enrollment (December 2016 to June 2017) data, from Malawi, South Africa, Uganda, and Zimbabwe. Wilcoxon Rank Sum and Fisher’s exact tests were used to compare continuous and categorical variables. Separate outcome (REC and LARC) modified-Poisson regression models were used to estimate prevalence risk ratio (PRR) and corresponding 95% confidence interval (CI). Results: : Of 1,987 enrolled WLHIV, 990 (49.8%) reported their last/current pregnancy was unintended; 1,027/1,254 (81.9%) non-pregnant women with child-bearing potential reported current use of effective contraception including 215/1,254 (17.1%) LARC users. Compared to Zimbabwe, REC rates were similar in South Africa, aPRR=0.97 (95% CI: 0.90-1.04), p=0.355, lower in Malawi, aPRR = 0.84 (95% CI: 0.78-0.91), p<0.001, and Uganda, 0.82 (95% CI: 0.73-0.91), p<0.001. Additionally, REC use was independently associated with marriage/stable union, aPRR=1.10 (95% CI: 1.01-1.21), p=0.039; no desire for another child, PRR = 1.10 (95% CI: 1.02-1.16), p=0.016; infrequent sex (none in the last 3 months), aPRR = 1.24 (95% CI: 1.15-1.33), p<0001; HIV load (≤ 1000 copies/ml), PRR = 1.10 (95% CI: 1.02-1.19), p=0.014, and education (secondary or higher), aPRR = 0.91 (95% CI: 0.84-0.98), p=0.013. LARC use was independently associated with country (Zimbabwe ref: South Africa, PRR = 0.39 (95% CI: 0.26-0.57), p<0.001; Uganda, PRR = 0.65 (95% CI: 0.42-1.01), p<0.054; and Malawi, aPRR = 0.87 (95% CI: 0.64-1.19), p=0.386); HIV load (≤ 1000 copies/ml copies/ml), aPRR = 1.73 (95% CI: 1.26-2.37), p<0.001; and stay home / no formal income, aPRR = 0.5 (95% CI: 0.59-0.97), p=0.027. Conclusions: : We observed high rates of unintended pregnancy and considerable gaps in use of effective contraceptives particularly LARCs. Integrated HIV and reproductive health country-level efforts to improve effective contraceptive utilization should consider HIV load, and social factors regarding education, sexual activity, sexual partnerships, fertility desires, and economic independence.