2 Approval Sheet Family Planning for Women with HIV on Antiretroviral therapy in Lilongwe, Malawi Open Access

Haddad, Lisa (2011)

Permanent URL: https://etd.library.emory.edu/concern/etds/vx021f987?locale=en
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Abstract

Abstract
Introduction: Preventing unintended pregnancy among women with HIV is essential to decrease unnecessary pregnancy-related morbidity and mortality and maternal to child HIV transmission. Given the high failure rate of condoms alone, promoting dual protection with additional forms of effective long-acting contraception is crucial. Our goal was to determine contraceptive medical eligibility, contraceptive preference, acceptance of the IUD, condom use, fertility intentions and contraceptive use among a cohort of HIV-infected women on antiretroviral therapy seeking contraceptive services. Methods: All women presenting for family planning services at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010 were invited to participate in a structured interview to assess eligibility for a prospective contraceptive study. A screening questionnaire assessed contraceptive medical eligibility and contraceptive choice. An enrollment questionnaire assessed fertility intentions, contraceptive and condom use. Results: 281 women were screened and 200 women were enrolled in the study. Of these women, all non-pregnant women met eligibility for at least 3 contraceptive methods, with 87% eligible for all 5 methods evaluated. After counseling, 34.9% of the women selected an IUD as their first choice contraceptive method with 222 (79%) willing to have an IUD placed even if not their first choice method. Most women (95%) did not desire future fertility. Contraceptive and condom use was inadequate and prior reported unintended pregnancy rates were high. Inconsistent condom use was often due to partner's refusal to use. Discussion: We successfully demonstrated that contraceptive services can be integrated into HIV care and that women in this setting are receptive to enrolling into a randomized contraceptive study that included the IUD. Most methods of contraception are safe for use present for family planning services. Although more women chose DMPA as a first choice for contraception, almost 80% of the women were willing to receive an IUD. Efforts must be made to increase access to long-acting reversible methods. We need to improve contraceptive and condom use in this setting, with efforts to enlist partners in programs aimed at increasing use.

Table of Contents

Table of Contents
Table of Abbreviations ..................................................................................................................... 1
Background/Literature Review .......................................................................................................... 2

Family Planning in Malawi: ............................................................................................................... 2
Barriers to family planning in sub-Saharan Africa ................................................................................. 4
Importance of integration of family planning and HIV care .................................................................... 6
Family Planning for women with HIV: ................................................................................................. 8
Fertility, family planning and sexual behavior among individuals with HIV .............................................. 11

Hypothesis and Objectives: .............................................................................................................. 13
Methods ......................................................................................................................................... 14

Study Design: ................................................................................................................................. 14
Criteria for the selection of subjects ................................................................................................... 15

Study Inclusion Criteria for enrollment in Randomized Controlled Trial .................................................. 15
Study Exclusion Criteria for enrollment in Randomized Controlled Trial .................................................. 16

Study Population: ........................................................................................................................... 17

Lilongwe, Malawi ............................................................................................................................. 17
The Lighthouse Clinic .................................................................................................................... .. 17

Permissions/Approvals .................................................................................................................... 18
Admission procedure ....................................................................................................................... 18

Recruitment .....................................................................................................................................18
Screening Consent ........................................................................................................................... 18
Screening Questionnaire ................................................................................................................... 19
Enrollment consent .......................................................................................................................... 19
Enrollment questionnaire ................................................................................................................... 20
Dual Method Use Counseling .............................................................................................................. 20

Statistical Considerations ................................................................................................................... 21

Sample size justification ..................................................................................................................... 21
Variables evaluated and coding ........................................................................................................... 22
Statistical Analysis: ............................................................................................................ .............. 23

Data Management: ............................................................................................................. ............. 25

Database entry and management ........................................................................................................ 25
Data Quality Assurance ...................................................................................................................... 25
Data Confidentiality Assurances: .......................................................................................................... 25

Results ............................................................................................................................................. 26

Screening and Enrollment ................................................................................................................... 26
Medical Eligibility ............................................................................................................................... 27
Contraceptive choice and acceptance of the IUD .................................................................................... ..27
Characteristics of women enrolled .......................................................................................................... 28
Fertility intentions, unintended pregnancy and family planning use ............................................................. 28
Condom usage ...................................................................................................................................... 29

Discussion ............................................................................................................................................ 31
Future Directions ................................................................................................................................... 37
References .......................................................................................................................................... 39
Tables& Figures .................................................................................................................................... 46

Figure 1 -Diagram for flow of Screening and Enrollment .............................................................................. 46
Figure 2: Summary of clients enrolled in study ........................................................................................... 47
Figure 3: Condom use at last coitus among women enrolled ......................................................................... 48
Figure 4: Condom use in past 12 months among women enrolled .................................................................. 48
Table 1: Differences between individuals screened who did enroll compared to those
who did not enroll ................................................................................................................................... 49
Table 2: Distribution of reasons for ineligibility among those not enrolled in the study....................................... 49
Table 3a. Incidence of Health/Medical issues that restrict (category 3 or 4) any
contraceptive method initiation according to World Health Organization medical
eligibility criteria for contraceptive use 2010. ............................................................................................... 50
Table 3b. Proportion of clients who are eligible for contraceptive initiation (category 1
or 2) according to World Health Organization medical eligibility criteria for
contraceptive use 2010 ............................................................................................................................. 50
Table 3c. Number of methods that can be offered to clients for initiation based on
eligibility for contraceptive initiation (category 1 or 2) according to world health
organization medical eligibility criteria for contraceptive use 2010 ................................................................... 50
Table 4a. First choice contraceptive method among 281 women screened with HIV
presenting for family planning .................................................................................................................... 51
Table 4b. Willingness for IUD placement among HIV positive clients presenting for
family planning in clinic ............................................................................................................................ 51
Table 5. Reasons for declining IUD among women who would not consider IUD
placement on that clinic day .................................................................................................................... 51
Table 6. Demographic characteristics of 200 women enrolled in study: .......................................................... 52
Table 7: Partner related characteristics among women 200 enrolled in the study ............................................ 53
Table 8. Fertility intentions and unplanned pregnancy among HIV+ clients enrolled in
study ................................................................................................................................................... 54
Table 9. Family planning use among HIV+ clients enrolled in study .............................................................. 55
Table 10. Factors associated with current contraceptive use (including condoms for
intention of family planning), crude and adjusted odds ratios with all variables in
model: ................................................................................................................................................... 56
Table 11. Condom use reported by 200 women enrolled in study ................................................................... 57
Table 12a. Primary reason reported for inconsistent condom use (n=127) ....................................................... 57
Table 12b. Primary reason reported for inconsistent condom use .................................................................... 57
(n=127), categorized into factors for non-use ......................................................................................... 57
Table 13. Factors associated with consistent condoms, unadjusted and adjusted odds
ratios with all variables included in the model ............................................................................................. 58
Table 14. Factors associated with using a condom during last coitus, unadjusted and
adjusted odds ratios will all variables in model ............................................................................................ 59
APPENDICES .......................................................................................................................................... 60
Table 15a: Ever use of contraception among women interviewed and in Malawi DHS 60
Table 15b: Current use of contraception among women interviewed and in Malawi
DHS ...................................................................................................................................................... 60

Appendix ............................................................................................................................................... 61

Screening Eligibility Assessment ................................................................................................................ 61
Enrollment Assessment ............................................................................................................................ 68
English screening consent ......................................................................................................................... 78
English Enrollment Consent ....................................................................................................................... 83

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