Contraceptive use and associated factors among sexually active HIV positive women attending ART clinic in FHRH in Bahir Dar, north west, Ethiopia, 2018. Facility based cross-sectional study.


 Abstract
Back ground: Contraception helps prevent unplanned pregnancies and mother to child HIV transmission among human immune virus positive women. Contraceptive use status and associated factors were not well addressed in the study area. This study aimed to assess contraceptives use and associated factors among HIV positive sexually active women at anti-retroviral therapy clinic in Felege Hiwot Referral Hospital, Northwest Ethiopia.
 Method : A facility based quantitative cross-sectional study was conducted from June 01 -30, 2018, among 308 randomly selected sexually active HIV positive women of reproductive age in Felege Hiwot Referral Hospital anti-retro viral treatment clinic. A pre-tested interviewer-administered questionnaire was used to collect data. Data were analyzed using SPSS version20. Descriptive statistics were used to summarize socio-demographic characteristics of participants. A multivariate logistic regression analysis method was employed and odds ratio with 95% confidence interval was used to control possible confounders. Statistical significance was declared at p-value <0.05.
Results: The current study revealed that overall contraception use among sexually active HIV positive women was 38.3 %( 95%CI: 32.5%-43.5%). Women with age range of 15-34 years old (AOR =3.089, 95%CI: 1.591-5.999), HIV status disclosure to sex partner, (AOR=2.75995%CI: 1.142-6.663), previous contraception utilization experience; (AOR=3.361, 95%CI: 1.677-6.736), Sexual activity in the last six months (AOR5.451, 95%CI: 2.724-10.908) and had drinking habit (AOR=4.351, 95%CI: 1.824-10.379) were the main predictors of contraceptive use.
Conclusion: Contraceptive use was low in the current study area. Efforts should be strengthened to increase contraception use among human immune virus positive women. Anti-retro viral treatment and family planning services should be integrated to increase contraceptive use uptake in the study area.
Keywords: Contraceptive use, Contraception, Human immune virus positive women, Bahir Dar, North west Ethiopia.


Introduction
Although global community is working to end HIV/AIDS epidemic by 2030, it remains a major global epidemic in post millennium development era. It remains the leading cause of morbidity and mortality throughout the world. Since the start of the epidemic, around 76.1 million peoples infected and 35 million people died from AIDS (Acquired Immunodeficiency Syndrome) related illness [1]. Globally in 2017, there were 36.9 million people living with HIV; 18.2 million women of reproductive age group and 1.8 million were children under 15 years old. There were also a total of 1.8 million new infection and 940,000 AIDS related death in the same year. [2].
Eastern and southern Africa including Ethiopia remains the region most affected by the HIV epidemic, accounting for 45% of the world's HIV infection and 53% of people living HIV globally. Adolescent girls and young women continue to face disproportionately high risk of HIV in the region [2].Sub-Saharan Africa (SSA) contributed 76% of total of HIV-infected people,76% of a total of new HIV infection and 75% of a total of HIV/AIDS related deaths in 2015 [3].
As one of the sub-Saharan country, the scenario in Ethiopia is similar. In Ethiopia, the HIV epidemic has remained a major public health problem, largely affecting women of reproductive age group [4]. At the end of 2017, there were an estimated total 722,248 people infected with HIV, 22,827 new HIV infection and 14,872 annual AIDS related deaths. In the same year, an estimated HIV prevalence in the general population was at 1.5 percent [5].
The epidemic is well established in the urban areas of the country .According to Ethiopian population-based HIV impact assessment (EPHIA2017-2018), the annual incidence of HIV among adult age groups (15-64) years in urban Ethiopia is 0.06%. Prevalence of HIV among adult age 15-64 years in urban Ethiopia is 3.0%; 4.1% among women and 1.9% among men. Prevalence of HIV among children ages 0-14 years in urban Ethiopia is 0.3%, the same among both sexes. Viral load suppression among HIV-positive adults ages 15-64 years in urban Ethiopia is 70.1%: 71.7% among women and 66.8% among men [6].
Voluntary family planning a key intervention for health and development by enabling women and couples to decide number, timing and spacing of births.
Sexually active women can do this by using different contraceptive methods. Reducing maternal mortality, child mortality, abortion and transmission of HIV from mother to child are some of the health benefits of family [7,8]. Universal access for family planning and reproductive health is not the only path to sustainable development, but without addressing these issues achievement of other sustainable goals will be challenging [7].
Contraceptive is a cost-effective intervention for preventing mother to child HIV transmission [7]. The United Nations PMTCT strategy outlines four approaches necessary to cut mother-to-child transmission. Preventing unintended pregnancy in HIV infected woman is one of the recommended PMTCT strategy [9]. Study from U.S.based Johns Hopkins University and the World Health Organization have found that only moderate reductions in unintended pregnancy rates among HIV-infected women would cut rates of HIV-positive births [9].
Ethiopia is the most populous country next to Nigeria with an estimated population of more than 100 million [4]. It has one of the highest fertility rate in Africa, with 45% of its population under-15 years old. Ethiopia's strong investment in health sector have contributed to a significant progress over the last 10 years in increasing contraceptive use and reducing fertility rates. However, fertility and population growth rates remains high, at 4.1 and 2.6 percent [10].
Ethiopian health sector transformation plan has planned to increase proportion of contraceptive use from 42-55%, to decrease total fertility rate from 4 to 3 percent, unmet need for family planning from 24-10% and adolescent age pregnancy rate from 12-3% [11].However, the 2016 Ethiopian Demographics and Health Survey estimated only 36% of married women were using any of contraception which is lower than the HSPD II target [12].
Preventing unintended pregnancy among sexually active HIV positive women is cost effective approach to primary prevention of mother to child transmission of HIV. It is also a global public health priority for addressing the distracted state of maternal and child health in high HIV endemic areas like Ethiopia [13]. Every year, Meeting all unmet needs for modern contraceptive methods could avert 52 million untended pregnancies in developing region [14].
Meeting the family planning goals of women living with HIV through proper counseling and contraceptives services could optimize health outcomes for women, cut the potential HIV transmission to their children and help achieve an HIV free generation by 2020 [15,16].Therefore, the aim of this study was to assess contraceptive use and associated factors among sexually active HIV positive women at ART clinic in Felege Hiwot Referral Hospital, Northwest Ethiopia, 2018.

Study design
This study employed a facility based cross-sectional study design using a quantitative method with structured interview administer questionnaire to obtain data from sexually active HIV positive reproductive age women attending ART clinic.

Study area, population and period
The study was conducted from June 1-30, 2018 at Felege Hiwot Referral Hospital.
The hospital is a referral hospital which is found in Bahir Dar, capital city of Amhara regional state. The city is 564 km far away from Addis Ababa, the capital city of the Ethiopia. The Hospital provides different inpatient and outpatient services to the population of the region including ART and family planning services. The study population was all sexually HIV positive reproductive age women attending ART clinic of Felege Hiwot Hospital. There were about 6620 people living with HIV enrolled in the hospital during the study period. Out of these around 50.76% were reproductive age women. All of them were on HAART at the time of the study. In this study, we included non-pregnant sexually active women living with HIV in reproductive age group and who were available at the time of data collection.
Sample size determination and sampling procedure Sample size was determined single population formula. Assumptions used in sample size calculation were, prevalence (P) of contraceptive utilization = 76% [17], margin of error of (d) = 5% ,Zα⁄2 = 1.96 at 95% confidence interval and non-response rate of 10%. The total sample size was 308.
First, we determined the numbers of the sexually active HIV positive women aged 15-49 years in ART clinic at Felege Hiwot Referral Hospital. Then, we developed sampling frame based on the number of participants. Finally, we selected the study participants by simple random sampling method i.e., lottery method.

Inclusion criteria
All sexually active HIV positive reproductive age women who receive ART treatment in Felege Hiwot hospital at the time of data collection.

Exclusion criteria
Sexually active HIV positive reproductive age women with surgical removal of uterus, who had permanent contraception, who did not speak the local language or unable to communicate for any reason, were pregnant and who had a known infertility were excluded.
Sexually active HIV positive women who were below the age of 18 who came to the facility without guardian or family were excluded from study for consent issue.

Measurement
The main outcome variable was self-reported contraceptive use six months earlier the data collection period. We defined contraceptive use as current use of any method by women to delay or avoid pregnancy for the last six months. We defined modern contraceptive methods as use of Pills, intra-uterine contraceptive device (IUD), injectable (Depo-Provera), implants (implanol or jaddel), male/female condom, diaphragm, permanent methods such as tubal ligation and hysterectomy to delay or avoid pregnancy. We defined consistent condom use as the use of female or male condoms in all vaginal sexual relationships with casual and/or steady partners.
Independent variables included in this study were age of woman, educational level, number of living children, drinking habit, partner HIV status, HIV status disclosure to partner, having stable sexual partner, earlier contraceptive use experience, condom use, and having sexual activity in the last six months.
Data collection and data quality assurance Trained data collectors collected the data using structured interviewer administered questionnaire which we adopted from earlier studies [17,18]. The questionnaire had the following contents; Socio-demographic characteristics, reproductive and sexual characteristics, contraceptive use and HIV related health service factors. First, we prepared English version of the questionnaire then language experts translated it to local language (Amharic) and back to English to check consistency and accuracy.
We recruited four diploma nurses and two Bachelor of Science nurses as data collectors and supervisors. Assigned supervisors closely managed the data collection process. In addition, we gave training for data collectors and supervisors on the overall content of questionnaire and data collection process for two consecutive days. We have carried out pre-test study on 5% of the calculated sample size of women in Adiss Alem Hospital ATR clinic which is out of study area and readjusted the questionnaire. We also reviewed medical records of participants to get clinical information on anti-retroviral treatment and CD4 count.

Data processing and analysis
The collected data were checked manually for completeness and consistency. Then, coded and entered into EPI Info version3.5.3 and transferred to SPSS version 20 for analysis. We used descriptive statistics to summarize socio-demographic characteristics of participants and prevalence of contraceptive use. To show factors associated with contraceptive use, we carried out binary logistic regression analysis at two levels. We performed univariate logistic regression to each independent variable with the outcome variable and then we included variables with p-value < 0.05 in multivariate analysis. We measured strength of association using odds ratio, and 95% confidence intervals. Finally we declare statistical significance at p-value < 0.05.

Result
All 308 sampled HIV positive women participated in the current study making a response rate of 100%. The mean age of women was 26 years (SD ± 4.08). Almost half all participants, (52.2%) of women were aged between 15 and 29 years. More than two third (78.2%) were from Orthodox Christianity. Regarding to educational status, 144(46.8%) women were not educated while 164 (53.2%) were educated.
Two third (59.7%) of participants were not employed.
Majority of participants, 260(84.4%) had drinking habit. On the other hand, the result of this study revealed that 67(21.8%) of participants had previous child death. Almost half of participants (45.5%) had wish to have more children in the future. Nearly half (55.8%) of participants had stable sexual relationship. From all participants, (73.1%) had disclosed their status to their sexual partner. One hundred, two-third (58.8%) of participants had one partner during the last six months before the survey. Nearly one -fourth (24.4%) participants had changed their regular sexual partner after their diagnosis. Reasons for changing partner were; death of partner (25.3%), divorce (34.7%) and spousal rejection (40%) ( Table 1).
Regarding to contraceptive use, almost two third (64%) of study participants had previous experience of contraceptive use and only one-fourth (26%) of participants were using dual contraceptive method during the survey. The most commonly used contraceptive was injectable (43.5%) followed by pills (21.4) and implant (19.2%).  (Table 2).
Factors associated with contraceptive use First we carried out binary logistic regression to select variables having association with contraceptive use. Then, we retained nine variables for multivariate analysis.
After adjusting confounding factors, maternal age, drinking habit, earlier contraceptive use experience, HIV status disclosure to sex partner, and having sexual activity in the last six months were significant in multivariate logistic regression. Age was positively associated with contraceptive use. Women with younger age (15-34) years old were three times more likely to use contraception (AOR = 3.089, 95%CI: 1.591-5.999) than their counter parts i.e.35-49 years old.
Likewise, HIV status disclosure to sex partner was positively associated with contraceptive use.HIV positive women who disclosed their status to their sex partners were almost three times more likely to use contraception (AOR = 2.759,95%CI: 1.142-6.663) than their counterparts. Similarly, earlier contraceptive use history was positively associated with contraceptive use. Women who had previous contraceptive use experience almost three times more likely to use contraception (AOR = 3.361, 95%CI: 1.677-6.736) than their counterparts.
Having Sexual activity in the last six months also was positively associated with contraceptive use. Women who had sexual activity in the last six months were almost 5 times more likely to use contraception (AOR = 5.451, 95%CI: 2.724-10.908) than their counter parts. On the other hand drinking habit was negatively associated with contraceptive use. HIV positive women who had drinking habit were almost 4 times less likely to use contraception (AOR = 4.351, 95%CI: 1.824-10.379) than women who did not have drinking habit (Table 3

Ethics approval and consent to participate
Ethical clearance obtained from Bahir Dar University, department of nursing research committee and college of health science institutional review board. Each study participant was adequately informed about the aim of the study and anticipated benefit and risk of the study by their data collector. Written consent sought from all study participants for protecting autonomy and ensuring confidentiality.

Consent for publication
Not applicable.

Availability of data and materials
The data of this study can't be shared publically due to presence of sensitive (confidential) participants' information.

Competing interests
There are no competing interests amongst authors

Authors' contributions
All authors conceived and designed study. TA, analyzed, interpreted data and drafted the manuscript for important intellectual content. TT reviewed the manuscript.DJ, GM, MA and GT completed data collection and entry. All authors read and approved the last manuscript.

Consent for publication
Not applicable.

Availability of data and materials
The data of this study can't be shared publically due to presence of sensitive (confidential) participants' information.

Competing interests
There are no competing interests amongst authors

Funding
Not applicable

Authors' contributions
All authors conceived and designed study. TA, analyzed, interpreted data and drafted the manuscript for important intellectual content. TT reviewed the manuscript.DJ, GM, MA and GT completed data collection and entry. All authors read and approved the last manuscript.