Tanzania adopted HIV and family planning services integration strategy to address unintended pregnancies and MTCT of HIV among HIV-positive women. HIV treatment and PMTCT clinics in Tanzania provide family planning counselling and prescribe or refer clients for contraceptive services. This study has assessed the effect of enrollment into integrated services (ART) on modern contraceptive use among HIV-positive women. In a well-functioning integrated program, women enrolled on ART (integrated services) are likely to have higher modern contraceptives than those not enrolled. We assessed this hypothesis by comparing contraceptive prevalence among HIV-positive enrolled on integrated services (ART) and those not enrolled (HIV-positive not on ART or HIV-negative).
We analyzed nationally representative HIV impact survey data. Women on ART represent a subpopulation of HIV-positive potentially benefiting from family planning service integration through routine screening of contraceptive use, prescription and referral as stipulated in family planning and HIV care and treatment guidelines. This analysis demonstrated that enrollment into integrated services (ART) is associated with increased modern contraceptive prevalence in HIV-positive women compared to HIV-negative or HIV-positive women who are not on treatment. Contraceptive prevalence by HIV status shows that approximately one-third of HIV-positive women (35%) used modern contraceptives. Modern contraceptive prevalence was higher among HIV-positive enrolled on integrated services (40%) compared to those who are HIV-positive and not aware of their status (27%) or HIV-negative women (30%).
This study shows that HIV-positive women on integrated services had 13% higher modern contraceptive prevalence than those not on ART and unaware of their HIV status and 10% higher than HIV-negative. The increase in modern contraceptives may be attributed to family planning and HIV services integration and or reduced desire for more children following HIV diagnosis.[22, 23] Prior studies have demonstrated that service integration increases the uptake of modern contraceptives among HIV-positive women [16, 17, 22]. A systematic review study by Grant-Maidment and colleagues reported 8% higher contraceptive use in integrated than on non-integrated facilities [17]. The difference in contraceptive prevalence in women on ART and those not in ART in this study is smaller than the expected impact of service integration observed elsewhere. In a prospective study conducted in Rwanda, a higher impact was reported where modern contraception prevalence of 72% was found following service integration intervention compared to 30% before the intervention.[25]
In our multivariate analysis that combined HIV-positive and negative women (Model 1), HIV-positive status awareness increased the odds of modern contraceptives by 48%. In HIV-positive women (Model 2), being on integrated service increased the odds of modern contraceptives by 85%. These findings are consistent with the results reported among HIV-positive women in Malawi[26]. The increase may be attributed to family planning, HIV-service integration, and the intention to limit fertility and to avoid MTCT of HIV. Lower pregnancies and birth rates in this study support this hypothesis in HIV-positive women than in HIV-negative women. Age composition may also be essential in describing high modern contraceptives among HIV-positive people. More than half of HIV-positive women are in their middle ages (35–49) and possibly have attained their optimum number of children; therefore, most prefer not to have more children. This contrasts HIV-negative women who are adolescents or youth at their peak fertility age.
This study presents a precise and reliable situation of modern contraceptive use among HIV-positive women and in the general population in Tanzania. Our findings are comparable with studies from sub-Saharan African countries where low modern contraceptive prevalence was observed. These studies are from Kenya (32%)[27], Northern Uganda 25% [28], and Ghana 18%, 15% and 21% in 2003, 2008 and 2014, respectively [19]. Some countries have successfully managed to scale up modern contraceptives to the general population, particularly HIV-positive women. Our estimate is lower than the comparative study conducted in Ethiopia, where modern contraceptive prevalence in HIV-positive women was 94% and 73% in HIV-negative women [29]. Other studies reported high modern contraceptive prevalence are from Uganda (69%)[30] and South Africa (89%)[31]. These observations may be linked to the comprehensive integration of sexual and reproductive health and ART/HIV services in these countries.[26–28]
One facility-based study in Kilimanjaro, Tanzania, reported a modern contraceptive prevalence of 54% among HIV-positive women attending HIV care and treatment clinics (CTCs). [33]The higher contraceptive prevalence observed at CTCs may be linked to selection bias because those attending CTCs may be a subset of health-conscious women or from high-performing facilities. This study is representative and population-based, therefore more reliable due to the robust survey design, which included a random selection of study areas and households from the general population in a multistage process. Consequently, this approach often results in better estimates than health facility-based surveys.
The differences in the distribution of preferred contraceptive methods may be associated with many factors, such as contraceptive availability, individual preferences, and perceived risks by providers and users. Concerning perceived risks, the National Guideline on Family Planning in Tanzania cautions providers when prescribing oral contraceptives and implants due to reported reduced contraceptive efficacy among HIV-positive women treated with some ARV. [12] High-risk monocomponent or fixed ARV dose combinations include efavirenz, nevirapine and ritonavir/ritonavir. The guideline also prohibits the prescription of IUDs to patients poorly responding to ARV and those with untreated chlamydia and/or gonorrhoea, which are very common in HIV-positive individuals. HIV-positive women encountering these limitations remain with the male condom as the only option.
Contraceptive choice limitations in the family planning guidelines for HIV-positive may have contributed to high injectables and male condom use. Injectables and male condoms (32% and 31%, respectively) were the most common methods of contraceptives among HIV-positive women. The order of preference is consistent with a similar study from Malawi, where injectables (20%) and male condoms (13%) were the most popular methods of contraception among HIV-positive women. [8] A comparable study from Tigray, Ethiopia shows a similar pattern, where injectables (71%) and male condoms (48%) were the most preferred contraception method among HIV-positive.[34] Facility-based study in Kilimanjaro among HIV-positive women shows injectables and male condoms are the most preferred methods, but male condoms were the most preferred (76%), followed by injectables (28%).[35] Similar observations have been reported in Uganda, where condoms were the most used method (61%)[30]. In HIV-negative women, this study shows injectables (39%) and implants (29%) were the most preferred method of contraception. A similar pattern was observed in the general population for injectables and male condoms, with an estimated contraceptive prevalence of 36% and 32%, respectively, in Tigray study. [36] An analysis of sexually active unmarried women in the general population in Tanzania shows injectables and male condoms were the most used methods of contraception (15% prevalence each). [37]
Study Limitations
The family planning and fertility modules of THIS 2016/17 survey collected data on a few variables, thus missing potential variables such as family planning knowledge, fertility intentions, male involvement, uptake of family planning counselling, and the sources of family planning information. The missing variables could have provided additional and valuable information for assessing the determinants of modern contraceptives among HIV-positive women. Morever, majority of HIV positive women (94%) were on ART, hence we can not make a definitive conclusion on weather being on ART was the only factor responsible for the observed difference in contraceptive use between women on ART and those not on ART.