Determinants and Patterns of Contraceptive Use among Sexually Active Women Living with HIV in Ibadan, Nigeria

Background: Contraception is a strategy to meet the family planning goals of women living with human immunodeficiency virus (WLHIV) as well as to reduce the transmission of HIV. There is limited data from Nigeria, where HIV prevalent is the second-largest in the world. This study aimed to examine contraceptive use and identify factors influencing its use among sexually active WLHIV in Ibadan, Nigeria. Methods: A facility-based cross-sectional study was conducted among 443 sexually active WLHIV across three HIV treatment centers in Ibadan, Oyo State. The inclusion criteria were WLHIV, aged 18–49 years, who asserted being fecund and sexually active. An adopted questionnaire was used to collect data, and the data was analyzedusing the Statistical Package for Social Sciences (SPSS) Windows version 25. Statistical significance was set at p < 0.05. Results: Among sexually active WLHIV (n = 443), 73.1% used contraceptives, with 26.9% having unmet needs. The results revealed a significant association between employment status and the use of contraceptives (AOR = 2.150; 95% CI 1.279–3.612 p=0.004); accessibility to contraceptive methods and the use of contraceptives (AOR = 21.483; 95% CI 7.279–63.402 p=0.00). Also, a significant association was found between payment for service and contraceptive use (AOR = 14.343; 95% CI 2.705–76.051; p = 0.003). Previous reactions towards contraceptive use were also significantly associated with contraceptive use (AOR = 14.343; 95% CI 2.705–76.051 p = 0.003). The dual contraceptives usage rate was 30.7%. Conclusions: Although contraceptive use among sexually active WLHIV was high, the study highlighted the need for increased adoption of dual contraceptive methods to mitigate the risk of unintended pregnancy and HIV re-infection among this population. It emphasized the importance of continuous sensitization and counseling services healthcare providers provide to promote contraceptive use among WLHIV.


INTRODUCTION
Globally, there are about 37.7 million Human Immunode ciency Virus (HIV)-positive individuals worldwide, of which 20.2 million are women living with HIV.[1,2] It has been determined that Sub-Saharan Africa is the area most severely affected by the HIV epidemic, accounting for more than twothirds of all HIV infections worldwide.Nigeria has the second-largest HIV epidemic in the world and the region's highest incidence of new infections.In Nigeria, 1.7 million people lived with HIV (PLHIV) in 2020.[3] Women can make independent choices about having children and having sex, regardless of their HIV status.Women living with HIV (WLHIV) must be informed, given the freedom to choose a safe, effective method of contraception, and provided with it at nearby health centers.[4] Because it prevents unplanned pregnancies, contraception may also be essential for preventing Mother-to-Child Transmission of HIV.[5] Strengthening contraceptive programs is therefore essential to lower the high incidence of unintended pregnancies, which could contribute to the elimination of HIV/AIDS outbreaks by 2030 (Sustainable Development Goal 3.3).[6,7] There appears to be a substantial unmet need for contraception among WLHIV and contraceptive failure due to the high incidence of unwanted pregnancy and abortion.[8]Nigeria accounts for 70% of sexually active WLHIV, 5.5 million WLHIV births annually, and 15% of the world's low contraceptive uptake.[9] Furthermore, prior research found that Nigerian WLHIV had a high level of awareness about contraception, but that knowledge did not match their use of contraceptives, which was linked to a high proportion of unwanted pregnancies.[10] Women who are fecund, sexually active, and who report not wanting any more children or wishing to delay the next child are considered to have unmet needs, according to the WHO.[11] Because ART has increased the overall survival rate of PLHIV, WLHIV must have de ned reproductive life plans that include accessible access to contraception.Most of the research that has been done on contraceptive use among WLHIV has focused on married women.[12] Because of this, sexual activity among sexually active unmarried women puts them at a higher risk of having an unexpected child because of the idea that sex can only take place within the setting of a married relationship.Therefore, there is a lack of reproductive plans for these women through health services.[13][14][15] Although the WHO has recommended that WLHIV have the right to choose any method of contraception, similar to HIV-negative women, the choice of contraception in the presence of HIV appears to be more complicated because WLHIV is required to strike a balance between the prevention of unintended pregnancy and HIV transmission.[16,17] Sexually active WLHIV can also plan their reproductive lives to avoid unwanted pregnancies and enjoy parenthood like their counterparts who are not living with HIV.
Hence, this study aims to identify key predictors of contraceptive use among sexually active WLHIV in Ibadan, Oyo State, Nigeria.

Design Overview
The research employed a facility-based cross-sectional survey approach.In a cross-sectional survey, researchers observe and collect data from participants simultaneously rather than over a prolonged period.This study design is bene cial for understanding the prevalence of a phenomenon, condition, or opinion at a given moment.[18] Target Population The study speci cally focused on sexually active women living with WLHIV.By targeting this particular group, the research aimed to gain insights relevant to their experiences, challenges, and needs.

Geographical Setting
The study was conducted in Ibadan, Oyo State, Nigeria.Oyo State, located in the southwestern part of Nigeria, is one of the country's signi cant states, with a rich cultural heritage and diverse population.Understanding the experiences of WLHIV in this region could provide insights that might re ect broader trends within the state or even the country, given its diverse demographic makeup.

Facility Details
Three prominent HIV treatment centers in Oyo State were chosen as the study sites:

Study Timeline
This study's data collection and observations were carried out over three months, from September to November 2022.This timeframe was chosen to ensure comprehensive data collection while minimizing seasonal or temporal biases that might affect the participants' responses.

Study population and sampling
Purposive Sampling for Facilities A purposive sampling technique was utilized for this study.Purposive sampling is a non-probabilistic method where researchers select particular groups or individuals for their speci c qualities or characteristics.[19] In this case, the health facilities were chosen based on antiretroviral therapy (ART) treatment availability.Not all health facilities offer ART treatment; hence, selecting those that speci cally provide this service was vital to ensure the study's participants were relevant to the research objectives.

Random Selection of Participants
Once the facilities were determined, the actual participants for the study were chosen through a random sampling process within each facility.This method ensures that each eligible participant in the selected health facilities has an equal chance of being chosen for the study, minimizing biases and ensuring the results represent the target population within those facilities.[20] Inclusion Criteria Participants were included in the study based on the following set of criteria: 1.They identi ed as WLHIV.
2. They were aged between 18 and 49 years, ensuring the study focused on the reproductive age group.
3. They had been sexually active within the last six months.
This criterion was crucial to understanding the current sexual behaviors and practices among WLHIV.

Study Flowchart and Numbers
A comprehensive owchart was designed to map out the participant selection process.Initially, 750 WLHIV from the selected facilities were approached and interviewed.However, after applying the inclusion criteria, particularly the requirement of recent sexual activity, the nal sample size was narrowed down.Out of the initial 750 participants, 443 sexually active WLHIV were found to meet all the study's criteria and were subsequently analyzed in-depth.
Insert "Figure 1: Flow Chart Illustrating the Eligibility Process to Obtain The Final Sample For Analysis of Sexually Active WLHIV"

Data Collection
Data was collected using adapted questionnaires from a previous study on contraceptive use among sexually active WLHIV.[17] The questionnaire was divided into three sections: Socio-Demography Data Questionnaire among sexually active WLHIV, Contraceptive Use Questionnaire among sexually active WLHIV, and Perceived factors in uencing Contraceptive Use Questionnaire among sexually active WLHIV.
Before the main study, the adapted questionnaire was pretested on a representative sample, feedback on clarity and relevance was collected, and statistical analyses, including Cronbach's Alpha, a rmed their internal solid consistency (α = 0.85) and validity, ensuring their suitability for the research objectives.[21] The selected participants were those who voluntarily consented to participate.All research assistants were trained before the commencement of the study on the research tools, interviewing skills, data management, and clari cations of ethical issues in research.The research assistants administered the questionnaires in English or the local language to participants who could neither read nor write.The questionnaires were administered privately, and clari cation and assistance were provided where necessary.The interviews took approximately 20 minutes to complete.

Statistical Analysis
The data gathered from the comprehensive questionnaires was diligently processed and meticulously analyzed utilizing the Statistical Package for Social Science (SPSS) version 25.SPSS is a widely recognized and powerful software for handling and analyzing statistical data, particularly in social sciences research.Variables in the dataset were assessed to determine if they were normally distributed or not to determine the appropriate statistical analysis to be used.Mean was used to describe the customarily distributed variables, while the median was used for the non-normally distributed variables.Linear regression was used to assess the statistical association between variables that had categorized outcomes more than 3.
Meanwhile, logistic regression assessed the statistical association between selected variables and variables with dichotomized outputs such as contraceptive use: Yes/No, True/False.The adjusted regression models included covariates such as age, education level, marital status, income level, and others.The strength of the association was assessed by setting a signi cance level at p-value < 0.05.

Ethical Considerations
The Health Department of Planning Research & Statistics Division, Oyo State Ministry of Health, provided the Ethics Approval for this study (AD 13/479/ 44542A).O cial permission was obtained from hospitals included in this study.The verbal/written consent procedure was conducted in a separate and private room, administered by trained data collectors.The study participants were assured that their involvement was entirely voluntary, and they retained the right to decline participation or revoke their consent at any juncture.
Signi cantly, it was stressed that their participation would not impact the medical care they received.
Participants were also apprised that the survey might entail sensitive or personal inquiries related to reproductive health concerns, which could be uncomfortable or distressing.Also, participants were explicitly informed that they were under no obligation to answer any question that they found uncomfortable and had the liberty to withdraw from the study or choose not to respond to speci c questions at any point.In cases where participants required emotional support, female nurses were available to offer psychological assistance.All collected data were transformed into an anonymized format and stored on laptops protected by passwords throughout the data collection.Furthermore, the data was stored on secure, password-protected computers to ensure con dentiality and security.).The study results show that women with tertiary or secondary education also showed differences in contraceptive use when compared to those with primary education, though these results were not statistically signi cant.

Socio-demographic Characteristics of Participants
In terms of marital status, single women had a higher likelihood of contraceptive use than divorced, widowed, or married women; however, this difference did not attain statistical signi cance.Separated women, on the other hand, were more likely to use contraceptives than single women, but again, this difference was not statistically signi cant (AOR: 1.799, 95% CI: 0.184-17.619,p=0.614).Employment emerged as a signi cant factor: employed women were more inclined to use contraceptives than their unemployed counterparts (AOR: 2.150, 95% CI: 1.279-3.612,p=0.004).
Regarding the type of partner, women with steady partners were less likely to use contraceptives than those married, with the difference nearing statistical signi cance (AOR: 0.102, 95% CI: 0.022-0.485,p=0.067).Yet, women with casual or no partners showed reduced contraceptive use compared to married women, without a signi cant difference.Notably, the source of contraceptives was in uential: women obtaining contraceptives outside the ART center demonstrated a signi cantly higher tendency to use them compared to those who did not (AOR: 21.483, 95% CI: 7.279-63.402,p=0.00).
Distance to health facilities also in uenced contraceptive use, with an increase in usage as the distance from these facilities grew.Speci cally, the distance between 2 and 3 kilometers from the health facilities was signi cant compared to the reference (AOR: 4.021, 95% CI: 1.343-12.036,p=0.020).Additionally, payment for services was a determinant: women paying for services showed a signi cantly higher likelihood of using contraceptives (AOR: 14.343, 95% CI: 2.705-76.051,p=0.020).Lastly, concerning adverse reactions to contraceptives, the odds ratio indicated a diminished likelihood of experiencing an adverse reaction (AOR: 0.006, 95% CI: 0.002-0.20),suggesting that women not reporting adverse reactions had signi cantly lower odds of having them compared to the reference group.(See Table 3)

DISCUSSION
The study underscored the signi cant use of contraceptives among sexually active WLHIV in Ibadan, Nigeria, mirroring the contraceptive adoption rates seen in Ethiopia, where 75% of sexually active WLHIV used contraceptives while the remaining 25% faced unmet contraceptive requirements.[17,22,23] This utilization of contraceptives plays a fundamental role in advancing family planning goals and reinforcing the Prevention of Mother-To-Child Transmission programs.[24] Yet, the contrasting ndings from Oyo State, Nigeria, remind us that awareness does not always lead to action.Even with high contraceptive knowledge levels among WLHIV, usage rates remained disappointingly low [10]; male condoms were most popular, trailed by pills and female condoms.
Conversely, less conventional methods like male and female sterilization and herbal mixtures were minimally favored.Compared to data from Togo, these rates were marginally lower.[25] Although dual contraceptive methods could effectively prevent unwanted pregnancies and sexually transmitted infections (STIs), their adoption was overshadowed by the preference for single methods.
[26] Several factors are pivotal in determining contraceptive choices.[27][28][29] Employment status stood out, corroborated by Banten Province, Indonesia's ndings, which identi ed employment as a critical in uencer.[30] Similarly, the absence of side effects encouraged continuity in contraceptive use, emphasizing the value of a smooth experience.
Contrastingly, the necessity of payments acted as a deterrent, with a study from Uganda linking payment barriers to reduced contraceptive use.
[28] Nevertheless, the challenges faced by WLHIV are multi-layered.Sociocultural dynamics heavily in uence contraceptive choices.[31] In many African settings, reproductive choices are often determined more by a woman's partner than by herself.Moreover, the stigma attached to HIV often discourages WLHIV from availing contraceptive services, particularly if healthcare professionals hold biased views.[31][32][33][34] The types of available contraceptives also matter.The dominant use of male condoms, while indicative of their dual protective nature against STIs and pregnancies, also shows a limitation in contraceptive choices.There is an evident need for long-acting methods like IUDs and implants, offering women greater autonomy, but their accessibility is often constrained by availability or cost.[35][36][37] The role of healthcare infrastructure is undeniable.The inconsistency in contraceptive stock can discourage WLHIV from relying on speci c methods, prompting them to settle for less preferred options.Integrating HIV care with contraceptive services might present a more consistent and comprehensive solution.[10] Comprehensive counseling provides essential information about contraceptive options, side effects, and effectiveness and can signi cantly guide WLHIV in making informed choices.This approach can demystify misconceptions and align contraceptive choices with individual reproductive and health goals.
[38, 39] Lastly, policy frameworks are pivotal.For effective contraceptive adoption among WLHIV, governments, and health bodies must craft policies prioritizing their unique challenges, encompassing contraceptive procurement, training of healthcare professionals, and robust monitoring mechanisms.In essence, while global data paints an overarching picture, addressing the contraceptive needs of WLHIV requires a deeper understanding of the intricate blend of personal, sociocultural, and structural factors.Only a holistic approach, cognizant of these intricacies, can genuinely champion the reproductive rights of every woman.
Self-reported data were used, which may be affected by social desirability and recall bias.The study only focused on women living with HIV and did not include men living with HIV, which limits the understanding of the contraceptive needs of male partners of women living with HIV.The study did not explore the impact of cultural and religious beliefs on contraceptive use, which could signi cantly in uence contraceptive use among this population.The study's strengths include a large representative sample of the three facilities and participants, including WLHIV, which was possible due to the nature of the facilities that participated in the study.
In evaluating the reproductive health choices of WLHIV, our study traverses a landscape underscored by the United Nations' Sustainable Development Goals (SDGs).[40] The signi cance we attribute to contraceptives for enhancing overall health and the crucial PMTCT resonates deeply with the ethos of SDG 3: Good Health and Well-being.[41] Delving into the sociocultural dynamics impacting WLHIV's reproductive decisions and their multifaceted challenges, our ndings mirror SDG 5: Gender Equality [42], which brings to the forefront the pressing narratives of SDG 10, highlighting the stark inequalities faced by WLHIV compared to the broader population.[41,43] Furthermore, our proposition for integrated and cooperative policy frameworks, tailored by governments and health bodies alike, echoes the collaborative spirit of SDG 17: Partnerships for the Goals.[43,44] Through the lens of these SDGs, our study ampli es the need for an all-encompassing approach to uphold and advocate for the reproductive rights of WLHIV genuinely

CONCLUSION
This study provides evidence that shows high levels of contraceptive use among sexually active WLHIV.However, the study identi ed the need for greater uptake of dual contraceptive methods to reduce the risk of unwanted pregnancy and HIV re-infection among WLHIV.The study also highlighted various factors, such as employment status, access to contraceptive methods, payment for service, and previous experience with contraceptive use, that in uence the use of contraceptives among this population.These

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Figure 1 Flow
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Table 2
presents data on the contraceptive utilization patterns among the participants.Out of the participants, 30.7% (N=136) reported using dual contraceptives.Meanwhile, 42.4% (N=188) indicated that they use a single contraceptive method.Notably, 26.9% (N=119) of the participants mentioned that they do not use any contraceptives at all.

Table 2 :
Level of Dual Contraceptive Utilization Regarding religion, while women identifying with Islam showed a reduced likelihood of contraceptive use compared to their Christian counterparts, this difference was not statistically signi cant (Adjusted Odd Ratio (AOR): 0.461, 95% CI: 0.176-1.213,p=0.117).Educational background played a role, with women without formal education being less inclined to use contraceptives compared to those with primary education (AOR: 0.518, 95% CI: 0.162-1.651,p=0.266

Table 3 :
Factors Affecting the Use of Contraceptives among Sexually Active Women Living with HIV