HI V status and fertility desires, HI V status and fertility - - PowerPoint PPT Presentation

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HI V status and fertility desires, HI V status and fertility - - PowerPoint PPT Presentation

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HI V status and fertility desires, HI V status and fertility desires, contraceptive use, and pregnancy rates in contraceptive use, and pregnancy rates in Rakai, Uganda Rakai, Uganda Fredrick Makumbi, PhD School of Public Health, Makerere

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HI V status and fertility desires, HI V status and fertility desires, contraceptive use, and pregnancy rates in contraceptive use, and pregnancy rates in Rakai, Uganda Rakai, Uganda

Fredrick Makumbi, PhD

School of Public Health, Makerere University, and Rakai Health Sciences Program A presentation to Wilson Center March 29th 2011 Washington DC, USA

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Background: Fertility in sub-Saharan Africa

  • Fertility in SSA is high and contraceptive use is low

Fertility in SSA is high and contraceptive use is low

  • Fertility in Uganda is among highest in SSA

Fertility in Uganda is among highest in SSA

– – TFR 6.7 TFR 6.7 – – Annual growth rates 3.4% Annual growth rates 3.4% – – ~ 50.8% of population < 15 years ~ 50.8% of population < 15 years (Uganda National Household Survey Report 2009/ 2010) – – Built Built-

  • in potential for population momentum

in potential for population momentum

  • Factors that maintain high fertility include fertility

Factors that maintain high fertility include fertility desires, unmet need for FP, and lack of male desires, unmet need for FP, and lack of male involvement involvement

  • Impact of the HIV/AIDS epidemic on fertility has been

Impact of the HIV/AIDS epidemic on fertility has been felt more at individual than at population level felt more at individual than at population level

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Background: Contraceptive use by HI V+ women

  • Knowledge of contraceptives is almost universal

Knowledge of contraceptives is almost universal… …

– – In Uganda, 98% of all women know at least one method In Uganda, 98% of all women know at least one method – – Modern method use is 18%, and there is increasing use of modern Modern method use is 18%, and there is increasing use of modern methods over time methods over time… … (

(UDHS 2006) )

  • …

…but contraceptive use is still low among HIV+ women but contraceptive use is still low among HIV+ women

– – 30% unmet need in a Kenyan Hospital setting 30% unmet need in a Kenyan Hospital setting (East Afr Med J. 2008 Apr;85(4):171-7.) – – 90% unmet need for highly effective FP in Kabarole, Uganda 90% unmet need for highly effective FP in Kabarole, Uganda (AI DS. 2009

Nov;23 Suppl 1:S37-45.)

  • Access to contraception is critical, particularly since HAART ca

Access to contraception is critical, particularly since HAART can n increase pregnancy rates in HIV+ women increase pregnancy rates in HIV+ women (

(PLoS Med 7(2): e1000229.

doi:10.1371/ journal.pmed.1000229)

)

  • Integrating FP services into HIV services could help address FP

Integrating FP services into HIV services could help address FP needs of both HIV needs of both HIV-

  • infected/uninfected

infected/uninfected (Reproductive Health: Integrating family

Reproductive Health: Integrating family planning and HIV services planning and HIV services http://www.africa http://www.africa-

  • health.com/articles/march_2010/FHI%20March%20final.pdf

health.com/articles/march_2010/FHI%20March%20final.pdf downloaded March downloaded March 20 2011) 20 2011)

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Objectives Objectives

  • Share findings on fertility preferences and

Share findings on fertility preferences and behaviors and contraceptive uptake in context of behaviors and contraceptive uptake in context of HIV infection and care in Rakai, Uganda HIV infection and care in Rakai, Uganda

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Rakai district, Rakai district, Uganda Uganda

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Rakai Community Cohort Study Rakai Community Cohort Study

  • Annual census and surveys of adults 15

Annual census and surveys of adults 15-

  • 49 in 50

49 in 50 communities since 1994 communities since 1994

  • 10,000

10,000-

  • 15,000 population

15,000 population

  • Interviews including use of contraceptives, fertility desires

Interviews including use of contraceptives, fertility desires and preference, and collection of blood and genital swab and preference, and collection of blood and genital swab samples samples

  • RCCS is the population

RCCS is the population-

  • core for multiple nested studies

core for multiple nested studies including clinical trials, molecular epidemiology, behavioral including clinical trials, molecular epidemiology, behavioral science science

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Health Education and Community Mobilization

Field teams

  • Collection of biological

samples for HI V

  • Field editing

questionnaires after data collection

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I n 1994 I n 1994-

  • 95, pregnancy prevalence and incidence rates

95, pregnancy prevalence and incidence rates were higher among HI V were higher among HI V-

  • than HI V+ women in Rakai

than HI V+ women in Rakai

Pregnancy prevalence rates: Combined : 19.3% HI V+ Positive 13.4% HI V-negative 21.4% Pregnancy incidence per 100 woman-yrs: HI V+ Positive 23.5 HI V – Negative 30.1 (p= 0.007)

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Between 2004 Between 2004-

  • 2008, pregnancy prevalence rose for

2008, pregnancy prevalence rose for HI V+ women on ART care in Rakai HI V+ women on ART care in Rakai

5 10 15 20

Pregnancy prevalence, %

Pre-ART initiation On ART

15-24 25-34 35-45 15-24 25-34 35-45

Age (years)

Pregnancy prevalence rates: Pre-ART , 7.2% ; On-ART, 10.1% ; p= 0.0315

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Age (years)

I ncidence Pregnancy : Pre-ART , 13.1 CI (10.14, 16.75); On-ART , 24.6 CI(18.1, 32.6) p= 0.0017

Pregnancy incidence and prevalence signifcantly increase while On-ART suggesting need for more attention to reproductive health needs of HI V+ individuals

10 20 30 40

I ncidence / 100 py Pre-ART initiation On ART

15-24 25-34 35-45 15-24 25-34 35-45

Between 2004 Between 2004-

  • 2008, pregnancy incidence rose for

2008, pregnancy incidence rose for HI V+ women on ART care in Rakai HI V+ women on ART care in Rakai

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I ncidence of pregnancy by partners fertility desires among HI V+ women seeking HI V care in Rakai, 2004-2008

Both want

10 20 30 40

Incidence/100py

Pre-ART On-ART

Both do not

Only male

Only female

Desire for a(nother) child

Both do not

Only male

Only female Both want

  • Male partner’s fertility desires play an important role in pregnancy rates
  • High pregnancy incidence even when both do not want indicates high levels
  • f unmet need for FP
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Need for FP among HI V+ and HI V- women who want to stop or postpone their next birth in Rakai, 2007/ 8

  • Need for FP among HI V+ women, married and unmarried, is high and

not unlike the levels among HI V- women.

Proportion NOT using FP, %

20 40 60 HI V-negative HI V+ positive

Un married

Married

Un married Married

Proportion NOT using FP

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Changes in proportions using a FP method in Rakai, 1994/ 5 and 2007/ 8

  • Use of FP has significantly increased, irrespective of HI V status
  • I ncrease is greater in the HI V+ relative to HI V-negative

10 20 30 40 50 1994/ 1995 2007/ 2008

HI V- Negative

HI V+

HI V- Negative

HI V+

Changes in proportion using any FP method Proportion using FP, %

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Contraceptive use among HI V+ women who want to stop Contraceptive use among HI V+ women who want to stop

  • r postpone their next birth, Rakai 2007/ 2008
  • r postpone their next birth, Rakai 2007/ 2008
  • Condom use increases with increasing level of HI V care services
  • Use of other modern methods decreases with increasing care among the married

20 40 60

Proportion using contractive, %

Unmarried Married

No care HI V care, No ART On-ART No care HI V care, No ART On-ART

Contraceptive use by marital status and HI V care

Condoms-only Other modern methods

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Other results Other results

Desire for large (6+ ) family size still an important

factor in fertility

VCT receipt was associated with higher use of

condoms

VCT without result discussion with partner was

associated with higher use of modern methods, but not condoms

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Summary of findings Summary of findings

Condom use is more common among unmarried

HIV+ women, but use of other modern contraceptives is more common among married women

Condom use among HIV-infected women increases

and protection by other modern contraceptives decreases with increasing level of HIV care

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Summary of findings, continued Summary of findings, continued

Unmet need for FP is still high, especially among

married women, irrespective of HIV-status

Use of FP has significantly increased over time,

irrespective of HIV status

Being in HIV care significantly increases use of FP,

especially condoms over other modern methods

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Recommendations

Strategies to address desire for high fertility need to

be developed and/or strengthened (especially male involvement)

There is need to strengthen FP services in HIV care

programs, with promotion of modern contraceptive methods, and with particular attention to women on ART

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Acknowledgements Acknowledgements

Rakai Health Sciences Management and Staff Rakai district leadership including community leaders Cohort study participants Rakai funders who have enabled continued research

activities

Bill and Melinda Gates Institute at Johns Hopkins

Bloomberg School of Public Health

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Thank you Thank you