Background
Family planning services can help women with HIV use birth control and prevent unwanted pregnancies. People with HIV are living longer due to better treatment. More HIV-positive women will want to choose whether and when to have a child.
Methods
We ran computer searches for studies of family planning (FP) programs for HIV-positive women until 2 August 2016. The services could be compared to a different program, usual care, or no counseling. Studies could also compare HIV-positive and HIV-negative women. We tried to find results adjusted for factors that affect the outcomes. Otherwise, we used unadjusted data. We assessed the research quality.
Results
We included three new studies for a total of 10. These studies from seven African countries had 16,116 participants. Three studies compared an enhanced FP program versus usual care, three looked at FP services combined with HIV care, and four studied HIV-positive versus HIV-negative women.
For four studies of good quality, the special program was related to birth control use or pregnancy. In Nigeria, sites combined FP and HIV services. Women with enhanced FP services used modern birth control more often than women with basic FP services. A study in Kenya compared FP combined with HIV care versus referral to a separate FP clinic. Women with combined services used more effective birth control more often than those referred elsewhere for FP. One study in Kenya, Namibia, and Tanzania tested an HIV prevention and FP program. Women with the special program in Tanzania used effective birth control more often than women who had usual care. Also, they were more likely to report condom use during the most recent sex. Overall, women with the prevention program were less likely to have had unprotected sex in the past two weeks. A study from Côte d'Ivoire combined HIV testing with FP services. Pregnancy rates were similar for HIV-positive and HIV-negative women, but HIV-positive women had fewer unwanted pregnancies.
Authors' conclusions
Studies since 2009 were better quality than those from the 1990s. Training on FP and counseling was more common, which could strengthen the FP services. Research was still limited on birth control counseling for HIV-positive women. Better counseling methods would help women choose and use a birth control method. The need is especially great in areas with few resources, such as HIV clinics.
The studies since 2009 focused on using modern or more effective methods of contraception. In those later reports, training on FP methods and counseling was more common, which may strengthen the intervention and improve the ability to meet clients' needs. The quality of evidence was moderate from the more recent studies and low for those from the 1990s.
Comparative research involving contraceptive counseling for HIV-positive women is limited. The FP field needs better ways to help women choose an appropriate contraceptive and continue using that method. Improved counseling methods are especially needed for limited resource settings, such as clinics focusing on people living with HIV.
Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling or education, can help women choose and use an appropriate contraceptive method.
We systematically reviewed studies of behavioral interventions for HIV-positive women intended to inform contraceptive choice, encourage contraceptive use, or promote adherence to a contraceptive regimen.
Until 2 August 2016, we searched MEDLINE, CENTRAL, Web of Science, POPLINE, ClinicalTrials.gov and ICTRP. For the initial review, we examined reference lists and unpublished project reports, and we contacted investigators in the field.
Studies evaluated a behavioral intervention for improving contraceptive use for family planning (FP). The comparison could have been another behavioral intervention, usual care, or no intervention. We also considered studies that compared HIV-positive versus HIV-negative women. We included non-randomized studies as well as randomized controlled trials (RCTs).
Primary outcomes were pregnancy and contraception use, e.g. uptake of a new method or improved use or continuation of current method. Secondary outcomes were knowledge of contraceptive effectiveness and attitude about contraception or a specific contraceptive method.
Two authors independently extracted the data. One entered the data into RevMan and a second verified accuracy. We evaluated RCTs according to recommended principles. For non-randomized studies, we examined the quality of evidence using the Newcastle-Ottawa Quality Assessment Scale. Given the need to control for confounding factors in non-randomized studies, we used adjusted estimates from the models when available. Where we did not have adjusted analyses, we calculated the odds ratio (OR) with 95% confidence interval (CI). Due to varied study designs and interventions, we did not conduct meta-analysis.
With three new reports, 10 studies from seven African countries met our eligibility criteria. Eight non-randomized studies included 8980 participants. Two cluster RCTs had 7136 participants across 36 sites. Three studies compared a special FP intervention versus usual care, three examined FP services integrated with HIV services, and four compared outcomes for HIV-positive and HIV-negative women.
In four studies with high or moderate quality evidence, the special intervention was associated with contraceptive use or pregnancy. A study from Nigeria compared enhanced versus basic FP services. All sites had integrated FP and HIV services. Women with enhanced services were more likely to use a modern contraceptive method versus women with basic services (OR 2.48, 95% CI 1.31 to 4.72). A cluster RCT conducted in Kenya compared integrated FP and HIV services versus standard referral to a separate FP clinic. Women with integrated services were more likely to use more effective contraception (adjusted OR 1.81, 95% CI 1.24 to 2.63). Another cluster RCT compared an HIV prevention and FP intervention versus usual care in Kenya, Namibia, and Tanzania. Women at the special intervention sites in Tanzania were more likely to use highly effective contraception (adjusted OR 2.25, 95% CI 1.24 to 4.10). They were less likely to report unprotected sex (no condom use) at last intercourse (adjusted OR 0.23, 95% CI 0.14 to 0.40). Across the three countries, women at the special intervention sites were less likely to report any unprotected sex in the past two weeks (adjusted OR 0.56, 95% CI 0.32 to 0.99). A study in Côte d'Ivoire integrated HIV and FP services. HIV-positive women had a lower incidence of undesired pregnancy, but not overall pregnancy, compared with HIV-negative women (1.07 versus 2.38; reported P = 0.023).