Contraceptive Use and Desired Fertility Among HIV-infected Women in Rochester, NY

1. Contraceptive Use and Desired Fertility Among HIV-infected Women in Rochester, NY Susan E. Cohn, MD, MPH June 8, 2005

2. A Global View- 2004 39.4 Million Adults Living With HIV/AIDS Adult prevalence rate 15.0% – 36.0% 5.0% – 15.0% 1.0% – 5.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% not available

3. Adults and Children Estimated to Be Living With HIV/AIDS, End of 2004 Eastern Europe & Central Asia 1.4 million Western Europe 610 000 North America 1,000 000 East Asia & Pacific 1.1 million North Africa 540 000 South & South-East Asia7.1 million Caribbean 440000 sub-Saharan Africa 25.4 million Latin America 1.7 million Australia & New Zealand 35 000 Total: 39.4 million

4. Estimated number of Adults and Children newly infected With HIV during 2004 Eastern Europe & Central Asia 210,000 Western Europe 21,000 North America 44,000 East Asia & Pacific 290,000 North Africa 92,000 South & South-East Asia890,000 Caribbean 53,000 sub-Saharan Africa 3.1 million Latin America 240,000 Australia & New Zealand 5,000 Total: 4.9 million

5. Worldwide - HIV/AIDS in 2004 • 1.1% of 15-49 year olds are HIV positive • 4.9 million new HIV infections in 2004 • 14,000 a day • 50% are women, 50% 15-24 year olds • 3.1 million AIDS deaths in 2004 • > 90% are in low or middle income countries • Less than 10% of people in low or middle income countries who warrant therapy are receiving it • Worldwide 80% of adults acquire HIV heterosexuallyUNAIDS/WHO Global HIV/AIDS and STD Surveillance

6. AIDS in the USA-2003 • The proportion of AIDS cases in women increased from 7% in 1985 to 27% in 2003 • Among women with AIDS in 2003: Whites 15%, Black 68%, Hispanic 16%, <1% other • Rates among Hispanic and Black females were more than 6 and 25 times respectively the rate among White females

12. Background: Fertility Desires and Contraception Use • Few studies • Most involved limited populations of women, often in the postpartum period • Women interviewed before HAART and improved outcomes of HIV+ women in care

13. Background: Fertility Desires • 28-29% of HIV+ men and women desire children in the future (HCSUS interviews 1998) • Among those desiring children, 69% of women and 59% of men expect to have children in the future • Women’s desire for children is more affected by personal health status vs men’s Chen JL et al. Fam Plann Perspect 2001;33 (4):144-52, 165

14. Background: Fertility Desires • 322 HIV+ women in the South - 1998-99 • AA (88%), single (79%), between 17-48 yrs • 59% asymptomatic, 15% with AIDS • 81% had a child, 40% had been pregnant after becoming HIV+, 6% had an HIV+ child • 37% of those with children would like to have another baby; 21% were undecided Sowell RL et al. AIDS Care. 2002;14(2):181-191

15. Background: Fertility Desires • Increased motivation for child bearing, higher traditional gender role orientation, decreased HIV symptoms, greater avoidance coping, less perceived threat of HIV, and younger age were all associated with greater intent to get pregnant • Motivation for childbearing (OR 16.1, CI 7.95, 30.41) and traditional gender roles (OR 4.49, CI 1.44, 13.55) were significantly associated with greater intent to get pregnant • Women with HIV are similar to non-HIV infected women in what influences their desire to get pregnant Sowell RL et al. AIDS Care. 2002;14(2):181-191

16. Background: Contraceptive use • Retrospective study of inner-city, prenatal population of 83 HIV+ and 218 HIV- women interviewed 7/87-6/89 • HIV+ women more likely to undergo BTL 27% vs 15%, less likely to select oral contraceptives 34% vs 68%, both controlling for age, race, marital status, and parity • Most repeat pregnancies among HIV+ and HIV- women were unplanned (90% and 82% respectively) Lindsay MK, et al. Obstetrics & Gynecology 1995;85:675-9.

17. Background: Contraceptive use • 2040 HIV+ and 561 HIV- women reported sexual activity within 6 months (65% HIV+ W, 76% HIV-W) (WIHS baseline data) • Of women with HIV, 63% always used condoms vs 28% of HIV- women • Crack, cocaine, or IVDU was associated with inconsistent condom use independent of serostatus (27% HIV+ vs 35% HIV- women) • HIV+ women used condoms less consistently if on another contraceptive method than HIV- women (57% vs 67%) Wilson TE et al. AIDS;13(5):591-8, 1999

18. Background: Contraceptive use • In a Brazil study of 140 HIV+ women, 75% were sexually active after HIV diagnosis • 5 of 23 women with no children used hormonal contraceptives, 15 of 23 used condoms, and 3 of 23 used no contraceptive methods • 12.4% used no contraceptives as did 25% of HIV-partners despite knowing their partner’s HIV serostatus • Despite counseling, only 28% of sexually active women used a combined methods (condoms plus another contraceptive) Magalhaes J, et al. Contraception 2002;66:87-91.

19. Study Goals • To assess the use of contraception by HIV-positive women in care • To identify factors associated with contraceptive use • To assess the desires of HIV-infected women in care to have children in the future • To identify factors predicting desire for future fertility

20. Hypotheses • Most HIV-infected women will be sexually active • Hormonal contraceptive use and tubal ligation will be associated with lower condom use • Having an HIV-negative partner will be associated with higher condom use • Advanced HIV disease will be associated with lower desire for future childbearing

21. Methods • Cross-sectional study of 100 HIV+ women in care at SMH AIDS Center • Self-administered, written questionnaire on reproductive history and contraceptive use • Chart review for contraceptive methods including sterilization, ARV and HIV diagnoses including CD4 and HIV RNA levels • January through June 2004 • IRB approved • Participants were compensated $5 for their time

22. Inclusion criteria HIV-positive women Age 18-45 Exclusion criteria Incarcerated Pregnant Non-English speaking Subjects

23. Analysis • Descriptive statistics of study population • Bivariate analyses of demographic and HIV disease factors associated with contraceptive use and desire for future children • Logistic regression modeling of factors that predict desire for future children

24. Demographics

25. 71% Medicaid, 14% ADAP 43% Less than HS education 37% Employed 80% Acquired HIV by heterosexual contact 49% were single and never married 14% currently married Sociodemographics

26. 91% had had children 75% were sexually active with men 57% had only one partner in the past year Of those with ongoing sexual activity, 89% used condoms 60% had an HIV- partner 27% had an HIV+ partner Reproductive Characteristics

27. HIV Characteristics • An average of 9 years since HIV diagnosis • 53% had AIDS • Median CD4 432, (range 18-1348) • 51% with HIV RNA <1000 copies • 24% rated their health as fair to poor

28. Contraceptives and Sterilization

29. Contraception Ever Used Before and After HIV Diagnosis-Percent (N=100) Chi-squared or Fisher’s exact

30. Sterilization (N=100) • No significant association with disease stage (p=0.7) or with condom use (p=0.6)

31. Method N % Condoms 30 68% Abstinence 8 18% Female Condoms 5 11% OCPs 5 11% DMPA 5 11% IUD 1 2% NONE 3 7% Contraceptive Use in the Past 3 months N = 44

32. Condom use: 19% Never, 39% Always 97% said they use condoms to prevent their partner from getting HIV 57% used condoms to prevent pregnancy Of those not using condoms, 50% said their partner did not like to use condoms Factors Influencing Contraceptive Use: Condoms

33. Condom use was associated with known partner HIV status (p=0.035) Women with HIV-negative partners were more likely to use condoms (70% vs 60%) There was no association between hormonal contraception use and condom use There was no association between tubal ligation and condoms use Factors Influencing Contraceptive Use: Condoms

34. Contraceptive Methods for Subjects on Efavirenz, N=23 Method Percent (N) Sterile 78% (18) Condoms only 13% (3) Hormonal only 4% (1) Condoms and hormonal 4% (1)

35. Reproductive Plans and Sterilization • Had had children 91% (91/100) • Sterilized 56% (56/100) • Sexually active, not 93% (41/44) sterilized, using reversible contraception • Want future children 34% (33/98) • Sterilized but may want 21% (12/56)future children • Sterilized after HIV dx 25% (4/16)but may future children • Disease stage did not predict desire for future children

36. Predictors of Wanting Future Children

37. Study Limitations • Sample bias - Women were recruited at visits, thus sicker and more adherent patients more likely to be enrolled • Fewer Hispanic women and fewer IVDU enrolled vs. women in the AIDS center • Recall bias of subjects • Social stigma and bias of reported condom use • May not be generalizable to all HIV-positive women in US

38. Conclusions • HIV-positive women have normal reproductive histories • Many want to have future children, even if they have advanced disease • Tubal ligation may have been overused in this population; 21% of sterilized women said that they would like have children in the future • This “tubal regret” is higher than the 13% reported in the general population

39. Conclusions • Condom use, TL and abstinence rates all rose after diagnosis • Hormonal method use and TL were not associated with lower condom use • Having an HIV-negative partner was associated with higher condom use • HIV medication use and being non-White were the strongest predictors of wanting future children

40. Implications • Women with HIV are living longer, healthier lives and we need to counsel them on effective reversible methods of contraception • HIV providers should discuss with HIV+ women their thoughts about having children before starting HIV medications and at each visit, to avoid prescribing potentially teratogenic medications to someone who may become pregnant

41. Future Research • Hormonal contraception and ARV • Examine PK interactions between DMPA and Contraceptive patch and ARV • Hormonal contraception and genital virology & immunology • levonorgestrel IUD • Self-empowerment for women to increase condom use both for STDs and HIV prevention as well as for pregnancy prevention

42. Thank you! Kenneth J. Ryan Grant and WHIN for funding Thanks to Jennifer Heiser, Mary Ann Pugliese, Nancy Stanwood, and the AIDS Center staff and participants who helped contribute to the success of this study