The trajectory of the HIV epidemic has changed significantly over the past 2 decades globally with increased life expectancy among PLWHA [9]. Widespread access to safe and effective antiretrovirals [10] has enabled women to live full reproductive lives, and children who were born with HIV are reaching adolescence and adulthood. As people become healthier, the desire for sexual activities naturally increases [11]. It is critical to ensure that women living with HIV and AIDS are enabled to enjoy their adulthood fully, and against this background, ensure safer sexual practices with regards to acquiring other sexually transmitted infections, cross-infection with other HIV strains and prevention of unintended pregnancies. A key element of sustainable development number 3 is ensuring equitable access of reproductive health services across all populations [12]. Dual protection encompasses the use of protective barrier methods concurrently with another effective method of contraception and this should be the target for the cohort of women living with HIV/AIDS.
In this cross-sectional study we analysed the mix of methods used by sexually active women living with HIV/AIDS and compared the use to their HIV-negative counterparts. Overall, the contraceptive prevalence in this study was 60%. Though there are differences in the definition of contraceptive prevalence used by the ZNFPC, which reports contraceptive prevalence for married or in-union women only [2], and what we used in our study, where we included all sexually active women regardless of their marital/union status, the contraceptive prevalence rates are still comparable. The ZNFPC and UNFPA reported the prevalence of contraceptive use to be about 67% [13]. Our study population, randomly selected from the ZHDS for this study, was therefore representative of the population of Zimbabwean women. However, there is still a considerable unmet need in our study population and the general population of reproductive age Zimbabwean women, and public health stakeholders in family planning must devise strategies to continually improve contraceptive uptake and use.
The combined oral contraceptive pill has traditionally dominated the method mix in Zimbabwe [2]. Unfortunately, for the HIV positive woman, this may not be the best choice because of interaction with some antiretroviral medicines. Nevirapine and efavirenz, which were previously integral components of most antiretroviral regimens, which have hepatic metabolism, have been known to possibly reduce the efficacy of hormonal contraceptives [14]. Fortunately, there is currently a general switch to dolutegravir-containing regimens, which has no documented interactions with hormonal contraception. Progestin-only pills, which are commonly used by breastfeeding women, also interact significantly with anti-retrovirals and other medicines such as anti-tuberculous medicines. HIV/TB coinfection is significant in Zimbabwe [15], with a consequent risk of unintended pregnancies among women on ARVs, anti-TB medicines and some hormonal contraceptive method.
The discrepancy in the use of oral contraceptives was not accompanied by a rise in the use of the other methods such as the injectables, implants and intrauterine contraceptive devices. The use of long-acting reversible methods of contraception (LARC) was low in this study, and this is comparable to results from other studies. In one study, the use of LARC was reported by only 5.3% of women, and women who used LARC or an injectable were likely to be aged 18–29 years, and much lower in older age groups [16]. In that study, the high prevalence of unintended pregnancies, and the low use of LARC necessitated the need for strengthening integration of family planning and contraceptive awareness among women living with HIV. Innovative interventions are needed to realise maximum benefit from integration of HIV care and treatment services with family planning services [17], and must be an ongoing process.
Statistically significant differences were noted in the use of condoms, with a higher prevalence of use among the HIV-infected women (13% versus 3%, p = 0.001). Whilst it’s encouraging that those who have a positive HIV status have higher usage of condoms, which may reflect knowledge of HIV status, receipt of appropriate counselling messages or protecting their partners, the use of barrier methods is still very low in both groups. More needs to be done to promote the use of barrier methods, which are not only contraceptive, but also significantly reduce the risk of acquiring other sexually transmitted infections such as Neisseria gonorrhoeae, Chlamydia trachomatis and Human Papilloma Virus, all of which are quite prevalent in the population. Health education and health promotion messages aimed at improving the uptake of barrier methods are critical as public health aims at reducing the occurrence of new HIV infections to zero, but also to protect against other STIs which substantially increase the risk of other problems such as subfertility and cervical cancer.
This study corroborates that the use of implants and intrauterine contraceptive devices is very low both among the HIV-positive and HIV-negative women, with no statistically significant differences. These are tier 1 methods, highly protective against pregnancy and their protective efficacy is not user dependent. However, several factors serve as barriers against their uptake, including lack of knowledge, limited availability in resource-limited settings, and lack of appropriately trained and skilled manpower to administer these methods [18, 19]. Several fears, myths and misconceptions surround reduced uptake of long-acting reversible contraception (LARC), including fears of disappearing IUDs, weight changes, altered bleeding patterns and subfertility [20]. Though these studies were carried out among non-HIV positive populations, there are no reasons to believe that the same barriers do not apply to the HIV-positive cohorts. Unfortunately, these are the more reliable methods for women living with HIV. The copper IUCDs have no known interactions with antiretrovirals and other medicines commonly prescribed to this cohort of women.
Examining associations between contraceptive usage and HIV status revealed statistically significant differences in the use of oral contraceptive pills, with higher use among HIV negative women (OR 0.54, 95% CI 0.45–0.64. p = 0.001). There were also statistically significant differences in the use of condoms as highlighted earlier, with more HIV-positive women using condoms (OR 3.37, 95% CI 2.64–4.32, p = 0.001). Reasons for this difference need to be explored further to tailor-make public health interventions to promote dual contraception in the HIV-positive cohort, but also to reduce risky sexual behaviour in the HIV-negative cohort. Because this was a cross-sectional study, we cannot explain the differences, but in-depth qualitative studies would be useful for identifying the possible explanations to address them appropriately.