Dual Contraception Method Use and Determinant Factors Among HIV-positive Women of Reproductive age in Hawassa, Sidama, Ethiopia, An institutional based Cross- sectional Study

doi:10.21203/rs.3.rs-5020456/v1

Background

The use of dual contraception method (DCM) is recommended as an effective method to prevent Human Immunodeficiency Virus (HIV) transmission and the adverse consequences of pregnancy in people living with HIV infection. In developing countries like Ethiopia contraception use is subjected to sociocultural, knowledge and accessibility related factors that influence consumption. Accordingly, this study aims to explore the magnitude of DCM use and factors related to consumption in HIV positive women of reproductive age.

Methods

An institutional-based cross-sectional study was conducted in Hawassa University comprehensive Hospital, located in Hawassa city, Ethiopia. The study used systematic sampling technique to select 268 consenting participants. Data were collected using semi-structured questionnaire via face-to-face interview. Descriptive statistics were used to present background information and a hierarchical binary logistic regression was used to investigate DCM use predictive factors.

Results

The magnitude of DCM use was 30% (95% CI; 24.0–35.0). After controlling for potential confounding variables women aged 15–36 years, (AOR = 8.65, 95% CI: 2.60, 28.75) and 37–40 years, (AOR = 6.25, 95% CI, 2.08, 18.82), women with no fertility desire (AOR = 8.34, 95% CI: 3.95, 17.61), women who have open discussions with their partners (AOR = 5.71, 95% CI: 2.15, 15.11), and women with knowledge of CD4 count (AOR = 2.94, 95% CI: 1.35, 6.38) were found to have higher likelihood of DCM use.

Conclusions

The magnitude of DCM use among reproductive age HIV positive women was unsatisfactory. This provided an enormous window for counseling and reproductive health promotion measures. Interventional studies and strengthening of ART and family planning services must be customized to target the major social, cultural and knowledge barriers identified in this study to enhance the practice of DCM use.

Dual Contraceptive Method

Contraception

HIV/AIDS

Pregnancy desire

Hawassa

Ethiopia

Dual contraception method use (DCM) is the use of a barrier contraceptive (i.e., condoms) plus another effective family planning (FP) method that can prevent pregnancy (e.g., sterilization, hormonal methods, intrauterine devices, hormonal pills). This method is recommended by the World Health Organization (WHO) for people living with Human Immuno-Deficiency Virus (PLHIV) (1).

The human immunodeficiency virus/acute immunodeficiency syndrome (HIV/AIDS) continues to have disastrous economic, social, and physical impacts on individuals, nations, and the global community to the present day (2). Globally, more than 2 million HIV-positive women become pregnant every year, which is a consequence of inadequate contraceptive use and risky sex behaviors. Out of these, 600,000 deaths are due to pregnancy-related complications (3). Studies found that mother-to-child transmission (MTCT) of HIV due to unintended pregnancies accounted for 21.3% of new pediatric HIV infections, 90% of which were from Sub-Saharan Africa (2,3)

Several studies have evaluated the prevalence of DCM use worldwide. The prevalence of DCM in Africa ranges from 17% to 35.5% according to literature (4–11). The knowledge and practice of DCM use by people with HIV/AIDS (PLHIV) in many developing countries, including Ethiopia, is unsatisfactory. A few systematic reviews and meta-analyses conducted in Ethiopia reported pooled prevalences of DCM use of 27.7% and 26.1% (12,13). Studies conducted in different regions of Ethiopia. For example, DCM use in Gondar (13.2%), Mekelle (15.7-45.2%), Borena (19.4%), Keffa (19.8%), Wolayta (28.6%), Fitche (32.0%), and Bahir-Dar (64.2%) showed significant variability, ranging from low to moderate consumption (14–21).

Determining the magnitude of DCM use or nonuse and factors that favor or hinder utilization among women with HIV is valuable information that can reflect the existing reproductive health-related knowledge, quality of care, and effectiveness of counseling services provided by ART clinics, as well as sociocultural influencers of women’s behavior that need to be considered.

Hence, studies have tried to investigate factors associated with DCM use. Accordingly, sociodemographic factors such as age, marital status, place of residence, and educational and employment status were found to differentially influence the use of DCM (7,12,14–17,19,22,23). In addition, increasing parity, having no fertility desire, disclosure of serostatus, open discussion with partners about contraception use, higher CD4 count, and access to counseling services in ART clinics were among the sexual, reproductive, and HIV-related factors associated with DCM use (15,18,20–25).

The literature is lacking data on the magnitude, accessibility, and availability of contraception use among HIV-positive reproductive-age women in the Sidama region, except for a study conducted in Yirgalem Hospital in 2014 that reported that the level of modern contraception use among men and women PLHIV was 57.7% (26). Therefore, this study attempted to fill the gap in knowledge by describing the preferences for contraception use and the prevalence and predictors of DCM use among HIV-positive reproductive-age women at Hawassa University Comprehensive Specialized Hospital (HUCSH) ART clinics, which is the largest tertiary hospital in the region and represents a catchment area of the entire region and surrounding areas in southern Ethiopia.

Study Design and Setting

An institutional-based cross-sectional study was conducted to assess the magnitude of DCM use and to explore factors that predict its use among HIV-positive reproductive-age women attending the ART clinic at Hawassa University Comprehensive Specialized Hospital (HUCSH) in Hawassa, Ethiopia. This study was conducted from June to July 2022.

The study was conducted at HUCSH, which is located in Hawassa, Ethiopia. The hospital has a catchment area of 18 million people. The ART clinic provides regular follow-up, care, and counseling to 2800 patients diagnosed with HIV. Among them, 1,575 HIV-positive women of reproductive age were regularly followed up. In addition, the ART clinic collaborates with family planning services to address reproductive health issues, including the prevention of MTCT.

Study Participants

The study recruited voluntary and consenting participants from the source population, which included all HIV-positive women of reproductive age who were regularly followed up at the HUCSH ART clinic. The study excluded HIV-positive women who were pregnant during the study period.

The single population proportion formula was used to estimate the sample size using the proportion of DCM use drawn from a previous study conducted in Gebretsadik Shawo Hospital in Keffa, Ethiopia, which reported a DCM use rate of 19.8% (19). After accounting for a 10% non-response rate, the final sample size was determined to be 268. Participants were selected using a systematic sampling technique after computing the value of k as 6 by taking the number of source population as the denominator.

Study Variables

The primary objective of this study was to assess the prevalence of DCM use among HIV-positive women of reproductive age (15-49 years old). In this study, DCM use was defined as the use of a barrier contraception along with another family planning method that can reduce the transmission of STIs/HIV and prevent pregnancy, within one month prior to the study period. DCM use was the dependent variable for which exploratory analysis was conducted to determine factors that predicted its use (14,22).

The explanatory variables were classified into three main classes based on previous studies. Sociodemographic characteristics include age (categorized into three equal proportions), marital status (married and unmarried which includes previously married, never married or widowed women), locality (urban versus rural), level of education, family income (categorized into three proportional parts), and religion (includes Muslims, orthodox and non-orthodox Christians, the latter included protestant and catholic Christians). Sexual and reproductive factors were comprised of parity, pregnancy or childbirth after HIV diagnosis, children’s HIV serostatus, history of abortion, stillbirth, or early neonatal death (END), self or partner’s desire to have children, and number of sexual partners defined as either single or multiple, where multiple in this study implies concurrent relations with more than one partner. The last category, clinical and HIV-related factors, includes the duration of HIV infection and treatment, knowledge of CD4 count, previous history of and treatment for STIs, sero-discordant status defined as a partner with negative serostatus, open discussion with partner regarding family planning, counseling by ART providers about DCM use, and partner’s involvement in counseling.

Data collection method

Prior to data collection, ethical clearance was obtained from the Institutional Review Board of Hawassa University College of Medicine and Health Sciences. A formal letter of approval was obtained from the college’s ethical review committee. Data were collected using semi-structured and interviewer administered questionnaire. Due to the private nature of the survey, the significance of the study was clearly explained, and informed consent was obtained from each participant. Data were collected via face-to-face interviews with nurses working in the ART clinic. Obtained data had no subject identifiers, data protection, and confidentiality were assured throughout the study.

Statistical Analysis

Data were entered and analyzed using the Statistical Software for Social Sciences (SPSS) Version 26. Descriptive statistics were used to describe dependent and independent variables. Categorical variables are presented as frequencies and percentages, whereas continuous variables are presented as median and interquartile range. Crosstabulation was used to describe the magnitude of DCM use according to each category of predictive variables.

A stepwise multivariate binary logistic regression was performed to explore the association between DCM use and explanatory variables. An unadjusted model was used to identify associations with p-values of 0.25 or less. In the second model, these variables were adjusted for covariates found within the class of explanatory factors (i.e. SDC, sexual and reproductive factors and clinical factors). The final model was constructed to adjust for strong confounders across the three classes of factors. Variables associated with DCM use with a p value of less than 0.05 in the second model were included in the final model. Variables dependent on the women’s relationship status, such as Partner’s desire to have children, having multiple sexual partners, sero-discordance, open discussion with partner, and partner’s involvement in ART counseling, were analyzed for the subgroup of women who indicated to be in a relationship (N = 166) during the study period.

Results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Presented results were based on a significance-level α = 0.05. Furthermore, decisions to exclude variables that introduced poor model fit and imprecision were made while maintaining the logical framework. Model fit was assessed using the Hosmer–Lemeshow test, and the positive predictive value of the model was also considered.

Background Characteristics of Study Participants

The study included 268 eligible and consenting participants, yielding a response rate of 100%. The median age of the participants was 38.0 (IQR 35.0-40.0). Nearly half, 146 (54.5%) were married; the majority, 230 (85.8%) reside in urban areas. The number of participants who completed secondary education was 94 (35.1%), whereas only 42 (15.7%) completed higher education. The median income for women in Ethiopian birr was 3000.00 (IQR 1500.00-5000.00).

All participants were interviewed about their sexual and reproductive health-related history. The study revealed that 166 (61.9%) women were in ongoing relationships, and 25 (15.1%) claimed to have multiple sexual partners; 84 (31.3%) women had more than three live children, 152 (56.7%) had a history of pregnancy or childbirth after HIV diagnosis, and 86 (32.1%) had experienced either abortion, stillbirth, or END. Among the participants, 119 (44.4%) indicated that they had no desire to have children.

Regarding information related to clinical factors, the median duration of HIV infection in years was 12 (IQR 8 – 14). Of all the respondents, 74 (26.9%) knew their CD4 count, and 26 (35.2%) reported a CD4 count less than 500. Of the women, 66 (24.6%) had STI history, and 204 (76.1%) reported having been counseled about DCM use. Within the subgroup of women who reported to be in a relationship, 30 (18.0%) were sero-discordant, 120 (72.3%) had an open discussion with their partners regarding contraception use, and 44 (33.4%) said their partners were involved in one of the counseling sessions. (Table 1).

Prevalence of DCM use

The magnitude of DCM use among HIV-positive reproductive-age women was 80 (30%), (95% CI; 24.0 - 35.0). The number of study participants who reported using any contraceptive method after HIV diagnosis was 192 (71.6%). Condom use was reported by 140 (52.2%) participants after HIV diagnosis. Implants (34.5%) and injectables (29.1%) were the most common additional contraception methods used with condoms. These women indicated that they received FP services at ART clinics (33.0%) and FP centers (19.1%), whereas the rest did not specify the location.

Factors associated with DCM use

In the unadjusted binary logistic regression model, young age (<40 years) and marriage were associated with DCM use. In addition, women who have more than three children, have a history of pregnancy or childbirth after HIV diagnosis, and who had no desire to have children have increased use of DCM.

After controlling for potential confounding variables within the class of sexual and reproductive factors in model 2, women who had pregnancy or childbirth after HIV diagnosis had twice-greater odds and those who had no desire to have children had approximately six times increased odds of DCM use,, (AOR = 2.46, 95% CI: 1.21, 4.82) and (AOR = 5.95, 95% CI: 2.84, 2.49), respectively.

Similarly, among clinical and HIV-related factors, duration of HIV infection, sero-discordance, and open discussions with partners about contraception were significantly associated with DCM use in the unadjusted model. Further adjustment within the class of factors showed that knowledge of CD4 count was associated with increased DCM use (AOR = 2.35, 95% CI: 1.22, 4.53). Similarly, duration of HIV infection (AOR =1.10, 95% CI: 1.00, 1.20) and open discussion with partners about contraception (AOR = 3.50, 95% CI: 1.49, 8.20) have statistically significant association with DCM use.

A final regression model was constructed to account for significant confounding among SDCs, sexual and reproductive factors, and clinical factors. The model included age, marital status, no desire to have children, pregnancy/childbirth after HIV diagnosis, open discussions with partners, and knowledge of CD4 count. This model explained 45.4% of the variability in DCM use and had a PPV of 71.2%. According to this model, women younger than 40 years (15-36 years, (AOR = 8.65, 95% CI: 2.60, 28.75) and 37-40 years, (AOR = 6.25, 95% CI, 2.08, 18.82), women with no desire to have children (AOR = 8.34, 95% CI: 3.95, 17.61), women who have open discussions with their partners (AOR = 5.71, 95% CI: 2.15, 15.11), and those with knowledge of their CD4 count (AOR = 2.94, 95% CI: 1.35, 6.38) have an increased frequency of DCM use. Table 2 details the results of all factors associated with DCM use in the logistic regression models.

In this study, 268 HIV-positive reproductive-age women were included, and the prevalence of DCM use was low. This result is consistent with a recent meta-analysis reporting a pooled prevalence of 27.7% (12). Additionally, studies conducted in Thailand (29.6%), southeast Nigeria (27%.), Malawi (26.5%), Gondar-Ethiopia (28.8%), Fitche (32.0%), and Wolaita zone-Ethiopia (28.6%) have reported comparable results (5, 9, 16, 20, 21, 24).

However, studies from other countries and regions in Ethiopia have reported much lower prevalence, contrary to the present study. For instance, studies in India (23.0%), Zambia (17.7%), and Togo (16.9%) from Africa, as well as studies conducted in Mekelle (15.7%), Gonder University (13.2%), and Keffa (19.8%), all revealed lower percentages of DCM use (7, 11, 18, 19, 22, 23). This marked disparity can be mainly explained by temporal differences, in which older studies reported lower rates (11, 23). The increasing trend in DCM use over the years might indicate the effect of interventions that addressed underutilization and improved ART follow-up in recent years. Another possible explanation for this disparity might be sociodemographic variability and different study designs and data collection techniques (16, 23).

The prevalence of DCM use in this study was lower than that in other countries such as the USA (39%), Kenya (38.5%), and in Tigra region, Ethiopia (45.2%) (17, 25, 27). These studies show that some countries have managed to improve DCM use years in advance compared to several other regions. It is evident that recognition of the effectiveness of DCM use and the presence of controlled studies may have encouraged health promotion services targeting PLHIV (27).

This study revealed factors significantly associated with DCM use among HIV-positive women. Younger age (less than 40), no desire to have children, and open discussions with partners about contraception strongly predicted DCM use. Being married, having a CD4-count and pregnancy or childbirth after HIV diagnosis were found to have weaker associations in this study.

The finding of increased DCM use among women younger than 40 years is supported by studies conducted in Gonder University and Fitche zone in Ethiopia and in studies conducted in Kenya, Tanzania, and Namibia in 2014 and in Zambia (4, 11, 20, 22), whereas a reversed association was found in Cameron and in Keffa region, Ethiopia (8, 19). In this study, women at the peak of their reproductive age (30s), who also represented most of the participants, showed stronger associations than older women, which may be explained by the decline in sexual activity and desire to have children at an advanced age. Marital status was significantly associated with DCM use in this study; however, the extremely wide CI found in this study, likely due to an inadequate sample size, allows no meaningful interpretation.

Furthermore, an association was detected between the lack of desire to have children and DCM use. This finding is in-line with studies conducted in Thailand, Kenya, Bahir-Dar, Borena, Fitche and Wolaita regions in Ethiopia (14, 15, 20, 21, 24, 25). This association could be the consequence of having knowledge of increased pregnancy-associated complications in HIV-infected women and fear of MTCT, which, although not investigated in this study, may have a mediating effect on other factors that predict DCM use. In the present study, the association between parity, pregnancy/childbirth after HIV diagnosis, and marital status was significantly attenuated in the final model, independently leaving desire for having no children as a strong predictor.

The association between DCM use and CD4 count knowledge was also reported in a systematic review by Ayele et al. in 2021 (13). A similar finding was evident in the Keffa zone, Ethiopia, and Zambia (11, 19). This study also found that the proportion of women who had knowledge about their CD4 count was extremely low, which could contribute toward the low prevalence of DCM use in general. Sero-discrodant couples were found to have decreased DCM use in this study, the odds of which became insignificant during model adjustment. However, this is a concerning finding that may be related to women not disclosing their HIV status, which may not have been reported during this survey.

Open discussions about contraception use with partners showed a consistent association with DCM use across studies according to systematic reviews conducted in Ethiopia (12, 13). Studies that reported similar finding were conducted in Gonder University, Tigray, Mekele, Keffa, and Wolaita (17–19, 21, 22). Discussing contraception use is a marker of women’s freedom to negotiate safe sex and birth spacing. Unlike other studies, this study failed to detect an association between DCM use and counseling about DCM use by ART service providers and partners involved in counseling sessions (12, 15, 18, 22, 23). Although the majority of women reported having been counseled, the absence of increased DCM use in this group may indicate disorganized and ineffective counseling regarding family planning and failure to encourage partners to participate in these sessions in HUCSH.

This study was conducted to fill the knowledge gap discovered about the status of HIV-positive women practice of contraception use, in Hawassa and surrounding areas, Sidama, Ethiopia. This study was institutional based, acquired the desired sample size, and used random sampling. All these attributes allow us to generalize the study findings to most HIV-positive reproductive-age women who receive ART services at HUCSH and grossly reflect explanatory factors that promote DCM use. However, since the analysis of associated factors was conducted in an exploratory manner, a study that provides accurate power is needed to confirm predictive ability. It is also noteworthy that due to the private nature of the queries in this survey the data is subject to reporting bias.

Nevertheless, the factors described and identified to have an association with DCM use provide directions on what sociocultural influencers require prudent intervention to promote women’s freedom to seek knowledge, counseling, healthcare, and access to family planning services. Accordingly, ART services and family planning counselors must be accountable for the initiation of DCM use once diagnosed and follow for sustained use throughout the reproductive period; They must strongly relay the relevance of DCM use, pregnancy risks, and must ensure that these women have their CD4 counts known. Equally significant is the provision of counseling and psychological support for women who wish to overcome fear, disclose their status, and discuss their desires and reproductive plans with their partners.

The prevalence of DCM use among reproductive-age HIV-positive women was unsatisfactory, providing an enormous window for counseling and reproductive health promotion measures. Fertility desire, knowledge of CD4 levels, and discussion of contraception use with partners were among the most significant determinant factors that explained dual contraceptive use. Interventional studies and strengthening of ART and family planning services must be customized to target the major social, cultural, and knowledge barriers identified in this study to enhance the use and practice of DCM.

AOR Adjusted Odds Ratio

ART Antiretroviral Therapy

CI Confidence Interval

DCM Dual Contraception Method

END Early Neonatal Death

FP Family Planning

HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

HUCSH Hawassa University Comprehensive Specialized Hospital

IQR Interquartile Range

MTCT Mother-to-child Transmission

PLHIV People Living with HIV Infection

STI Sexually Transmitted Infections

WHO World Health Organization

Ethics approval and consent to participate

Study was approved by Hawassa University College of Medical and Health Sciences, Institutional Review Board and ethical clearance was provided by the college’s ethical review committee.

Consent for publication

Not Applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

No funding was received for conducting this study

Authors' contributions

MG Conceptualized and designed the study, wrote parts of the paper, YH Supervised the study edited the manuscript, MA Performed data analysis and wrote parts of the paper. All authors reviewed and edited the manuscript.

Acknowledgements

Authors of this paper like to acknowledge the contributions obtained from the department of obstetric and gynecology, and HUCSH ART clinic staff who facilitated participant recruitment and data collection.

Cates WJ, Steiner MJ. Dual Protection Against Unintended Pregnancy and Sexually Transmitted Infections: What Is the Best Contraceptive Approach? Sex Transm Dis [Internet]. 2002 Mar [cited 2024 Jun 23];29(3):168. https://journals.lww.com/stdjournal/abstract/2002/03000/dual_protection_against_unintended_pregnancy_and.7.aspx
World Health Organization. 2007 AIDS epidemic update. 2007; https://data.unaids.org/pub/epislides/2007/2007
UNFPA, Preventing HIV, Pregnancies U. Strategic Framework 2011–2015 [Internet]. 2012 [cited 2024 Jun 23]. https://www.unfpa.org/publications/preventing-hiv-and-unintended-pregnancies-strategic-framework-2011-2015
Antelman G, Medley A, Mbatia R, Pals S, Arthur G, Haberlen S et al. Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania. J Fam Plann Reprod Health Care [Internet]. 2015 Jan 1 [cited 2024 Jun 23];41(1):e1–e1. https://srh.bmj.com/content/41/1/e1
Gausi B, Chagomerana MB, Tang JH, Hosseinipour MC, Haddad LB, Hannock T et al. Human Immunodeficiency Virus Serodiscordance and Dual Contraceptive Method Use Among Human Immunodeficiency Virus-infected Men and Women in Lilongwe, Malawi. Sex Transm Dis [Internet]. 2018 Nov [cited 2024 Jun 23];45(11):747–53. https://journals.lww.com/00007435-201811000-00007
Antelman G, Medley A, Mbatia R, Pals S, Arthur G, Haberlen S et al. Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania. J Fam Plann Reprod Health Care [Internet]. 2015 Jan [cited 2024 Jun 23];41(1):e1–e1. https://jfprhc.bmj.com/lookup/doi/10.1136/jfprhc-2013-100784
Yaya I, Patassi AA, Landoh DE, Bignandi EM, Kolani K, Namoro ADD et al. Modern contraceptive use among HIV-infected women attending HIV care centres in Togo: a cross-sectional study. BMJ Open [Internet]. 2018 Apr [cited 2024 Jun 23];8(4):e019006. https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2017-019006
Tsafack M, Essiben F, Momo RJ, Moyo GPK, Mpoah YM, Mbu RE. Dual Contraception Use and Associated Factors among HIV Positive Women Follow-Up at Treatment Center Unit of Yaounde Central Hospital, Cameroon. Open Access Libr J [Internet]. 2020 Apr 23 [cited 2024 Jun 23];7(5):1–12. https://www.scirp.org/journal/paperinformation?paperid=99934
Ezugwu EC, Nkwo PO, Agu PU, Ugwu EO, Asogwa AO. Contraceptive use among HIV-positive women in Enugu, southeast Nigeria. Int J Gynecol Obstet [Internet]. 2014 Jul [cited 2024 Jun 23];126(1):14–7. https://obgyn.onlinelibrary.wiley.com/doi/10.1016/j.ijgo.2013.12.014
Lawani LO, Onyebuchi AK, Iyoke CA. Dual method use for protection of pregnancy and disease prevention among HIV-infected women in South East Nigeria. BMC Womens Health [Internet]. 2014 Mar 7 [cited 2024 Jun 23];14:39. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3973850/
Chibwesha CJ, Li MS, Matoba CK, Mbewe RK, Chi BH, Stringer JSA et al. Modern Contraceptive and Dual Method Use among HIV-Infected Women in Lusaka, Zambia. Infect Dis Obstet Gynecol [Internet]. 2011 [cited 2024 Jun 23];2011(1):261453. https://onlinelibrary-wiley-com.ezproxy.uef.fi:2443/doi/abs/10.1155/2011/261453
Mesfin Y, Argaw M, Geze S, Tefera B. Dual Contraceptive Use and Factor Associated with People Living with HIV/AIDS: A Systematic Review and Meta-Analysis. Infect Dis Obstet Gynecol [Internet]. 2021 [cited 2024 Jun 23];2021(1):5440722. https://onlinelibrary.wiley.com/doi/abs/10.1155/2021/5440722
Ayele AD, Kassa BG, Beyene FY, Sewyew DA, Mihretie GN. Dual contraceptive utilization and determinant factors among HIV positive women in Ethiopia: a systematic review and meta-analysis, 2020. Contracept Reprod Med [Internet]. 2021 Jul 1 [cited 2024 Jun 23];6(1):19. https://doi.org/10.1186/s40834-021-00161-w
Amare G, Cherie N, Mekonen AM. Dual Contraceptive Use and Associated Factors Among Reproductive Age Group on Antiretroviral Therapy in Borena District, Northeast Ethiopia: A Cross-Sectional Study. HIVAIDS Auckl NZ [Internet]. 2021 Jan 26 [cited 2024 Jun 23];13:107–14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847380/
Kebede HG, Nahusenay H, Birhane Y, Tesfaye DJ. Assessment of Contraceptive Use and Associated Factors among HIV Positive Women in Bahir-Dar Town, Northwest Ethiopia. Open Access Libr J [Internet]. 2015 Oct 30 [cited 2024 Jun 23];2(10):1–19. https://www.scirp.org/journal/paperinformation?paperid=68684
Abay F, Yeshita HY, Mekonnen FA, Sisay M. Dual contraception method utilization and associated factors among sexually active women on antiretroviral therapy in Gondar City, northwest, Ethiopia: a cross sectional study. BMC Womens Health [Internet]. 2020 Dec [cited 2024 Jun 23];20(1):26. https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-020-0890-3
Kalayu H. Dual Contraceptive Use and Associated Factors among HIV Positive Women on Art Follow up In Mekelle Town Tigray, Ethiopia. 2017 Aug [cited 2024 Jun 23]; http://repository.smuc.edu.et/handle/123456789/3984
Gebrehiwot SW, Azeze GA, Robles CC, Adinew YM. Utilization of dual contraception method among reproductive age women on antiretroviral therapy in selected public hospitals of Northern Ethiopia. Reprod Health [Internet]. 2017 Dec [cited 2024 Jun 23];14(1):125. http://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0390-6
Mariam Erashi MW, Yadassa Tesso F, Tema Beyene T. Dual-Contraceptive Method Utilization and Associated Factors among HIV Positive Women Attending Art Clinic in Gebretsadik Shawo Hospital, SNNPR, South West Ethiopia. J Womens Health Care [Internet]. 2015 [cited 2024 Jun 23];04(06). http://www.omicsgroup.org/journals/dualcontraceptive-method-utilization-and-associated-factors-amonghiv-positive-women-attending-art-clinic-in-gebretsadik-shawo-hospitalsnnpr-south-west-ethiopia-2167-0420-1000267.php?aid=61602
Demissie D, Girma T, Abdissa G. Dual Contraceptive Utilization and Associated Factors among People Living with HIV Attending ART Clinic in Fitche Hospital, Ethiopia. J Health Med Nurs. 2015;20.
Haile D, Lagebo B. Magnitude of dual contraceptive method utilization and the associated factors among women on antiretroviral treatment in Wolaita zone, Southern Ethiopia. Heliyon [Internet]. 2022 Jun [cited 2024 Jun 23];8(6). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168601/
Reta MM, Tessema GA, Shiferaw G. Prevalence of dual contraceptive use and associated factors among HIV positive women at University of Gondar Hospital, Northwest Ethiopia. BMC Res Notes [Internet]. 2019 Jan 18 [cited 2024 Jun 23];12(1):36. https://doi.org/10.1186/s13104-019-4053-2
Chakrapani V, Kershaw T, Shunmugam M, Newman PA, Cornman DH, Dubrow R. Prevalence of and Barriers to Dual-Contraceptive Methods Use among Married Men and Women Living with HIV in India. Infect Dis Obstet Gynecol [Internet]. 2011 [cited 2024 Jun 23];2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195532/
Munsakul W, Lolekha R, Kowadisaiburana B, Roongpisuthipong A, Jirajariyavej S, Asavapiriyanont S et al. Dual contraceptive method use and pregnancy intention among people living with HIV receiving HIV care at six hospitals in Thailand. Reprod Health [Internet]. 2016 Feb 3 [cited 2024 Jun 23];13:8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739396/
Mulongo AM, Lihana RW, Githuku J, Gura Z, Karanja S. Factors associated with uptake of dual contraception among HIV-infected women in Bungoma County, Kenya: a cross-sectional study. Pan Afr Med J [Internet]. 2017 [cited 2024 Jun 23];28. http://www.panafrican-med-journal.com/content/series/28/1/2/full/
Lemma L. Assessment of utilization of modern family planning methods among women living with HIV/AIDS who are on chronic care follow up in Yirgalem public health facilities, Sidama Zone, SNNPR, Ethiopia [Internet]. 2014 [cited 2024 Jul 28]. https://scholar-google-com.ezproxy.uef.fi:2443/scholar_lookup?title=Assessment+of+utilization+of+modern+family+planning+methods+among+women+living+with+HIV/AIDS+
who+are+on+chronic+care+follow+up+in+Yirgalem+public+health+facilities&author=L.+Lemma&publication_year=2014&amp.
Wilson TE, Koenig LJ, Walter E, Fernandez I, Ethier K, Perinatal Guidelines Evaluation Project. Dual contraceptive method use for pregnancy and disease prevention among HIV-infected and HIV-uninfected women: the importance of an event-level focus for promoting safer sexual behaviors. Sex Transm Dis. 2003;30(11):809–12.

Table 1 Background Characteristics of study participants

Variables (N)	Frequency (%)	Dual Contraception Method Use
Variables (N)	Frequency (%)	No	Yes
Sociodemographic characteristics
Age (268)
15 - 36	92 (34.3)	64 (69.6)	28 (30.4)
37 - 40	118 (44.0)	72 (61.0)	46 (39.0)
41 - 49	58 (21.6)	52 (89.7)	6 (10.3)
Marital status (268)
Not married	122 (54.5)	106 (86.9)	16 (13.1)
Married	146 (55.5)	82 (56.2)	64 (43.8)
Education (268)
No formal education	26 (9.7)	20 (76.9)	6 (23.1)
Primary education	106 (39.6)	66 (62.3)	40 (37.7)
Secondary education	94 (35.1)	68 (72.3)	26 (27.7)
Higher education	42 (15.7)	34 (81.0)	8 (19.0)
Income (268)
<1500	70 (26.1(	46 (67.7)	24 (34.3)
1500-3000	96 (35.8)	70 (72.9)	26 (27.1)
>3000	102 (38.1)	72 (70.6)	30 (29.4)
Place of Residence (268)
urban	268 (85.8)	158 (68.7)	72 (31.3)
rural	38 (14.2)	30 (78.9)	8 (21.1)
Religion (268)
Orthodox	150 (56.0)	98 (65.3)	52 (34.7)
Muslim	18 (6.7)	14 (77.8)	4 (22.2)
Nonorthodox Christian	100 (37.3)	76 (76.0)	24 (24.0)
Sexual and Reproductive factors
Number of live children (268)
Less than three	184 (68.7)	136 (73.9)	48 (26.1)
More than three	84 (31.3)	52 (61.9)	32 (38.1)
Pregnancy or childbirth after HIV diagnosis (268)
no	116 (43.3)	98 (84.5)	18 (15.5)
yes	152 (56.7)	90 (59.2)	62 (40.8)
HIV positive children (268)
No	178 (66.4)	126 (70.8)	52 (29.2)
Yes	74 (27.6)	48 (64.9)	26 (35.1)
I don't know	16 (6.0)	14 (87.5)	2 (12.5)
History of abortion/stillbirth/END (268)
No	182 (67.9)	130 (71.4)	52 (28.6)
Yes	86 (32.1)	58 (67.4)	28 (32.6)
Pregnancy desire (268)
Yes	149 (55.6)	123 (82.6)	26 (17.4)
No	119 (44.4)	65 (54.6)	54 (45.4)
Partner’s desire to have children (166)
Yes	82 (43.3)	56 (68.3)	26 (31.7)
no	84 (50.6)	44 (52.4)	40 (47.6)
Sexual Partner (166)
Single	138 (51.5)	79 (57.2)	59 (42.8)
Multiple	28 (10.4)	16 (57.1)	12 (42.9)
Clinical Factors
Duration of HIV infection (268)
Median	12
IQR	8 - 14
HIV treatment Duration (268)
Median	11
IQR	7 - 13
Knowledge of CD4 count (268)
No	194 (73.1)	144 (73.5)	52 (26.5)
yes	74 (26.9)	44 (61.1)	28 (38.9)
CD4 (74)
>500	48 (64.8)	20 (41.7)	28 (58.3)
<500	26 (35.2)	26 (100)	0
History of STI (268)
No	202 (75.4)	148 (73.3)	54 (26.7)
yes	66 (24.6)	40 (60.6)	26 (39.4)
Treatment for STI (66)
No	6 (9.0)
yes	62 (93.9)
Sero-discordance (166)
positive	136 (81.9)	76 (55.9)	60 (44.1)
Negative	30 (18.0)	24 (80.0)	6 (20.0)
Discussion with partner (166)
No	46 (27.7)	38 (79.2)	10 (20.8)
yes	120 (72.3)	62 (52.5)	56 (47.5)
Counselling about DCM by ART provider (268)
No	64 (23.8)	48 (75.0)	16 (25.0)
yes	204 (76.2)	140 (68.6)	64 (31.4)
Partner involvement in the counselling (132)
No	88 (66.6)	50 (58.1)	36 (41.9)
Yes	44 (33.4)	24 (54.5)	20 (45.5)

Table 2 Result of multivariable logistic regression models constructed to determine factors associated with DCM use

Variables	N	Dual contraception method use
Variables	N	Unadjusted Model OR (95% CI)	Model I^a OR (95% CI)	Model II^b OR (95% CI)
Sexual and Reproductive factors
Number of live children	268
Less than three		1	1
More than three		1.74 (1.01 - 3.02) *	1.24 (0.65 - 2.36)
Pregnancy or childbirth after HIV diagnosis	268
No		1	1	1
Yes		3.75 (2.06 - 6.82) ***	2.46 (1.21 - 4.82) **	1.06 (0.49 - 2.31)
HIV positive children	268
No		1
Yes		1.31 (0.79 - 2.34)
History of abortion/stillbirth/END	268
No		1
Yes		1.21 (0.69 - 2.10)
Pregnancy desire (Self)	268
Yes		1	1	1
No		3.93 (2.25 - 6.85) ***	5.95 (2.84 - 2.49) ***	8.34 (3.95 - 17.61) ***
Partner’s desire to have children	166
Yes		1	1
no		1.96 (1.04 - 3.68) *	0.59 (0.24 - 1.41)
Sexual Partner	166
Single		1
Multiple		1.00 (0.44 - 2.28)
Clinical and HIV related Factors
Duration of HIV infection (For every 1-year)	268	1.08 (1.01 - 1.17) *	1.10 (1.00 - 1.20) *	1.10 (0.98 - 1.22)
Knowledge of CD4 count	268
No		1	1	1
yes		1.76 (0.99 - 3.12)	2.35 (1.22 - 4.53) **	2.94 (1.35 - 6.38) **
History of STI	268
No		1	1
yes		1.78 (0.99 - 3.19)	1.31 (0.67 - 2.57)
Sero-discordance (Partner’s HIV status)	166
positive		1	1
Negative		0.32 (0.12 - 0.82) *	0.37 (0.13 - 1.05)
Discussion with partner	166
No		1	1	1
yes		3.43 (1.57 - 7.52) **	3.50 (1.49 - 8.20) **	5.71 (2.15 - 15.11) ***
Counselling about DCM by ART provider	268
No		1
yes		1.37 (0.72 - 2.60)
Partner involvement in the counselling	132
No		1
Yes		1.30 (0.61 - 2.75)
Sociodemographic characteristics
Age	268
15 - 36		3.79 (1.46 - 9.85) **	2.75 (1.01 - 7.50) *	8.65 (2.60 - 28.75) ***
37 - 40		5.54 (2.20 - 13.93) ***	4.48 (1.71 -11.71) **	6.25 (2.08 - 18.82) **
41 - 49		1	1
Marital status	268
Not married		1	1
Married		5.17 (2.78 - 9.60) ***	5.12 (2.66 - 9.85) ***	11.55 (2.99 - 44.68) ***
Education	268
No formal education		1
Primary education		2.02 (0.75 - 5.45)
Secondary education		1.27 (0.46 - 3.53)
Higher education		0.78 (0.24 - 2.59)
Income	268
<1500		1
1500-3000		0.71 (0.36 - 1.39)
>3000		0.79 (0.42 - 1.53)
Place of Residence	268
Rural		1	1
Urban		1.71 (0.75 - 3.91)	2.01 (0.81 - 4.97)
Religion	268
Orthodox		1.68 (0.95 - 2.97)
Muslim		0.90 (0.27 - 3.01)
Nonorthodox Christian		1
ART: Antiretroviral therapy, DCM: Dual contraception method, END: Early neonatal death a Model I Covariate adjustment was done within the classes of explanatory factors; namely sexual and reproductive characteristics, clinical and HIV related characteristics and SDC, variables with a p value of <0.25 in the unadjusted model are included in model I. b Model II Variables with statistical significance (p value <0.05) in model I were included in model II with further adjustment for age and marital status. * P value <0.05 P value < 0.01 * P value <0.001

No competing interests reported.

Dual Contraception Method Use and Determinant Factors Among HIV-positive Women of Reproductive age in Hawassa, Sidama, Ethiopia, An institutional based Cross- sectional Study

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Abstract

Background

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Introduction

Method

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Discussion

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Abbreviations

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