Optimizing Prevention of HIV and Unplanned Pregnancy in Discordant African Couples

Abstract

<p id="d6796734e428"> <b> <i>Background:</i> </b> Dual method use, which combines condoms with a more effective modern contraceptive to optimize prevention of HIV and unplanned pregnancy, is underutilized in high-risk heterosexual couples. </p><p id="d6796734e436"> <b> <i>Materials and Methods:</i> </b> Heterosexual HIV-discordant Zambian couples were enrolled from couples' voluntary HIV counseling and testing services into an open cohort with 3-monthly follow-up (1994–2012). Relative to dual method use, defined as consistent condom use plus modern contraception, we examine predictors of (1) condom-only use (suboptimal pregnancy prevention) or (2) modern contraceptive use with inconsistent condom use (effective pregnancy prevention and suboptimal HIV prevention). </p><p id="d6796734e444"> <b> <i>Results:</i> </b> Among 3,049 couples, dual method use occurred in 28% of intervals in M+F− and 23% in M−F+, <i>p</i> &lt; 0.01; condom-only use in 56% in M+F− and 61% in M−F+, <i>p</i> &lt; 0.01; and modern contraceptive use with inconsistent condom use in 16% regardless of serostatus. Predictors ( <i>p</i> &lt; 0.05) of condom-only use included the man being HIV+ (adjusted hazard ratio, aHR = 1.15); baseline oral contraceptive pill (aHR = 0.76), injectable (aHR = 0.48), or implant (aHR = 0.60) use; woman's age (aHR = 1.04 per 5 years) and lifetime number of sex partners (aHR = 1.01); postpartum periods (aHR = 1.25); and HIV stage of the index partner III/IV versus I (aHR = 1.10). Predictors ( <i>p</i> &lt; 0.05) of modern contraceptive use with inconsistent condom use included woman's age (aHR = 0.94 per 5 years) and HIV+ male circumcision (aHR = 1.51), while time-varying implant use was associated with more consistent condom use (aHR = 0.80). </p><p id="d6796734e464"> <b> <i>Conclusions:</i> </b> Three-quarters of follow-up intervals did not include dual method use. This highlights the need for counseling to reduce unintended pregnancy and HIV transmission and enable safer conception. </p>