A Prospective Cohort Study of Fertility Desire, Unprotected Sex, and Detectable Viral Load in HIV-Positive Female Sex Workers in Mombasa, Kenya

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Abstract

<div class="section"> <a class="named-anchor" id="S1">  </a> <h5 class="section-title" id="d8662029e210">Background</h5> <p id="P1">Little is known about fertility desire in HIV-positive female sex workers (FSW). Fertility desire could increase HIV transmission risk if it were associated with condomless sex or lower adherence to antiretroviral therapy (ART). </p> </div><div class="section"> <a class="named-anchor" id="S2">  </a> <h5 class="section-title" id="d8662029e215">Methods</h5> <p id="P2">A prospective cohort study was conducted among 255 HIV-positive FSWs in Mombasa, Kenya. Using generalized estimating equations, fertility desire was evaluated as a risk factor for semen detection in vaginal secretions by prostate specific antigen (PSA) test, a biomarker of condomless sex, detectable plasma viral load (VL), and HIV transmission potential, defined as visits with positive PSA and detectable VL. </p> </div><div class="section"> <a class="named-anchor" id="S3">  </a> <h5 class="section-title" id="d8662029e220">Results</h5> <p id="P3">The effect of fertility desire on PSA detection varied significantly by non-barrier contraception use (p-interaction<0.01). At visits when women reported not using non-barrier contraception, fertility desire was associated with higher risk of semen detection (82/385, 21.3% versus 158/1007,15.7%; aRR 1.58, 95%CI 1.12–2.23). However, when women used non-barrier contraception, fertility desire was associated with lower risk of PSA detection (10/77,13.0% vs.121/536, 22.6%; aRR 0.58, 95%CI 0.35–0.94). Fertility desire was not associated with detectable VL (31/219,14.2% vs.128/776,16.5%; aRR 0.82, 95%CI 0.46–1.45) or higher absolute risk of transmission potential (10/218, 4.6% vs. 21/769, 2.7%; adjusted risk difference=0.011, 95%CI −0.031–0.050). </p> </div><div class="section"> <a class="named-anchor" id="S4">  </a> <h5 class="section-title" id="d8662029e225">Conclusion</h5> <p id="P4">Fertility desire was associated with higher risk of biological evidence of semen exposure when women were not using non-barrier contraceptives. Low HIV transmission potential regardless of fertility desire suggests that the combination of condoms and ART adherence was effective. </p> </div>

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Contraceptive failure in the United States.

James Trussell (2011)

This review provides an update of previous estimates of first-year probabilities of contraceptive failure for all methods of contraception available in the United States. Estimates are provided of probabilities of failure during typical use (which includes both incorrect and inconsistent use) and during perfect use (correct and consistent use). The difference between these two probabilities reveals the consequences of imperfect use; it depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly. These revisions reflect new research on contraceptive failure both during perfect use and during typical use. Copyright © 2011 Elsevier Inc. All rights reserved.

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Reproductive Intentions and Outcomes among Women on Antiretroviral Therapy in Rural Uganda: A Prospective Cohort Study

Jaco Homsy, Rebecca Bunnell, David Moore … (2009)

Background Antiretroviral therapy (ART) may influence the biological, social and behavioral determinants of pregnancy in HIV-infected women. However, there are limited longitudinal data on the reproductive intentions and outcomes among women on ART in Africa. Methodology /Principal Findings Using a prospective cohort design, we analyzed trends in desire for children and predictors of pregnancy among a cohort of 733 HIV-infected women in rural Uganda who initiated ART between May 2003 and May 2004 and were followed up in their homes until June 2006. Women answered in-depth social and behavioral questionnaires administered every quarter in year 1 after initiating ART, and every 6 to 12 months thereafter. Use of family planning methods was assessed at 18 and 24 months after starting ART. We tested for non-constant pregnancy incidence by using a shape parameter test from the Weibull distribution. We modeled repeated measurements of all variables related to the women's desire for children over time using a generalized estimating equation (GEE) extension to the logistic regression model. Risk factors for pregnancy were examined using Cox proportional hazards model. 711 women eligible for the study were followed-up for a median time of 2.4 years after starting ART. During this time, less than 7% of women reported wanting more children at any time point yet 120 (16.9%) women experienced 140 pregnancies and pregnancy incidence increased from 3.46 per 100 women-years (WY) in the first quarter to 9.5 per 100 WY at 24 months (p 18.5 (HR = 1.09, CI: 1.01–1.18) and not having used condoms consistently in the last 3 months (HR = 1.79, CI: 1.02–3.13) were independently associated with pregnancy. Conclusion/Significance Women on ART and their partners should be consistently counseled on the effects of ART in restoring fertility, and offered regularly free and comprehensive family planning services as part of their standard package of care.

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Childbearing intentions of HIV-positive women of reproductive age in Soweto, South Africa: the influence of expanding access to HAART in an HIV hyperendemic setting.

Fatima Laher, Patricia A. Janssen, R E Hogg … (2011)

We investigated whether the intention to have children varied according to HIV status and use of highly active antiretroviral therapy (HAART) among women in Soweto, South Africa. We used survey data from 674 women aged 18 to 44 years recruited from the Perinatal HIV Research Unit in Soweto (May through December 2007); 217 were HIV-positive HAART users (median duration of use = 31 months; interquartile range = 28, 33), 215 were HIV-positive and HAART-naive, and 242 were HIV negative. Logistic regression models examined associations between HIV status, HAART use, and intention to have children. Overall, 44% of women reported intent to have children, with significant variation by HIV status: 31% of HAART users, 29% of HAART-naive women, and 68% of HIV-negative women (P < .001). In adjusted models, HIV-positive women were nearly 60% less likely to report childbearing intentions compared with HIV-negative women (for HAART users, adjusted odds ratio [AOR] = 0.40; 95% confidence interval [CI] = 0.23, 0.69; for HAART-naive women, AOR = 0.35; 95% CI = 0.21, 0.60), with minimal differences according to use or duration of HAART. Integrated HIV, HAART, and reproductive health services must be provided to support the rights of all women to safely achieve their fertility goals.