THE EFFECT OF VCT TESTING AND UPTAKE OF HIV/ART CARE ON MODERN CONTRACEPTIVE USE AMONG WOMEN IN RAKAI, UGANDA Fredrick Makumbi; Gertrude Nakigozi; Tom Lutalo; Joseph Kagaayi; Joseph Sekasanvu; Absalom Settuba; David Serwada; Maria Wawer; Ronald Gray Family Planning conference, Kampala, Uganda November 15-18 th 2009
Background Fertility in SSA is high and contraceptive use is low Knowledge of contraceptives is almost universal Uganda (UDHS 2006) 98% know at least one method Modern method use 18%, Increasing use of modern methods over time Modern contraceptive use is low among HIV+ women 30% among women on HAART in Mbarara (Am J Public Health. 2009 Feb;99(2):340-7.) Integration of FP into VCT and HIV care could increase modern contraceptive use
Objective To assess the effect of VCT uptake and enrolment into ART/HIV care on use of modern contraceptives and condoms for family planning among women aged 15-49 years in Rakai, Uganda.
Methods-1 A population-based cohort in 50 rural villages in Rakai since 1994 Annual follow-up of all persons aged 15-49 year Data collection Census (marital status, sex, age, household possessions, structure) re) Detailed survey, with individual interviews and blood for HIV testing Information on pregnancy status, fertility desires, use of FP methods, m receipt of HIV test results (VCT) in past 12 months Enrolment into HIV care including ART from RHSP HIV care clinics
Methods-2 Data from RCCS survey 2007-2008 2008 Follow up visits for women 15-49 years Non-pregnant, currently married or single women, sexually active in past 12 months Exclude sterilization VCT acceptance in past 12 months Enrolment into HIV care before survey visit
HIV care program Methods-3 started June 2004, Supported by PEPFAR Services offered via 17 mobile community-based out-patient clinics, called Suubi or Hope clinics Reproductive health education including use of Family planning, prevention messages Provide HIV basic care package, which includes condoms ART, general HIV care, PMTCT VCT services in RHSP Pretest counseling and blood draw during the community surveys and at HIV clinics HIV results returned by community resident trained HIV counselors
Statistical Analysis-1 A cross sectional analysis to assess prevalence of modern contraceptive and condoms for FP Outcome defined as use of modern Family Planning Non-users as a referent group condoms-only only Modern methods (pills, injections, IUD, and Norplant) Dependent variables Uptake of VCT in the past 12 months prior to the survey Enrolment into HIV care if HIV+ whether started on ART or not
Statistical Analysis-2 Multinomial logistic regression Estimated unadjusted and adjusted Odds ratios (OR) and 95% confidence intervals (CI) Condoms-only only versus Non-users Modern methods versus Non-users OR of outcomes comparing VCT recipients to non- recipients, and HIV care/art enrollees to non-enrollees Factors adjusted for included age, HIV status, desired number of lifetime children, child spacing, education level All stratified by marital status STATA version 9.2
Results -1 Characteristics of married and sexually active unmarried women unmarried % Married % Total 1128 100 3,392 100 Age (years) Mean (SD) 30.0(8.4) 31.1(7.4) Median (IQR) 30.0(23,36) 30.0(25,36) Age group 15-24 335 29.7 700 20.6 25-39 620 55.0 2152 63.4 40-49 173 15.3 540 15.9 Desire for child within 2- yrs No 854 75.7 2,448 72.2 Yes, within 2-years 274 24.3 944 27.8 Ever VCT receipt Never received 165 14.6 411 12.1 Ever received 963 85.4 2981 87.9
HIV prevalence, VCT receipt status and HIV care among non-pregnant women HIV prevalence by marital status VCT receipt in past 12m by marital status 60 Proportion(%) 40 35 30 25 20 15 10 5 0 25.0% Unmarried 11.9% Married Positive Proportion(%) 50 40 30 20 10 0 54.8% 47.7% Unmarried Married Marital status Received HIV+; 25.0% unmarried, 11.9% married VCT; 54.8% unmarried, 47.7% married Enrollment into HIV care among HIV+ Proportion (%) 60 50 40 30 20 10 Care and on ART Care, not on ART Not in care 0 Unmarried Married Marital status HIV+ in care; 57.1% unmarried; 52.1% married
Contraceptive use among women NOT desiring children in the next 2 years Contraceptive use Prop ortion(% ) 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Unmarried Married condoms-only Modern methods Use of condoms-only is more common in the unmarried compared to the married Use of modern methods is more common in married compared to unmarried
Contraceptive use among women NOT desiring children in the next 2 years Contraceptive use, among HIV+ Proportion(% ) 60.0 50.0 40.0 30.0 20.0 10.0 Unmarried Married condoms-only Modern methods 0.0 Not in CARE In care, no ART In care, on ART Not in CARE In care, no ART In care, on ART Use of condoms-only is more common except for married women Not in care Appears an increasing trend in condom use with increasing level of HIV care
Results -2, Married Proportions and OR, among married women Condoms-only Modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total 10.0 31.1 VCT & discussion ** No receipt 7.4 1.0 31.4 1.0 Received-discussed 11.6 1.65 (1.15,2.38) 33.6 1.30(1.03,1.66) Received +discussed 13.3 1.88 (1.45,2.45) 29.7 0.99(0.83,1.18) HIV status Negative 7.8 1.0 31.5 1.0 Positive 25.7 3.55 (2.64,4.78) 28.2 1.06 (0.82,1.38) * Adjusted for age, number of desired children, spacing; ** unmarried had no discussion with partner variables VCT and HIV+ status were associated with higher use of condoms VCT without result discussion was associated with higher use of modern methods
Results -2, Unmarried Proportions and OR, unmarried women Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total 35.5 21.0 VCT & discussion ** No receipt 31.6 1.0 20.4 1.0 Received 38.8 1.33(1.01,1.77) 21.5 1.26(0.91, 1.74) HIV status Negative 32.5 1.0 20.1 1.0 Positive 42.1 2.07(1.49,2.87) 23.1 1.31(0.90,1.91) * Adjusted for age, number of desired children, spacing; ** unmarried had no discussion with partner variables VCT and HIV+ status were associated with higher use of condoms but not modern methods
Results -3, HIV+ Married Proportions and OR, among married HIV+ Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total 25.7 28.2 VCT & discussion ** No receipt 17.3 1.0 28.5 1.0 Received-discussed ** 22.8 1.40(0.64,3.06) 30.4 1.28(0.66,2.50) Received +discussed 37.4 1.69(0.87,3.28) 26.5 1.21(0.65,2.27) Enrollment into HIV care HIV+ Not in care 10.0 31.4 1.0 Care, No ART 32.1 4.1 (1.96,8.36) 27.5 1.15(0.62,2.14) Care, On ART 51.8 10.8 (4.70, 24.61) 21.7 1.52(0.68,3.39) * Adjusted for age, number of desired children, spacing; ** Being in HIV care is strongly associated with higher use of condoms for FP
Results -3, HIV+ Unmarried Proportions and OR, among unmarried HIV+ Condoms-only modern methods (%) * Adj. OR 95%CI (%) Adj. OR 95%CI Total 23.1 42.1 VCT & discussion ** No receipt 21.9 1.0 35.9 1.0 Received-discussed ** 23.7 1.85(0.98,3.47) 45.7 1.69(0.98, 2.91) Enrollment into HIV care HIV+ Not in care 26.9 1.0 31.5 1.0 Care, No ART 20.9 0.69(0.33,1.45) 44.6 1.35(0.71,2.54) Care, On ART 19.3 0.98(0.43,2.20) 56.8 2.57(1.30,5.07) * Adjusted for age, number of desired children, spacing; ** Being on ART is strongly associated with higher use of modern methods
Summary of other findings Factors associated with non-use of contraceptives desire for family size of 6 or more children Desire for a child within two years Older age, 40-49 years Factors associated with increased use of contraceptives Education level, primary or higher Being a student, or working for money (among married) Condom use as FP method was more common among unmarried women, 35.5 % compared to the married, 10.0% However, modern contraceptive was more common among Married women, 31.1% compared to the unmarried, 21.0%
Conclusion VCT receipt, especially among HIV+, and HIV care programs can increase contraceptive use especially condoms, but more needs to be done to increase the modern methods High fertility desires still significantly determine contraceptive use in this rural setting
Recommendation Strategies to address desire for high fertility need to be developed, or strengthened There is need to strengthen FP services in VCT and HIV care programs, with promotion of modern contraceptive methods
Acknowledgements Rakai Health Sciences Management & Staff Rakai district leadership including community leaders Cohort participants Rakai Funders who have enabled continued research activities
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