|Year : 2016 | Volume
| Issue : 2 | Page : 84-90
Knowledge of contraception and contraceptive choices among human immunodeficiency virus-positive women attending antiretroviral clinics in Zaria, Nigeria
Adamu U Shehu1, Istifanus Anekoson Joshua2, Zuwaira Umar1
1 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
2 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
|Date of Submission||20-Jun-2015|
|Date of Acceptance||02-Apr-2016|
|Date of Web Publication||21-Jun-2016|
Adamu U Shehu
Department of Community Medicine, Ahmadu Bello University, Zaria
Introduction: Once human immunodeficiency virus (HIV)-positive women become aware of their status, many demonstrate a reduced desire for pregnancy, particularly because most of them know that there are risks involved in delivering an HIV-positive child. Others, on the other hand, want to have children despite their HIV-positive status. These women have reproductive needs that should be respected and attended to. This study assessed the knowledge of contraception and contraceptive choices among HIV-positive women of reproductive age (15-49 years) attending antiretroviral clinics in Zaria. Materials and Methods: A cross-sectional descriptive study was carried out on 340 HIV-seropositive women of reproductive age group in January 2015 using a simple random sampling technique. Data were collected via structured interviewer administered questionnaire. Data collected were analyzed using SPSS version 21.0 and results were presented in tables and charts. Statistical significance was at P = 0.005. Results: The modal age group of the respondents was 20-29 years (44.7%) with mean age of 24.5 ± 8.4 years, 45% were Hausa, 59.4% Muslim, and 57.4% married. The majority (32%) had secondary education and of different occupation. About 87% had knowledge of HIV transmission from infected mother to child and 73.8% had heard of contraception. Prevalence of past contraceptive usage among these women was 56.1%, of which male condom was the most commonly used contraceptive (60.4%), either alone or dual contraception. This was followed by injectables (52%) and oral pills (35%). However, the current contraceptive use among the respondents was 36.3%. There was statistical relationship between age and educational level of the respondents and contraceptive use. Conclusion: The study has demonstrated that majority of these HIV-positive women had good knowledge about contraception but they do not apply this knowledge they have toward using an appropriate family planning method. Hence, there is a need for proper counseling and education of these women and their spouses by the health workers as they attend the antiretroviral clinic to erase fear and misconceptions of modern contraception. Male involvement will also go a long way in promoting contraceptive utilization.
Keywords: Antiretroviral clinic, choices, contraception, human immunodeficiency virus-positive women, Zaria
|How to cite this article:|
Shehu AU, Joshua IA, Umar Z. Knowledge of contraception and contraceptive choices among human immunodeficiency virus-positive women attending antiretroviral clinics in Zaria, Nigeria. Sub-Saharan Afr J Med 2016;3:84-90
|How to cite this URL:|
Shehu AU, Joshua IA, Umar Z. Knowledge of contraception and contraceptive choices among human immunodeficiency virus-positive women attending antiretroviral clinics in Zaria, Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2019 Mar 25];3:84-90. Available from: http://www.ssajm.org/text.asp?2016/3/2/84/184355
| Introduction|| |
Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) represent the most important public health challenge globally, with greatest burden being in Sub-Saharan Africa (SSA).  According to the report, there were approximately 35 million people worldwide living with HIV/AIDS in 2013, of these 3.2 million were children (<15 years old). , According to the global HIV progress report, one-third (60,000) of all new HIV infections among children in the 21 priority countries in SSA in 2012 occurred in Nigeria, and mother-to-child transmission (MTCT) accounted for a considerable proportion of new infections. 
Many HIV-infected women are sexually active  and increase or resume sexual activity as their health improves while on antiretroviral therapy (ART).  Studies from Africa show that many pregnancies were unplanned and that maternal death can be avoided if correct and consistent contraceptive use is promoted among women of childbearing age living with HIV and AIDS.  Approximately 3.5 million people are living with HIV infection in Nigeria and women account for half of the estimated 31.3 million adults living with HIV and AIDS worldwide, of whom the majority are in their reproductive years. ,, In 2011, the incidence in children was also highest in SSA, representing more than 90% of children worldwide who became newly infected with HIV.  Women of reproductive age account for 58% of the people living with HIV and 53% of all adult deaths.  Most of these women are particularly vulnerable to HIV due to complex burden they have including physiological, social vulnerability, and gender inequalities.  The region also has the highest burden of pediatric HIV infection. Most cases (90%) of pediatric HIV/AIDS resulted from transmission from the mother to child during pregnancy, labor, delivery, or breastfeeding. 
Prevention of unintended pregnancy among HIV-positive women is the second element of prevention of MTCT (PMTCT) of HIV which is an important means to address the associated problems of HIV-positive women and children.  However, HIV-positive women have a need for and a right to have children. Hence, it is important for their pregnancies to be planned. Planning in this context means making sure that their CD4 cell count is equal to or above 500 and that their viral loads are at the undetectable level.  Therefore, the planning of pregnancy in HIV-positive mothers is one of the most important interventions for reducing MTCT.
The importance of Family Planning (FP) has increasingly gained recognition as having a vital role in the prevention of HIV transmission. Reducing unintended pregnancies among HIV-positive women through FP reduces the number of HIV-infected infants as much as the use of antiretroviral (ARV) prophylaxis for PMTCT. It also reduces the number of children potentially orphaned, when parents die of an AIDS-related illness, and decreases the vulnerability of women and infants to morbidity and mortality related to pregnancy and lactation. In addition, FP substantially reduces the morbidity known to increase for HIV-infected women during the year following delivery. Meeting the FP needs for women living with HIV contributes significantly to reducing the need for ARV prophylaxis and treatment. FP has also proven to be a cost-effective strategy for prevention of HIV transmission as contraception costs are less than those of PMTCT. 
HIV-infected women who do not wish to initiate pregnancy require effective contraception both to prevent unwanted pregnancy and for protection against sexually transmitted infections (STIs) and HIV superinfection. This approach referred to as dual protection involves simultaneous protection against unintended pregnancy and STI and/or HIV. Although the barrier method of contraception alone (condom) offers dual protection, it is associated with a high 1-year cumulative incidence of unintended pregnancy. Consequently, in regions with high unintended pregnancy rates including Nigeria, the use of condoms together with another effective modern contraceptive method is often promoted for optimal sexual and reproductive health of women living with HIV. 
Family planning is the key strategy for reducing the number of babies born to HIV-positive women. Making an informed choice about contraceptive use involves recognizing and acknowledging different methods and their effectiveness against pregnancy as well as the need to prevent STIs and HIV.
There is a growing recognition of the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-positive women continue to desire children despite the knowledge of their HIV status.
There are several studies published on the knowledge and use of FP among HIV-infected persons. There are, however, limited data on the attitudes of HIV-positive women toward the use of these FP methods, including Nigeria. Understanding the attitudes of HIV-positive women toward FP is critical to the expansion of comprehensive HIV prevention programs targeted at achieving a reduction in unwanted pregnancies and a decrease in the incidence of HIV-infected children.
Thus, despite the effectiveness of modern contraception as a strategy for preventing MTCT, contraceptive use among HIV-positive women in Nigeria, particularly those in the Northern part of the country, calls for a critical appraisal. This is in view of the fact that women in the region are generally disempowered about sex because most of them do not have the power to negotiate for safe sex. The aim of this study is to determine the contraceptive choices among HIV-positive women attending two antiretroviral clinics in Zaria-Nasara Clinic, Ahmadu Bello University Teaching Hospital (ABUTH) Shika and Hajiya Gambo Sawaba Hospital, Zaria.
| Materials and Methods|| |
The study was conducted in two health facilities within Zaria metropolis. ABUTH, Shika, was established as an Institute of Health in 1968 by statute 15 of the Ahmadu Bello University (ABU) law. The permanent site is about 3 km from ABU main campus, Samaru and about 2 km from Shika town. The hospital has 28 wards and 584-bed capacity and gynecology department is one of the busiest departments of the hospital, offering a wide range of consultancy and emergency services including reproductive health clinic which provides family planning services and also screening for cancer of the cervix. 
Hajiya Gambo Sawaba Hospital is the General Hospital in Zaria Zone; it is a 200-bedded hospital, providing services as the secondary referral center for all other hospitals and clinics in the zone. The hospital runs outpatient, antenatal, postnatal, family planning/child spacing, antiretroviral, hypertensive, eye, and gynecology clinics.
The study population included HIV-seropositive women attending Nasara Clinic, ABUTH Shika, and Hajiya Gambo Sawaba Hospital Zaria. Only HIV-seropositive women within the reproductive age group (15-49 years) attending the clinics were considered eligible for the study while the HIV-seropositive women not within the reproductive age group were excluded from the study. Eligible patients who were not willing to participate in the study were also excluded.
The study was a descriptive, cross-sectional in nature and carried out in January, 2015.
Sample Size Determination
The minimum sample size of 302.9 was determined using the formula:
where n = sample size, Z = standard normal deviation set at 95% confidence interval, which corresponds to 1.96, P is the contraceptive prevalence (73.1%) among HIV-positive women in a previous study  and q is the complementary probability of P = 1 − p .
Considering a dropout rate of 10%, the minimum sample size was adjusted to 332. The total number of respondents recruited for the study was rounded up to 340.
A simple random sampling technique was employed in both clinics to select the sample studied. The patients that fulfilled the eligibility criteria within the period of the study were selected at random. The list of the patients obtained from the hospital record book was used as the sampling frame.
Data collection was done using interviewer administered questionnaire with open and close ended questions.
Data were sorted, cleaned, coded, and entered into the computer using statistical package for social sciences (SPSS) software version 21.0 (SPSS Inc., Chicago USA). Data were analyzed and presented as charts, graphs, and frequency tables. Relationship between variables was tested with Chi-square test with P value set at 0.05.
Ethical clearances were obtained from the Health Research Committee of ABU, Zaria and Kaduna State Ministry of Health, and all the patients who participated in the study gave informed consent to participate in the study.
| Results|| |
The modal age group of the respondents was 20-29 years (44.7%) with mean age of 24.5 ± 8.4 years. Hausa ethnicity predominates other ethnic groups 153 (45%), followed by Yoruba 50 (14.7%). A majority (59.4%) of the respondents were Muslims while 39.6% were Christians. About 32% had completed their secondary education, slightly above one-quarter (25.4%) had completed their tertiary education, 7.6% had no formal education, 29.1% were still students, 24.7% were petty traders, and 24.4% are full-time homemakers. A majority of the respondents (57.4 %) were married, 30.9% were single, 8.2% widowed and divorced [Table 1].
About 87.1% of the respondents were aware of MTCT of HIV and almost three-quarter (73.8%) of the respondents have ever heard of contraception [Table 2].
|Table 2: Knowledge of transmission of human immune deficiency virus from mother to child and contraception by human immunodeficiency virus-positive women in Zaria, 2015 (n=340) |
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The majority of the respondents (60.2%) got their information about contraception through health workers/CHEW, followed by media (41.3%) while about one-third got their information through friends [Figure 1].
Approximately 56% of the respondents had used contraceptive in the past but about two-third (63.7%) of the respondents who have heard of contraception were not currently using it. Of the total 91 who were currently using contraceptives, 66.7% of them obtained it from chemist, followed by those who obtained contraceptives from hospital (27.5%) and community health extension workers (5.7%). The least source of contraceptives was the ones obtained from friends (2.2%) [Table 3].
|Table 3: Current usage of contraception and where they are currently obtaining the commodity among human immunodeficiency virus-positive women in Zaria, 2015 |
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A majority of the respondents use male condom (60.4%) followed by injectables (21.6%) and oral pills (10.2%) among others [Figure 2].
There was statistically significant relationship between age, educational status, and use of contraception among HIV-positive women attending antiretroviral clinics in Zaria.
| Discussion|| |
Three hundred and forty women of reproductive age group (15-49 years of age) participated in the study. The respondents were concentrated in the age group 20-29 years (45%) with a mean age of 26. This mean age group was lower than that of a similar study conducted in Enugu, Southeast Nigeria, in 2014, where the highest number of respondents fell within the age group 30-39 years.  The least age group was 40-49 years with 12%. Hausa tribe predominated of the three major ethnic groups with 45%, with Igbo being the lowest at 13.5%. A majority (60%) of respondents were Muslims. Only 25.4% of respondents had reached the tertiary level of education, which is lower than the study conducted in Enugu where the value was 33.5%; 32% had completed secondary school education and the lowest number (7.6%) had no education. About 14.1% had had Quranic education. Most of the respondents (57.4%) were married, which is almost similar to that of Enugu which had 62% of women married. 
The knowledge of contraception among the respondents was found to be good, about three-quarter (73.8%) of the respondents from this study had knowledge of contraception. This is lower than that obtained from a similar study in Namibia where 97% of the HIV-positive women who participated in the study knew that it is important for them to protect themselves against unintended pregnancies and 83% knew that prevention of unintended pregnancies minimizes the chances of transmitting HIV to their newborn baby.  It also revealed that 95.7% of these women knew that it is important for them to use condoms together with the other hormonal family planning methods available because condoms can burst, and if used on their own, they could fall pregnant.  Majority of the respondents (60.2%) from the present study got their information about contraception through health workers/CHEWs followed by media (41.3%) while about one-third got their information through friends. Condoms (65%), injectables (64%), and oral pills (35%) were the most commonly heard of contraceptives among the respondents.
On contraceptive usage, this study demonstrated that the prevalence of contraceptive use among HIV-positive, nonpregnant women who did not desire pregnancy in Zaria was 56.1%. This is lower than the level of 73.1% and 85% reported in Enugu, Nigeria and Soweto, South Africa, respectively.  It is also lower than 71% obtained in a study in Ethiopia.  Although the contraceptive prevalence was 56.1%, about 36% (n = 47) of the HIV-positive women who did not desire pregnancy were not using any form of modern contraceptive. This is slightly higher than the level of 30% and 26.9% reported in Jos and Enugu, respectively, and greatly higher than that of 5%, 12.4%, and 16% reported in India, Brazil, and Soweto, respectively.  Being sexually active, this group of women are at risk of unintended pregnancy that might militate against the fight for preventing new pediatric HIV infections.
PMTCT of HIV is a global interventional program initiated by the United Nations Organization to protect the children of the world from the scourge of the HIV pandemic.
In addition to setting the goal of PMTCT, the UNGASS in 2001 also formulated four strategies for PMTCT, as follows: Prevention of primary infection in men and women of reproductive age, prevention of unintended pregnancy in HIV-infected women, PMTCT of HIV from HIV-infected pregnant women to their infants during pregnancy, delivery, and breastfeeding and care and support services to the HIV-infected women and members of the families. ,, To reduce the risk of MTCT of HIV, every pregnancy in an HIV-infected woman should be a planned pregnancy.
Without any intervention, the infant of an HIV-infected pregnant woman has 25-45% risk of HIV infection during pregnancy, delivery, and breastfeeding. In the absence of breastfeeding, intrauterine (transplacental) infection and peripartum infection account for 25-40% and 60-75%, respectively, of vertical infection. ,,,
Among the subgroup of HIV-positive women in Zaria who were using modern contraceptives, male condom (60%) was the most commonly used contraceptives similar to reports from Enugu, Jos, India, and Soweto.  Male condoms were used either alone by their male partners or part of the dual-contraceptive method. Nowhere, in the world, is the consistent and correct use of condom more important than in SSA in preventing STI infection including HIV. The effective and consistent use of condom alone has the potential to offer dual protection, thus reducing the burden of unwanted pregnancy and HIV infection in the subregion.
The study also revealed that the use of injectables (52%) and oral pills (35%) were common among HIV-positive women attending ART clinic in Zaria. This is slightly higher than the findings from a study in Namibia where about 32% were using injectables.  This is a reasonable percentage, which can be explained by the convenience and privacy of injectable contraceptives. In this regard, women only have to go to a service delivery point every 2-3 months and can do so without their partner's knowledge should they not approve. The lower percentage of use of hormonal contraceptives compared to condoms can be explained by the side effects that often accompany their use.
Only about 1% reported use of female condom. Although the female condom has a higher risk of unintended pregnancy rate compared with the male condom,  it has the advantage of being under the control of the woman and should be encouraged in combination with other modern contraceptives for dual protection. The low use of female condom observed in the present study might be due to the scarcity, and in some places, the nonavailability of the female condom in most health facilities in Nigeria.
There seems to be limited use of noncondom contraceptives among HIV-positive women in Zaria. The use of long-acting reversible contraceptives (LARC) (intrauterine devices [IUD] and implant) reported in the present study was relatively low (1.1% each) despite the safety and effectiveness of these methods. This finding may be due to low awareness of the safety of LARC among HIV-positive women and their health provider. Further studies are necessary to confirm this assumption; however, Ezugwu et al. (2014) reported that the clinician's perception that the IUD and implant are inappropriate for HIV-positive women, despite evidence to the contrary, might affect usage. 
Age was found to be significantly associated with contraceptive use [Table 4] from this study. Age is one of the most important demographic factors that affect different use of family planning methods. Older women tend to use family planning more than young women because couples usually use family planning methods only after they have reached a desired family size which usually corresponds to older ages and parities of women. Older women, on the other hand, tend to opt for more permanent methods of family planning such as sterilization, may be because they are too old to take care of children and due to the fear of being sicker being HIV-positive. Most of the young women are single and their sexual activities are sporadic, and therefore, they do not use family planning more compared to older women and most of them use condoms more than hormonal family planning methods.
|Table 4: Relationship between age, educational status, and use of contraception among human immunodeficiency virus-positive women of reproductive age group attending antiretroviral clinic (n=260) |
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Educational level of a woman was also found to be significantly associated with contraceptive use (P = 0.0001) [Table 4]. The study revealed that women with tertiary education had the highest (52%) usage rate, followed by secondary level (36%) while those women who did not have any education had the lowest usage rate (11%).This supports the finding in Namibia which showed that there was a positive association between respondent's educational level and the level of use of family planning. 
| Conclusion|| |
About three-fourth of participants have ever heard of contraception, of whom majority got their information from the health workers/CHEWs. Condoms (65%), injectables (64%), and oral pills (35%) were the most frequent types of contraceptive that respondents had heard of. Contraceptive prevalence among these HIV-positive women was 56.1%; still, about 36% of these women who did not desire pregnancy were not using any form of contraceptive method. Male condom (60%) was the most commonly used contraceptive, used either alone or part of a dual contraceptive method. Injectables (52%) and oral pills (35%) were the next common methods favored by the respondents. The most common reasons for nonusage were fear of side effects and desire for more children. About 7.8% of respondents who have ever used contraception had unplanned pregnancy while using contraceptives. Injectables and oral pills (both 45.5%) were the most common contraceptives that women became pregnant while using.
- Results of this study show that majority of these HIV-positive women had a good knowledge about contraception but they do not apply this knowledge they have toward using an appropriate family planning method. Hence, there is a need for proper counseling and education of couples to erase fear and misconceptions of modern contraception as they attend the antiretroviral clinic by the health care workers. Male involvement will also go a long way in promoting contraceptive utilization
- Use of noncondom contraceptives, especially LARC such as intrauterine contraceptive device and implants, which was found to be low, should also be advocated
- Female condom should be made readily available in all health facilities, especially for HIV-positive women
- Family planning services should be promoted and modern contraceptives made easily accessible and affordable to HIV-positive women desirous of either child spacing or limiting their family size.
Furthermore, the dual-contraceptive method should be encouraged among HIV-positive women with emphasis on consistent and effective use of the condom.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]