Canadian researchers call for improved integration of family planning care for HIV-positive women

• Canadian study finds 60% of pregnancies among HIV-positive women were unintended.
• Among HIV-positive women, unintentional pregnancies were more common if they were younger, single or born in Canada.
• Researchers highlight the need to integrate family planning within comprehensive HIV care.

A team of Canadian researchers has analysed a comprehensive survey of HIV-positive women living in British Columbia, Ontario and Quebec. The survey focused on pregnancy-related issues. The researchers found that about 25% of women disclosed that they became pregnant after their HIV diagnosis. About 60% of pregnancies were unintended. As a result, the researchers suggested that “a gap in family planning specific to HIV-positive women exists.” Furthermore, the researchers said that their finding “underscores the need for improved integration of family planning care as part of comprehensive HIV care for women.”

Study details

Researchers with the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) used several methods—word of mouth, advertisements in HIV clinics, community clinics and social media (Facebook, Twitter)—to recruit 1,165 HIV-positive women between August 2013 and May 2015.

The average profile of women upon entering the study was as follows:

• age – 41 years
• major ethno-racial groups – white: 41%; African/Caribbean/Black: 30%; Indigenous: 22%
• province of residence – BC: 24%; Ontario: 52%; Quebec: 24%
• 31% had a history of injecting street drugs

Results—Pregnancy

The researchers found that 278 of the women reported a total of 492 pregnancies after being diagnosed with HIV. Furthermore, 60% of those pregnancies were unintentional.

Here are the outcomes for most of the pregnancies reported by the women:

• single or multiple live births – 57%
• terminated – 21%
• miscarriages or stillbirths – 19%

Among the live births, here are the results of HIV testing on the infants:

• HIV negative – 95%
• HIV positive – less than 1%
• testing underway (at the time of the interview) – less than 1%
• unknown – 3%

Trends with recent or current pregnancies

Researchers studied 265 of the women who had a recent or current pregnancy. In this group of women, those who reported their pregnancy as unintentional were more likely to have the following factors (compared to women whose pregnancies were intentional):

• being single
• being younger (at the time of conception)
• born in Canada

Furthermore, the researchers stated that women whose recent/current pregnancy was unintentional “were more likely to report feeling unhappy about [that pregnancy] and identifying the pregnancy experience as ‘one of the worst times of her life’.”

The researchers found that women whose pregnancy was unintentional were more likely to disclose that they had terminated their pregnancy.

Pregnancy after an HIV diagnosis

The researchers noticed that the chances of pregnancy increased over time, after women began taking HIV treatment (commonly called ART). For instance, the chance of becoming pregnant was distributed as follows:

• chance of becoming pregnant one year after HIV diagnosis – 3%
• chance of becoming pregnant five years after HIV diagnosis – 17%
• chance of becoming pregnant 10 years after HIV diagnosis – 27%
• chance of becoming pregnant 20 years after HIV diagnosis – 32%

In the current era there are likely several factors that played a role in the increased rate of pregnancy that the researchers found, which they suggested were as follows:

• longer life expectancy (due to ART)
• improved overall health and fertility
• increased sexual activity

Comparisons

In the present study, about 60% of pregnancies among HIV-positive women were unintended. One study from the United States that focused on 620 pregnancies in HIV-positive women found that nearly 70% of pregnancies were unplanned. Among HIV-negative Canadian women, researchers estimate that about 27% are unintended.

For the future

Based on their study, the researchers said that their finding “underscores the need for improved integration of family planning care as part of comprehensive HIV care for women.” A similar finding has also emerged from a recent study in the U.S.

Resources

Canadian HIV women’s sexual and reproductive health cohort study (CHIWOS) – CIHR Canadian HIV Trials Network (CTN)

Prevention of vertical HIV transmission and management of the HIV-exposed infant in Canada in 2014 – Canadian Paediatric and Perinatal AIDS Research Group

Canadian HIV pregnancy planning guidelines

HIV screening in pregnancy

Guidelines for the care of pregnant women living with HIV and interventions to reduce perinatal transmission: Executive Summary

Recommendations for Use of Antiretroviral Drugs During Pregnancy from The Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women and Interventions to Reduce Perinatal HIV Transmission in the United States

La thérapie antirétrovirale pour les adultes infectés par le VIH : Guide pour les professionnels de la santé du Québec – Ministry of Health and Social Services of Quebec

Pregnancy Planning Information for HIV+ Women and Their Partners – Women’s College Hospital

—Sean R. Hosein

REFERENCES:

1. Salters K, Loutfy M, de Pokomandy A, et al. Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada. PloS One. One. 2017 Jul 20;12(7):e0180524.
2. Jones DL, Cook R, Potter JE, et al. Fertility desires among women living with HIV. PLoS One. 2016 Sep 9;11(9):e0160190.
3. Tepper NK, Krashin JW, Curtis KM, et al. Update to CDC’s U.S. medical eligibility criteria for contraceptive Use, 2016: Revised recommendations for the use of hormonal contraception among women at high risk for HIV infection. Morbidity and Mortality Weekly Report. 2017 Sep 22;66(37):990-994.