Low Rates of Contraception Use in Women With Human Immunodeficiency Virus

Abstract

Background: Women with human immunodeficiency virus (WWH) have low rates of hormonal or long-acting contraceptive use. Few studies have described contraception use among WWH over time.

Methods: We examined contraception (including all forms of hormonal contraception, intrauterine devices, and bilateral tubal ligations) use among cisgender women aged 18-45 years in care at Vanderbilt's human immunodeficiency virus (HIV) clinic in Nashville, Tennessee, from 1998 through 2018. Weighted annual prevalence estimates of contraception use were described. Cox proportional hazards models examined factors associated with incident contraception use and pregnancy.

Results: Of the 737 women included, median age at clinic entry was 31 years; average follow-up was 4.1 years. At clinic entry, 47 (6%) women were on contraception and 164 (22%) were pregnant. The median annual percentage of time on any contraception use among nonpregnant women was 31.7% and remained stable throughout the study period. Younger age was associated with increased risk of pregnancy and contraceptive use. Psychiatric comorbidity decreased likelihood of contraception (adjusted hazard ratio [aHR], 0.52 [95% CI {confidence interval}, .29-.93]) and increased likelihood of pregnancy (aHR, 1.77 [95% CI, .97-3.25]). While not associated with contraceptive use, more recent year of clinic entry was associated with higher pregnancy risk. Race, substance use, CD4 cell count, HIV RNA, smoking, and antiretroviral therapy were not associated with contraception use nor pregnancy.

Conclusions: Most WWH did not use contraception at baseline nor during follow-up. Likelihood of pregnancy increased with recent clinic entry while contraception use remained stable over time. Continued efforts to ensure access to effective contraception options are needed in HIV clinics.

Keywords: HIV; contraception; family planning; pregnancy; women.

Figure 1.

Proportion of person-time by contraception use of nonpregnant women per calendar year, weighted by individual observation time per year. Source: North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) Vanderbilt. Abbreviations: HIV, human immunodeficiency virus.

Figure 2.

Multivariable proportional hazard models for contraception initiation and for pregnancy. Models included 526 women not on contraception nor pregnant at clinic entry, of whom 142 initiated contraception and 84 became pregnant during follow-up. Multivariable models included the following covariates: age at clinic entry, year of clinic entry, race, psychiatric comorbidity at clinic entry, any history of substance use, any history of smoking, time-varying antiretroviral therapy use, time-varying human immunodeficiency virus RNA ≥400 copies/mL, and time-varying CD4 cell count. Abbreviations: ART, antiretroviral therapy; CI, confidence interval.

Figure 3.

Estimated cumulative incidence of contraception use among patients who were not on contraception and not pregnant at baseline (A) and patients who had first pregnancy during follow-up (B).