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Modern contraceptive prevalence rates differ across Southeast Asian countries due to the different levels of socio-economic development, cultural practices, and women's empowerment. This study investigates the relationship between women's empowerment and modern contraceptive use in Cambodia, Indonesia, Myanmar, and the Philippines, where Demographic and Health Surveys data are available. The main study variables include modern contraceptive use (as measured by the percentage of married women aged 15-49 currently using a modern contraceptive method) and women's empowerment measures, which include asset ownership, household decision-making, and attitudes towards spousal violence. Binary logistic regression is used to assess the association between modern contraceptive use and women's empowerment, controlling for the effects of women's age, education, work status, exposure to mass media, exposure to family planning via media, place of residence, wealth index, age at marriage, and number of living children. Results show that pills and injections were commonly used across the countries under study. Multivariate analysis reveals that women with greater empowerment were more likely to use a modern contraceptive method, but the effect varied across women's empowerment indicators. It is important to empower women in the household as disempowered women tend to neglect their rights to access primary health care, which could jeopardize their health. Hence, empowering women remains an important agenda for improving modern contraceptive use within Southeast Asian countries. Keywords: Women's empowerment, Contraception, Family planning, Southeast Asia, Binary logistic regression, Introduction Reproductive rights are fundamental human rights in the sphere of development and population concerns (United Nations Population Fund [UNFPA], 2014). Family planning practice allows women to control the frequency [...]

Objectives Although multi-component policy interventions can be important tools to increase access to contraception, we know little about how they may change contraceptive use among postpartum women. We estimate the association of the Delaware Contraceptive Access Now (DelCAN) initiative with use of postpartum Long-Acting Reversible Contraception (LARC). DelCAN included Medicaid payment reform for immediate postpartum LARC use, provider training and technical assistance in LARC provision, and a public awareness campaign. Methods We used a difference-in-differences design and data from the 2012 to 2017 pregnancy risk assessment monitoring system to compare changes in postpartum LARC use in Delaware versus 15 comparison states, and differences in such changes by women's Medicaid enrollment. Results Relative to the comparison states, postpartum LARC use in Delaware increased by 5.26 percentage points (95% CI 2.90-7.61, P < 0.001) during the 2015-2017 DelCAN implementation period. This increase was the largest among Medicaid-covered women, and grew over the first three implementation years. By the third year of the DelCAN initiative (2017), the relative increase in postpartum LARC use for Medicaid women exceeded that for non-Medicaid women by 7.24 percentage points (95% CI 0.12-14.37, P = 0.046). Conclusions for Practice The DelCAN initiative was associated with increased LARC use among postpartum women in Delaware. During the first 3 years of the initiative, LARC use increased progressively and to a greater extent among Medicaid-enrolled women. Comprehensive initiatives that combine Medicaid payment reforms, provider training, free contraceptive services, and public awareness efforts may reduce unmet demand for highly effective contraceptives in the postpartum months., Author(s): Mónica L. Caudillo [sup.1] , Constanza Hurtado-Acuna [sup.1] , Michael S. Rendall [sup.1] , Michel Boudreaux [sup.2] Author Affiliations: (1) grid.164295.d, 0000 0001 0941 7177, Department of Sociology, University [...]

Objectives To compare the prevalence of highly effective contraceptive use by 12 weeks postpartum among participants of Centering Pregnancy®, a model of group prenatal care (GPC), and traditional prenatal care (TPC), and to investigate differences in contraceptive method choice by type of prenatal care. Methods We performed a retrospective review of all eligible patients who participated in GPC (n = 143) and a random sample of patients participating in TPC (n = 290) who followed up at our institution within 12 weeks of delivery. Our primary outcome was the proportion of participants using a highly effective contraceptive method within 12 weeks postpartum. Contraceptives were classified in tiers (Tier 1, long-acting reversible and permanent contraception; Tier 2, oral contraceptive pills, transdermal patch, vaginal ring, or injection; Tier 3, barrier and fertility awareness methods, withdrawal, spermicide; and no method). Tier 1 and Tier 2 methods were considered highly effective. Results The prevalence of highly effective contraceptive use by 12 weeks postpartum was 63.6% (91 of 143) and 63.1% (183 of 290) among participants in GPC and TPC, respectively (p = 0.99). We found no difference in Tier 1 versus other method use (adjusted odds ratio (aOR) 1.05, 95% CI 0.95-1.15, p = 0.34) or Tier 2 versus other method use between groups (aOR 0.98, 95% CI 0.89-1.08, p = 0.69), in a multivariable model controlling for demographic and clinical factors. Conclusions for Practice The prevalence of highly effective contraceptive use at 12 weeks postpartum was not different between GPC and TPC participants in this study. GPC was not associated with increased use of Tier 1 or Tier 2 contraceptive methods., Author(s): Aishat Olatunde [sup.1] , Safiyah Hosein [sup.1] [sup.2] , Andrew Paoletti [sup.1] , Alexis Pitcairn-Ramirez [sup.1] [sup.3] , Elizabeth P. Gurney [sup.1] [sup.4] Author Affiliations: (1) grid.239276.b, 0000 0001 [...]

Narratives about birth control provide a window into the cultural responses to current contraceptive methods and can be used to achieve greater satisfaction among contraceptive users through the informed expansion of options. Stories about negative effects attributed to hormonal contraception and rumors about male birth control express social complaint about the burden of birth control on women. They also reveal a preference for nonhormonal and male options, which form a small proportion of currently available methods. KEYWORDS: birth control, contraception, reproductive health, narrative, rumor, When I was working in a public-health program for new mothers some time ago, I was required to ask my clients what form of birth control they planned to use [...]

Objective State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. Methods A retrospective cohort of women aged 15-45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. Results Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41-0.49 and APR = 0.13, 95% CI 0.10-0.17; Low income families APR = 0.82; 95% CI 0.77-0.88 and APR = 0.33, 95% CI 0.28-0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68-0.77 and APR = 0.35, 95% CI 0.30-0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. Conclusions for Practice The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women., Author(s): Nathan Hale [sup.1] , Wondimu S. Manalew [sup.1] , Edward Leinaar [sup.1] , Michael Smith [sup.1] , Bisakha Sen [sup.2] , Pradeep Sharma [sup.3] , Amal Khoury [sup.1] Author [...]

Objectives The aim of this study is to explore the factors that could predict contraceptive use. This will help develop interventions to increase the use of family planning methods among Syrian refugees. Methods We conducted a cross sectional survey on a random sample of male and female Syrian refugees residing in Lebanon. Data collection took place between September 2016 and February 2017 collected from 5 districts: Bekaa, Beirut and Mount Lebanon, North, and South Lebanon. Seven hundred and ninety-five Syrian refugees (males and females) were recruited from health care centers in areas with greatest concentration of Syrian refugees. The data were entered and analyzed using SPSS Version 22.0. Student t test was used for continuous variables and Chi-square test for categorical variables along with logistic regression models. Statistical significance was achieved at p-value < 0.05. Results Around 40% of the Syrian refugees currently use contraceptives. After adjusting for covariates, factors associated with use of contraceptives were discussing contraception use with a health care practitioner, originating from Damascus, planning for the desired number of children, and receiving any form of external assistance. On the other hand, factors associated with lack of use of contraceptives were residing in South Lebanon or Bekaa and living in unfinished buildings, work sites, or unused garage, with two or less rooms. Conclusions Contraception use among Syrian refugees in Lebanon is multifactorial with some factors being modifiable. Efforts should be made to educate and motivate health care practitioners to discuss contraceptive use with refugees for optimal public health outcomes that would protect women from the risks of unintended pregnancies., Author(s): Jinan Usta [sup.1] , Rim Taleb [sup.2] , Sarah El Harakeh [sup.2] , Rana El Kheir [sup.2] , Malak Jbahi [sup.2] , Shatha Dassouki [sup.2] , Issam Shaarani [sup.2] [...]

Government agencies, NGOs and medical personnel profess competing perceptions on Sri Lanka's female Free trade Zone (FTZ) workers' reproductive health needs. Varied statistical sources also present and interpret the overall reproductive health outcomes for FTZ workers in differing ways. In this extraordinarily saturated field of power, where different agents and agencies jostle for legitimacy to speak for female global factory workers, the overarching question is where the women workers themselves stand? How do they perceive and respond to discourses and practices within this field? What are their experiences of reproductive health and knowledge and how have their attitudes changed over time? Based on 15 in-depth interviews with workers and a reproductive health survey of 100 workers, this paper seeks to answer these questions. The analyses are also informed by numerous interviews with NGO staff, government officials, health professionals and educators. \ The continuing cultural restrictions and resultant practices of denial and silence surrounding premarital sex render contraceptive usage an 'after thought,' leading to workers believing that emergency contraceptives alone allow them agency when managing reproductive choices. While the number of agents and agencies vying to speak for workers' reproductive rights has increased, nothing much has changed for workers at the ground level, making them marginal actors in these discourses and policy-wars. By demonstrating that workers are neither ignorant about reproductive technology nor naive about the difficulties encountered when exercising their reproductive rights, I argue that their choice of morning-after pill and abortions is, in fact, a critique of the actors and agencies who represent and advocate for FTZ workers based on their own particular agendas. Keywords: Reproductive health, Emergency contraceptives, Global factory workers, Sri Lanka, In-depth interviews., Introduction In July 2018 Nitha, an NGO staff member agitatedly complained that the chief nursing officer of the Katunayake Medical Health Office (MHO), located within the Katunayke Free Trade Zone [...]

Byline: Elbert. Khiangte, Iheule. Khiangte, Nitya. Naiding, Kunal. Deka, Ronald. Bathari, Jimmy. Doungel Intrauterine contraceptive devices (IUCDs) are the most commonly used reversible contraceptive methods. Uterine perforation followed by transmigration [...]

Introduction: Young women in Southern Africa have extremely high HIV incidence rates necessitating the availability of female-controlled prevention methods. Understanding adolescent preference for seeking contraception would improve our understanding of acceptability feasibility and adherence to similar modes of delivery for HIV prevention. Methods: UChoose was an open-label randomized crossover study over 32 weeks which aimed to evaluate the acceptability and preference for contraceptive options in healthy HIV-uninfected, female adolescents aged 15 to 19 years, as a proxy for similar HIV prevention methods. Participants were assigned to a contraceptive method for a period of 16 weeks in the form of a bi-monthly injectable contraceptive, monthly vaginal Nuvaring[R] or daily combined oral contraceptive (COC) and then asked to state their preference. At 16 weeks, participants crossed over to another contraceptive method, to ensure that all participants tried the Nuvaring[R] (least familiar modality) and additionally either the injection or COC. Primary outcomes were contraceptive acceptability and preference. At the end of the 32 weeks they were also asked to imagine their preference for an HIV prevention modality. Secondary endpoints included changes in sexual behaviour, contraceptive adherence and preference for biomedical and behavioural HIV prevention methods. Results: Of the 180 participants screened, 130 were enrolled and randomized to the Nuvaring[R] (n = 45), injection (n = 45) or COC (n = 40). Significantly more Nuvaring[R] users (24/116; 20.7%) requested to change to another contraceptive option compared to injection (1/73; 1.4% p = 0.0002) and COC users (4/49; 8% p = 0.074). Of those that remained on the Nuvaring[R], adherence was significantly higher than to COC (p < 0.0001). Significantly more injection users (77/80; 96.3%) thought this delivery mode was convenient to use compared to Nuvaring[R] (74/89; 83.1%; p = 0.0409) or COC (38/50; 76.0%; p = 0.0034). Overall, the preferred contraceptive choice was injection, followed by the ring and lastly the pill. Conclusions: Adherence to daily COC was difficult for adolescents in this cohort and the least favoured potential HIV prevention option. While some preferred vaginal ring use, these data suggest that long-acting injectables would be the preferred prevention method for adolescent girls and young women. This study highlights the need for additional options for HIV prevention in youth. Keywords: HIV prevention; youth; South Africa; preference; adolescent girls; adherence, 1 | INTRODUCTION South Africa has the highest burden of HIV in the world with a national prevalence of 18.9% [1-3]. Adolescent girls and young women account for 29% of [...]

Introduction: Some observational data suggest that the progestogen injectable contraceptive depot medroxyprogesterone acetate (DMPA) may increase a woman's risk of HIV acquisition but a randomized clinical trial did not find a statistically significant increase in HIV risk for women using DMPA compared to two other methods. However, it could not rule out up to 30% increased HIV risk for DMPA users. We evaluate changes to contraceptive method mix in South Africa under different assumptions about the existence and strength of a possible undetected relationship between DMPA use and HIV risk. Methods: A mathematical model was developed to simulate the ongoing HIV epidemic and contraceptive method mix in South Africa to estimate how changes in method mix could impact HIV- and reproductive health-related outcomes. We made different assumptions about the relationship between DMPA use and HIV risk, from no relationship to a 30% increase in HIV risk for women using DMPA. Scenario analyses were used to investigate the impact of switching away from DMPA predominance to new patterns of contraceptive use. Results: In South Africa, the HIV-related benefits of reduced DMPA use could be as great as the harms of increased adverse reproductive health outcomes over 20 years, if DMPA did increase the risk of HIV acquisition by a relative hazard of infection of 1.1 or greater. A reduction in DMPA use among HIV-positive women would have no benefit in terms of HIV infections, but would incur additional negative reproductive health outcomes. The most important driver of adverse reproductive health outcomes is the proportion of women who switch away from DMPA to no contraceptive method. Conclusions: If there is any real increased HIV risk for DMPA users that has not been detected by the recent randomized trial, a reduction in DMPA use could reduce the ongoing number of new HIV infections. However, such a change would place more women at risk of adverse reproductive health effects. It is imperative that these effects are minimized by focusing on expanding access to safe, effective and acceptable alternative contraceptive methods for all women. Keywords: HIV; hormonal contraception; theoretical models; pregnancy complications; women; South Africa, 1 | INTRODUCTION Increasing access to modern contraceptive methods has been vital to global development over the past 30 years [1, 2]. The use of safe and effective methods of [...]

Background Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception. Objective To understand women's contraceptive needs and perceptions of accessing contraception through telehealth services. Methods Researchers conducted 52 in-depth interviews with women ages 18-44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2. Results Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women's complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women's overall health and well-being. Conclusions for Practice Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women's access to contraceptive methods in rural areas., Author(s): Beth Sundstrom [sup.1] , Andrea L. DeMaria [sup.2] , Merissa Ferrara [sup.1] , Stephanie Meier [sup.2] , Deborah Billings [sup.3] Author Affiliations: (Aff1) 0000 0004 1936 7769, grid.254424.1, Department [...]

Introduction To provide quality family planning services and reduce racial and socioeconomic disparities in unintended pregnancy and pregnancy outcomes, primary care clinicians should routinely assess women's reproductive health needs and provide patient-centered contraceptive and preconception counseling. One Key Question® asks women if they would like to become pregnant in the next year and prompts clinicians to provide counseling appropriate to each patient. We conducted a pilot study to assess if implementing One Key Question® in the Electronic Medical Record (EMR) of an urban community health center, coupled with brief clinician training, would increase rates of contraceptive and preconception counseling. Methods We incorporated One Key Question® into a new EMR form and provided a brief training to primary care clinicians on reproductive life plan assessment, preconception counseling, and contraception. We surveyed women patients, ages 18-49, after their visit and compared pre- vsersus post-intervention rates of patient-reported contraceptive and preconception counseling. Results After One Key Question® was introduced in the clinic EMR and clinicians underwent brief training on its use, patients reported significantly higher rates of their clinician counseling them about contraception (52% vs. 76%, p = 0.040) and recommending a long-acting reversible contraceptive (LARC) method (10% vs. 32%, p = 0.035). There were no significant changes in preconception counseling. Discussion After EMR integration of One Key Question® coupled with brief clinician training, rates of contraceptive counseling and LARC recommendations increased in this community health center pilot study. Future research should compare One Key Question® to standard care in a prospective randomized trial., Author(s): Debra B. Stulberg [sup.1] , Irma H. Dahlquist [sup.1] , Judith Disterhoft [sup.2] , Jennifer K. Bello [sup.3] , Michele Stranger Hunter [sup.4] Author Affiliations: (Aff1) 0000 0004 1936 [...]

Introduction Unintended pregnancy during the postpartum period is common. The aim of this study was to describe contraceptive use among postpartum women and assess whether family planning counseling offered by health care providers during well-baby clinic visits increased use of modern contraceptive methods at 6 months following delivery. Methods Data comes from a cohort of women enrolled in a breastfeeding promotion trial in Kinshasa, Democratic Republic of Congo who reported being sexually active at 24-weeks post-partum. Modern contraceptive methods included intrauterine devices, injectables, implants, and contraception pills. Logistic regression models were used to estimate odd ratios (OR) and 95% confidence intervals (CI) for the impact of nurse counseling on use of modern birth control methods. Results Of 522 participants who reported being sexually active, 251 (48.0%) reported doing at least one thing to avoid pregnancy and were included in this analysis. Of these 251, 14.3% were using a modern contraceptive method, despite availability at the clinic. Discussion with a nurse about family planning was associated with increased odds of using modern birth control relative to other methods (OR 4.0, 95% CI 1.9, 8.6). Discussion Discussion of family planning with a nurse increased the odds of using a modern contraceptive among postpartum women. Integration of family planning counseling into postpartum services offers a potential avenue to increase modern contraceptive use among women with access., Author(s): Paul N. Zivich [sup.1] , Bienvenu Kawende [sup.3] , Bruno Lapika [sup.4] , Frieda Behets [sup.5] , Marcel Yotebieng [sup.2] Author Affiliations: (Aff1) 0000000122483208, grid.10698.36, Department of Epidemiology, Gillings [...]

Introduction: In many African settings, women concurrently face substantial risk of human immunodeficiency virus type 1 (HIV-1) infection, sexually transmitted infections (STIs) and unintended pregnancies. Few studies have evaluated STI risk among users of hormonal implants and copper intrauterine devices (IUDs) although these long-acting reversible contraceptive methods are being promoted widely because of their benefits. Within a prospective study of women at risk for HIV-1, we compared the risk of acquisition of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis among women using different contraceptive methods. Methods: MTN-020/ASPIRE was a randomized trial of the dapivirine vaginal ring for HIV-1 prevention among 2629 women aged 18 to 45 years from Malawi, South Africa, Uganda and Zimbabwe, of whom 2264 used copper IUDs or progestin-based injectables or implants during follow-up. Screening for the above STIs occurred semi-annually. Results: Over 3440 person-years of follow-up, 408 cases of C. trachomatis (incidence 11.86/100 person-years), 196 of N. gonorrhoeae (5.70/100 person-years) and 213 cases of T. vaginalis (6.19/100 person-years) were detected. C. trachomatis and N. gonorrhoeae incidence were not significantly different across contraceptive methods. T. vaginalis incidence was significantly higher for copper IUD users compared to depot medroxyprogesterone acetate (DMPA), implant and norethisterone enanthate users. Conclusion: Among African women at high HIV-1 risk, STIs were common. Risk of cervical infections did not differ across contraceptive methods. Significantly higher rates of T. vaginalis were observed among progestin-based methods compared to copper IUD users. Overall, these findings call for more intensive routine screening for STIs, and they support current World Health Organization guidance that women should have a wide range of contraceptive options. Keywords: hormonal contraception; sexually transmitted diseases; chlamydia; gonorrhoea; trichomoniasis, 1 | INTRODUCTION The World Health Organization (WHO) estimates that 357 million adults acquire one of four curable sexually transmitted infections (STIs: Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum and Trichomonas [...]

CONTEXT: Unsafe abortion is common in Kinshasa, which contributes to high rates of maternal morbidity and mortality. Little is known about the complications and treatment experienced by women seeking postabortion care at health facilities in the city. METHODS: Data from 867 women admitted to a sample of health facilities providing postabortion care in Kinshasa in 2016 were drawn from a Prospective Morbidity Survey. A measure of severity of postabortion complications was developed on the basis of information from these women and their primary care provider. Generalized ordered logistic regression analyses were used to examine associations between the characteristics of postabortion care patients and complication severity. RESULTS: Nearly three-fourths (72%) of postabortion care patients were classified as certainly having had an induced abortion, and another 16% as probably having had one. Sixteen percent of postabortion care patients experienced severe complications, 46% moderate complications and 33% mild complications; 5% had no evidence of complications. Severity of complications was associated with certain patient characteristics: For example, poor patients and those who had never been married had elevated odds of having experienced severe or moderate complications rather than mild or no complications (odds ratios, 1.8-1.9). Patients' complications were most commonly treated with such outdated methods as dilation and curettage and digital curettage (49% and 23%, respectively); only 11% of patients received medication for pain. CONCLUSIONS: Policies and programs promoting contraceptive use and safe legal abortion are needed in Kinshasa to reduce women's recourse to unsafe abortion. Improved quality postabortion care provision is also needed, including World Health Organization-recommended methods. International Perspectives on Sexual and Reproductive Health, 2018, 44(1):1-9, Although women's access to safe induced abortion seems to be improving in many parts of the world, largely because of increasing access to such safer abortion methods as medication abortion [...]

Objectives Ineffective and inconsistent contraceptive use is common among adults, perhaps due to limited knowledge about reproduction and unfavorable attitudes toward contraception. Knowledge and attitudes are first developed in adolescence. We test whether adolescent knowledge and attitudes have long-term implications for adult contraceptive behavior. Methods Using the National Longitudinal Survey of Adolescent to Adult Health, our analytical sample (n = 6662) consists of those asked sex and contraception questions at Wave I (1995; students aged 15 and older) and who were sexually active and not pregnant at the time of the Wave IV (2007-2008) survey. We examined whether adolescent attitudes toward contraception, knowledge of condoms and reproduction, and confidence in contraceptive knowledge were predictive of adult contraceptive efficacy and consistency using logistic regression. Results In models adjusted for a range of socioeconomic, demographic, and life course factors, favorable attitudes toward contraception in adolescence increased the odds (aOR 1.21, CI 1.08-1.36) of using more effective methods rather than a less effective or no method of contraception in adulthood, as did more accurate condom knowledge (aOR 1.07, CI 1.00-1.14) and more accurate reproductive knowledge (aOR 1.07, CI 1.00-1.13). Adolescents with more favorable attitudes toward contraception also used contraception more consistently as adults (aOR 1.27, CI 1.14-1.43), as did those with more accurate condom knowledge (aOR 1.10, CI 1.03-1.18). Conclusions Attitudes towards contraception and knowledge about condoms and reproduction acquired during adolescence are predictive of adult contraceptive behavior. Results suggest that comprehensive sex education during adolescence could improve effective contraceptive behavior throughout the life course., Author(s): Karen Benjamin Guzzo [sup.1] , Sarah R. Hayford [sup.2] Author Affiliations: (1) Department of Sociology, Bowling Green State University, 0000 0001 0661 0035, grid.253248.a, , 212 Williams Hall, 43403, [...]

CONTEXT: Pregnancy ambivalence and pregnancy indifference are thought to be associated with nonuse of contraceptives, but their conceptualization and measurement vary, and their relationship to contraceptive use in developing countries [...]

Background Women living with HIV (WLHIV) have lower rates of contraceptive use than noninfected peers, yet concerns regarding contraceptive efficacy and interaction with antiretroviral therapy (ART) complicate counseling. Hormonal contraceptives may increase genital tract HIV viral load (gVL) and sexual transmission risk to male partners. We compared gVL, plasma VL (pVL), and intrauterine contraceptive (IUC) continuation between the levonorgestrel intrauterine system (LNG-IUS) and copper intrauterine device (C-IUD) in Cape Town, South Africa. Methods and findings In this double-masked, randomized controlled noninferiority trial, eligible WLHIV were ages 18-40, not pregnant or desiring pregnancy within 30 months, screened and treated (as indicated) for reproductive tract infections (RTIs) within 1 month of enrollment, and virologically suppressed using ART or above treatment threshold at enrollment (non-ART). Between October 2013, and December 2016, we randomized consenting women within ART groups, using 1:1 permuted block randomization stratified by ART use, age (18-23, 24-31, 32-40), and recent injectable progestin contraceptive (IPC) exposure, and provided the allocated IUC. At all visits, participants provided specimens for gVL (primary outcome), pVL, RTI, and pregnancy testing. We assessed gVL and pVL across 6 and 24 months controlling for enrollment measures, ART group, age, and RTI using generalized estimating equation and generalized linear models (non-ART group pVL and hemoglobin) in as-treated analyses. We measured IUC discontinuation rates with Kaplan-Meier estimates and Cox proportional hazards models. We enrolled 71 non-ART (36 LNG-IUS, 31 C-IUD; 2 declined and 2 were ineligible) and 134 ART-using (65 LNG-IUS, 67 C-IUD; 1 declined and 1 could not complete IUC insertion) women. Participant median age was 31 years, and 95% had 1 or more prior pregnancies. Proportions of women with detectable gVL were not significantly different comparing LNG-IUS to C-IUD across 6 (adjusted odds ratio [AOR]: 0.78, 95% confidence interval [CI] 0.44-1.38, p = 0.39) and 24 months (AOR: 1.03, 95% CI: 0.68-1.57, p = 0.88). Among ART users, proportions with detectable pVL were not significantly different at 6 (AOR = 0.83, 95% CI 0.37-1.86, p = 0.65) and 24 months (AOR = 0.94, 95% CI 0.49-1.81, p = 0.85), whereas among non-ART women, mean pVL was not significantly different at 6 months (-0.10 log.sub.10 copies/mL, 95% CI -0.29 to 0.10, p = 0.50) between LNG-IUS and C-IUD users. IUC continuation was 78% overall; C-IUD users experienced significantly higher expulsion (8% versus 1%, p = 0.02) and elective discontinuation (adjusted hazard ratio: 8.75, 95% CI 3.08-24.8, p < 0.001) rates. Sensitivity analysis adjusted for differential IUC discontinuation found similar gVL results. There were 39 serious adverse events (SAEs); SAEs believed to be directly related to IUC use (n = 7) comprised 3 pelvic inflammatory disease (PID) cases and 4 pregnancies with IUC in place with no discernible trend by IUC arm. Mean hemoglobin change was significantly higher among LNG-IUS users across 6 (0.57 g/dL, 95% CI 0.24-0.90; p < 0.001) and 24 months (0.71 g/dL, 95% CI 0.47-0.95; p < 0.001). Limitations included not achieving non-ART group sample size following change in ART treatment guidelines and truncated 24 months' outcome data, as 17 women were not yet eligible for their 24-month visit at study closure. Also, a change in VL assay during the study may have caused some discrepancy in VL values because of different limits of detection. Conclusions In this study, we found that the LNG-IUS did not increase gVL or pVL and had low levels of contraceptive failure and associated PID compared with the C-IUD among WLHIV. LNG-IUS users were significantly more likely to continue IUC use and had higher hemoglobin levels over time. The LNG-IUS appears to be a safe contraceptive with regard to HIV disease and may be a highly acceptable option for WLHIV. Trial registration ClinicalTrials.gov NCT01721798., Author(s): Catherine S. Todd 1,*, Heidi E. Jones 2, Nontokozo Langwenya 3, Donald R. Hoover 4, Pai-Lien Chen 5, Gregory Petro 6,7, Landon Myer 3,8 Introduction Across sub-Saharan Africa, many [...]