Women living with HIV are still missing

highly effective contraception

Results from the ANRS-Vespa2 Study, 2011

Lert F , Maraux B, Bajos N, Dray.Spira R, Spire B, Annabel Desgrées du Loû, Hamelin C

and the Vespa2 study group

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Context• In Western Europe, increase of life expectancy, normalisation of life expectations

including sexual life and parental expectations Renewed needs regarding family planning

• Among new diagnoses, • More than half in women of childbearing age

• Large proportion in migrant women from Sub Saharan Africa (UNAIDS 2013)

• Contraception among women living with HIV• Still large dominance of condom as contraceptive method (Heard 2004, Massad 2007, Sun

2012)• No effect of hormonal contraception on the response to ART (Robinson 2012)• Safety of intrauterine device (Curtis 2009)

• Unmet need for contraception• High rates of unintended pregnancies with proportions ranging from 50% to 85% (Loufty 2013)

• Overall, scarcity of information on the contraceptive profile of women living with HIV (Haberl 2013, Sutton 2014)

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Objectives

Describe the pattern of contraceptive use among women living with HIV in France (2011)

• To estimate the proportion of women of childbearing age concerned with contraception

• To document contraceptive methods • To assess the correlates of highly effective contraceptive

methods (HEC)

Methods

The ANRS-VESPA2 study, France, 2011

•Cross-sectional national representative survey of HIV-positive hospital outpatients•Face-to -face questionnaire using standardized questions on contraception•Weighted data to account for sampling and participation bias

Study population

• Women in childbearing age (18-49 years) n=662• women born in sub-Saharan Africa : 56 %• Other women 44 % = French native women (38%) and other migrant women (6%)

Frequency and characteristics of women concerned by contraception

•Frequency of methods of contraception•Stratified univariate logistic regression to explore the correlates of highly effective methods (HEC) vs Condom.

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Variables of interest

• Sexually active in the past 12months• Able to conceive (not sterile, not menopausal)• Neither pregnant nor seeking to be pregnant at

time of data collection

Women concerned by contraception

• Highly effective contraception (HEC)• Pill , Intra Uterine Device, Implant, Medical sterilization

• Condoms• None or traditional methods (withdrawal, periodic

abstinence)

Methods of contraception

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Distribution of women of childbearing age according to the need of contraception

22%

15%

14%

49%

n=327

Sexually inactive>12months

Being or seeking pregnancy

Infertile or Menopausal

Concerned by contraception

Characteristics of women concerned by contraception according to country of birth

 Migrant women

from sub-Saharan Africa N=174

Other women(French native and

other migrants) N=153

p.

Social and reproductive factors

Age (median) 32 years 42 years 0.001

With children 69 % 29 % 0.001

Time since diagnosis 6 years 17 years 0.001

Current stable partner 86 % 81% 0.27

Currently employed 48 % 56% 0.27

Severe material deprivation 43 % 26% 0.001

Access to HEC factors

Full health insurance coverage 51 % 80% 0.001

Visit to a gynaecologist<12months 77 % 81% 0.52

Medical factors

On ART 86 % 91% 0.22

Cardiovascular risk 16% 8% 0.067

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Methods of contraception

61%9%

12%

18%

Condom Double protection (HEC+Condom)

HEC None or traditional methods

Migrant women from sub-Saharan Africa N=174

p. = ns56%

9%

12%

23%

Other women (French natives and

other migrants) N=153

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Correlates of highly effective methods vs. condoms among women on contraception

    Migrant women from SSA N=146

Other women (French natives and other migrants) N=120

  Crude OR 95% IC p. Crude OR 95% IC p.

Age (years) 18-2930-3940-49

5.92.61

1.5-22.60.8-7.7

0.03 

0.61.91

0.9-3.20.7-5.5

0.31

At least one children Yes vs No 3.7 1.7-8.0 0.001 1.6 0.9-3.0 0.10

Current stable partner Yes vs No 1  1,0-1.0 0.20 4.5  1.2-17.2 0.02

Current employment Yes vs No 2.4  1-5.61 0.05 0.9  0.4-2.5 0.91

Severe material deprivation

Yes vs No 1.4 0.5-4.0 0.50 3.3  1.4-9.8 0.001

No statistical association with health insurance, visit to a gynaecologist, cardiovascular risk.

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Discussion (1/3)

Contraceptive patterns of women living with HIV

• One in five women is not using any modern contraceptive method : much higher than in the general population (9%, Bajos, 2012)

• Among women on contraception, condom has remained the most used contraceptive method (# 75%)

• No significant difference between migrant women from sub-Saharan Africa and other women regarding the use of contraceptive method

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Discussion (2/3)

Correlates of highly effective contraception methods • Difference in correlates of highly effective contraception methods

between Sub-Saharan women and other women (French native and other migrants)– Among migrant women from sub-Saharan africa

• Children : After delivery, heath professionals might offer a broader range of contraceptive methods in maternity hospitals

• Employment : a possible acculturation pathway

– Among French and other migrant women • Casual partnership associated with more condom : low sexual activity

(29% with sexual intercourse in the last 4 weeks)

• Low use of highly effective method : not an accessibility issue– No association with health insurance, 80% of women with a gynecologist

visit in the 12 month period– Physicians’ attitudes ?

Do they provide women living with HIV with the full range of contraceptive options ?

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Discussion (3/3)

Strengths and limitations of the Vespa2 study

Strengths

• Vespa2 study : a nationwide representative survey of women living with HIV in France• Contraceptive patterns were documented with a standardized questionnaire

Limitations

• Vespa2 questionnaire did not documented unintented pregancies and history of abortions.

• Not enough statistical power to perform a stratified multivariate logistic regression of correlates of contraception methods.

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Conclusion

In the future, preventive effect of ART in HIV transmission might further decrease the level of condom use

WHO recommendations, 2012 “Women living with HIV can safely use hormonal contraceptives”

Need to promote the concept of DUAL PROTECTION

To provide women living with HIV with the full range of contraceptive options, communication is urgently needed towards HIV care specialists,

gynaecologists, GPs and towards women as well.

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Acknowledgements

• The VESPA2 survey was sponsored and funded by the French National Agency for Research on Aids and Viral Hepatitis (ANRS). We thank all PLWHIV who agreed to participate in the ANRS VESPA2 survey, all medical staff members in the participating hospitals, as well as the community-based organisations AIDES and Act-Up Paris who supported the survey.

• The ANRS VESPA2 Study Group: France Lert and Bruno Spire (scientific coordinators), Patrizia Carrieri, Rosemary Dray-Spira, Christine Hamelin, Nicolas Lorente, Marie Préau and Marie Suzan-Monti, with the collaboration of Marion Mora.

• Methodological and ground support: Yann Le Strat (InVS, Saint-Maurice), Lise Cuzin (Hôpital Purpan, Toulouse), Laurence Meyer (Cesp, Inserm, Le Kremlin Bicêtre), Daniela Rojas-Castro (Aides, Pantin) and Hugues Fischer (Act-Up Paris).

• Data collection: The ClinSearch firm and the social research institute Ipsos.

• Participating hospitals and investigators