Journal of Public Health Policy and Planning

Research Article - Journal of Public Health Policy and Planning (2017) Volume 1, Issue 2

Factors influencing contraceptive uptake among sexually active HIV positive clients in TASO Masaka, Uganda.

Ivan Magala*, Lilian Onega, Nalubega Rose, Serunjogi Patrick

The Aids Support Organization, Uganda

Corresponding Author:
Ivan Magala
The Aids Support Organization, Uganda
E-mail: [email protected]

Received date: October 27, 2017; Accepted date: October 29, 2017; Published date: October 31, 2017

Citation: Magala I, Onega L, Rose N, et al. Factors influencing contraceptive uptake among sexually active HIV positive clients in TASO Masaka, Uganda. J Public Health Policy Plann. 2017;1(2):46-49.

Copyright: © 2017 Magala I, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Globally the prevalence rates of contraceptives are 63% and unmet need for family planning is 11%. Uganda's total fertility rate (TFR) of 6.2 has resulted in a population growth rate of 3.2%, the fastest in Africa and the third highest in the world. Uganda also has a high unmet need for FP services of 41. The study aimed at finding out client limiting factors and health worker factors affecting contraceptive use among clients. The study targeted sexually active clients in five clinics 2 outreaches and 3 facilities. The study discovered a high unmet need for family planning at 37%. Client’s choice of method was due to personal influence. Side effects prevented clients from using contraceptives; desire to have more children and ART interactions. Condoms and injection was high among methods used. Health workers need to come up with strategies to address the unmet need for contraceptive use, addressing side effects and social cultural practices that affect contraceptive use.

Keywords

HIV, Fertility rate, Family planning.

Background

Globally the prevalence rates of contraceptives are 63% and unmet need for family planning is 11% [1]. Uganda's total fertility rate (TFR) of 6.2 has resulted in a population growth rate of 3.2%, the fastest in Africa and the third highest in the world. The contraceptive prevalence rate (CPR) among married women, which has recently improved from 24% to 30% [2], is still unfortunately low. Uganda also has a high unmet need for FP services of 41% [3,4].

Family planning is prong 2 for e-mtct. The effective use of family planning methods (as dual protection) to HIV positive women may contribute to the primary prevention of HIV to the unborn child by 30% [5,6].

Based on the findings of Adding It Up, a joint Guttmacher/ UNFPA report [7] they argued that doubling that modest investment in FP and maternal child health programmes would result in a 70% reduction in maternal deaths and a 44% reduction in the deaths of new-borns with additional health, societal and economic benefits [8].

HIV prevalence in this region is 7.5%-10%.

The face of the HIV/AIDS epidemic has changed dramatically since its emergence in the 1980s. Far from its origins as an illness of homosexual men, HIV/AIDS is increasingly aecting women around the world: in 2008, women made up nearly half of the global population of those infected with HIV (15.7 million women, 33.4 million total) [1]. While spread of the epidemic has slowed, addressing the health needs of women infected with HIV remains an important priority. Recent eorts have largely focused on expanding access to HIV diagnosis and counselling, as well as treatment with highly active antiretroviral therapy (HAART). Providing reproductive health services to women living with HIV is crucial to improving their overall health. Preventing unplanned or mistimed pregnancy allows a woman with HIV to optimize her own health and has the potential to decrease maternal-to-child transmission of HIV. The World Health Organization (WHO) reports that approximately 90% of children living with HIV acquired the infection perinatally—during pregnancy, birth, or breastfeeding [9-20].

The level of unmet family planning need among the 1.18 billion women aged 15-49 worldwide is estimated to be 11%. Among the 128 million women (married or in a union) aged 15-49 in sub-Saharan Africa, the estimated unmet need for family planning is more than twice as high, at 25% and may be higher for women living with HIV. This highlights the urgency of finding innovative solutions that address the dual needs of women in preventing HIV and stopping unintended pregnancies [20-23].

However, uptake for contraceptives in TASO Masaka is at 24% this is low compared to the national uptake. It is against such a background that the study intends to investigate factors influencing uptake of contraceptives at TASO Masaka.

Study objectives

To ascertain the clients limiting factors for uptake of contraceptive services.

To examine the health worker related factors influencing contraceptive uptake by.

Strategic goals/secondary end points

- Change from a provider-centered approach with indicators of success based on the achievement of numerically tabulated professional activities and goals (number of patients seen, number of IUDs inserted, etc.) towards a user-centered approach with criteria for success based on user satisfaction, solutions for users’ health needs and sustained improvements in the health of the user population

- Change from an impersonal approach, in which users are treated anonymously and uniformly, to a more interactive approach, in which both user and provider are respected as individuals, with their own gender, ethnic, class, and generational experiences and identities.

- Change from a unilateral practice, in which health care providers monopolize information and decision-making, to a more equitably balanced participatory approach, in which users and providers share ideas, information, doubts and preferences.

- Change from a narrowly focused approach centered on family planning toward more comprehensive sexual and reproductive health services ranging from the prevention and treatment of sexually transmitted diseases (STDs), to pre- and postnatal care and education, to counselling on sexuality and domestic violence.

Methods

This was survey conducted in 2015, took three month study, targeting 150 sexually clients in 5 clinics, 3 facility clinics and 2 outreaches. The study targeted clients sexually active in child bearing age and attended a minimum of three clinic visits. Random sampling was used to select clients to participate in the study.

The study used questionnaires to capture primary and was analyzed by statistical package for social scientists.

Results

Female 98 and male 28. Clients aged 31-40 were 58%, 20-30 were 35%, 41-50 were 21%, 51-60 were 7 and 15-19 were 3%. 88 reached primary schools while 22 secondary and 15 never received education. The study did not find any relationship with education and usage of contraceptives. There were more females this is due to overall clientele receiving care in the facility as compared to males.

62 in urban while 64 in rural areas, usage of contraceptives was not affected by location of clients. Clients in either area had accessibility of contraceptives within a radius of 5 km and at no cost. Clients in rural areas had scheduled outreach clinics hence enabling them to receive the services as those at facility.

37% did not have planned pregnancies, 63% had planned pregnancies, and this shows unmet need for contraceptive use. This is a challenge given that clients appreciated that information is available and contraceptives are free of charge. There is need to change attitude to increase uptake of contraceptive use. Women with an unmet need for family planning are defined as those who do not want to become pregnant in the next two years but are not using contraception. We do not distinguish between unmet need for spacing and for limiting births. Further still Among HIV-positive women, unmet need for family planning ranges from 9 percent in Rwanda to 23 percent in Togo. Among HIV-negative women, the range is from 11 percent in Zimbabwe to 25 percent in Togo. In six of the eight surveys in which the total need for family planning is greater among HIV-positive women, met need is higher and unmet need is lower among HIV-positive women than among HIV-negative women (Cameroon, Côte d’Ivoire, Lesotho, Namibia, Rwanda, and Zambia). In the other two surveys in this category, Swaziland and Zimbabwe, levels of unmet need and met need both are higher for HIV-positive women than for HIV-negative women [23].

44% (55) are not current using Contraceptives yet they had used before because of side effects such as over bleeding, plans to have children, new partner, Breast feeding, spouse does not come regularly, replacing lost child and wanting male child. There is need to address these gaps by health workers so that clients continue using methods especially those that require reassurance and education.

ART interactions with some contraceptives hindered their usage, as clients feared getting pregnant due to lowered concentration of contraceptives by ART. Assessing the eects of antiretroviral drugs on the ecacy of hormonal contraceptives is a challenging undertaking for many reasons. Most drug-drug interaction studies aim to investigate only two drugs at a time so as to facilitate interpretation of any changes in pharmacokinetic parameters. Studying antiretroviral drugs individually does not reflect their real-world application as part of multi-agent HAART regimens, when there may be multiple layers of enzyme induction or inhibition as well as other physiologic eects that may alter drug absorption or excretion [22].

The study wanted to know who influences clients to use contraceptives, 90 % clients were influenced by personal decisions, 7% by spouse and 3% by health workers. Accessibility of contraceptives was rated at 91%. This showed low demand creation from health workers for contraceptive use.

5% used pills while 58% used condoms, 29% used injections, 7% used implants, 1% used permanent methods. It was noted that though female condoms were available at the facility, they were not used by participants. They so female condoms as not user friendly and needed more sensitization is required to address this gap and give women power because they do not wear male condoms. It was also noted that 17% of the clients reported use of dual method that is Condom and other methods, if scaled up this could offer more protection to not only pregnancy but also other sexually transmitted infections among HIV positive clients. The low use of pills was attributed to pill burden since the clients are on daily medication for ARVs and septrin. The use of permanent methods was also low as it is not offered at the facility and majority of clients wished to have more children.

93% (102) noted that there are not costs attached to contraceptive services against 7%, this means that accessibility of contraceptive is not a major issue affecting clients. At the center contraceptive methods are among other services that are provided free of charge. The same is true for government facilities were client’s access services with the exceptions of private clinics.

86% (100/116) agreed that contraceptive use offer benefits to them like avoiding reinfection, Prevention of STIs, Prevents unwanted pregnancy, child spacing and reduces the burden at the health facility. Furthermore it is should be noted that while a range of contraceptives protect against unintended pregnancies, only condoms, male and female, provide dual protection by stopping HIV transmission and preventing unintended pregnancies. The lack of methods of HIV prevention that are controlled by women and girls, along with low levels of condom use place women and girls at increased vulnerability to HIV infection. Women need safe contraceptive and HIV prevention options that they can own and manage. New investments into research for female-controlled technologies that allow women to prevent both HIV and pregnancy are essential [22].

Discussion

Education and contraceptive use

Though the study did not find any influence of education and contraceptive use other studies have however seen, higher proportions of respondents with primary, secondary and tertiary education levels were more likely to use condoms (p=0.004, p=0.000 and p=0.005, respectively) compared with those who never went to school.

Religious influences

Analysis of religion and how it influences use was not done but it cannot be under estimated, besides, condoms were being used by Protestants (p=0.000) compared to Catholics and Muslims. Also, more female respondents (p=0.000) used condoms with their partners compared with the male counterparts. The main barrier to contraceptive use among non-users was desire for more children [10].

Age, literacy, religion and desire for more children were key determinants to use of contraceptives among persons living with HIV. Contraceptive messages targeting the illiterate, youth, men and believers from different denominations need to be designed since these populations varied in use of contraceptives.

Utilization of contraceptives by persons living with HIV in Eastern Uganda: a cross sectional study [10].

Unmet need for contraceptive use

The study found out that unmet need for family planning at 37% which quite high in an environment where education is given and contraceptives are for free. This is also noted in other studies which indicate that unintended pregnancy is a common problem in both HIV-positive and HIV negative women. A study conducted in Swaziland has indicated that 69.2% of women reported that their recent pregnancy was unintended with no difference in sero-status. However, the rate of unwanted pregnancy was found to be significantly higher in HIV-positive women than their counterparts (20.7% versus 13.5%) [10].

Benefits

In Sub-Saharan Africa, use of modern contraceptives by HIVpositive women has led to a decrease in HIV-positive births by 31% [5]. In comparison, use of contraceptives prevents HIVpositive births (19.7%) better than antiretroviral therapy (ARV)-based PMTCT (8.1%) in Uganda [11].

Methods usage

The study revealed that majority of clients were using condoms 58%, followed by injections at 29%, this however different in other settings. In another study, injectable was the most commonly used type of contraceptive method which accounts 70.7% of users. This is also similar with a study conducted in South Africa, 70.2% [12]. Women were interested in using injectable because it can be used without their partners' awareness and injectable has less tension than pills like swallowing and remembering of timing of pills swallowing [13].

It is also noted that being HIV positive can influence choice of method. According to this study analyzed existing Demographic and Health Survey (DHS) data to determine how knowledge of one’s HIV sero-status is associated with fertility preferences and contraceptive use. In nationally representative samples in four African countries, the authors found that being HIV-infected is significantly associated with a desire to limit childbearing, as well as increased contraceptive use. They also report that HIV-positive women who know their status are more likely than other women to use condoms [14,15].

More still Women living with HIV appear to have a higher rate of unintended pregnancy (51-90%), compared to broader global estimates (38%) [16]. In addition, the likelihood of pregnancy for HIV-infected women is up to three times higher following initiation of antiretroviral therapy (ART) [17]. Improvements in quality of life and health status; renewed interest in sex and changes in sexual behavior; and high cultural value placed on parenthood likely influence this relationship [18,19].

Conclusion

There is unmet need for contraceptives as clients had unwanted pregnancies. Social cultural influences determined how many children a couple should have. Health workers need to address ART interactions with contraceptives to avoid clients getting pregnant. There is need to address side effects related to contraceptive use. There is need to engage men in decision making for contraceptive use.

Globally the prevalence rates of contraceptives are 63% and unmet need for family planning is 11% (WHO, 2010).

Uganda's total fertility rate (TFR) of 6.2 has resulted in a population growth rate of 3.2%, the fastest in Africa and the third highest in the world. The contraceptive prevalence rate (CPR) among married women, which has recently improved from 24% to 30% (UDHS 2011), is still unfortunately low. Uganda also has a high unmet need for FP services of 41% (UDHS 2006), (Shane Khan 2008). Uptake for family planning in TASO Masaka is at 24%.

HIV positive registered clients in TASO Masaka Clients sexually active in childbearing age. Clients who have received a minimum of three clinic visits.

References