Pregnancies Among Malawian Women Taking Antiretroviral Medication Are Often Unintended
Among pregnant HIV-positive women receiving antiretroviral therapy (ART) in Malawi, most report that their current pregnancy was unintended.1 According to a cross-sectional survey conducted in 2014, 75% of respondents characterized their pregnancies as unintended, 21% of which had occurred too soon and 79% of which had been unwanted; most women (79%) reported having used a contraceptive at conception. Women who had been on ART for two or more years were more likely than those who had been receiving therapy for less time to report an unintended pregnancy (79% vs. 65%). Number of living children was positively associated with increased odds of having an unwanted pregnancy instead of an intended pregnancy (odds ratio, 1.2).
In 2011, to reduce the country’s disproportionately high HIV prevalence rate, the Malawian government implemented Option B+, a strategy for HIV management that includes prevention of unintended pregnancies (through the provision of injectable contraceptives) and initiation of ART for HIV-positive pregnant and breast-feeding women, regardless of CD4 count or clinical stage. Because the association between ART and fertility desire among HIV-positive women had not been examined since Option B+ was implemented, researchers conducted a study among 220 pregnant HIV-positive women aged 18–45 who were attending a prenatal clinic in Lilongwe and had initiated ART at least six months prior to their current pregnancy. Descriptive analyses using t, chi-square and Fisher’s exact tests were conducted to assess differences in selected characteristics by length of time on ART; modified Poisson regression analyses were used to evaluate the association between length of time on ART and pregnancy intention.
Some 63% of the women were aged 25–34, and 94% were married. Three-quarters had been diagnosed with HIV at least three years before the study, and about half had initiated ART before Option B+ implementation. Eighty-two percent of participants had been receiving ART for less than five years, and 95% were on Malawi’s first-line ART regimen (tenofovir/lamivudine/efavirenz).
Seventy-five percent of the women reported that their current pregnancy was unintended; of these unintended pregnancies, 21% were mistimed and 79% were unwanted. Women on ART for two or more years were more likely than those on ART for less time to report their pregnancy as unwanted (65% vs. 45%); those on ART for two or more years were less likely to report a mistimed pregnancy (14% vs. 20%) or an intended pregnancy (21% vs. 35%). Compared with women on ART for less than two years, those on ART for two or more years were more likely to have been married for at least five years (68% vs. 47%), and less likely to report that the current pregnancy was the first with their partner (35% vs. 53%) and that they had no living children (7% vs. 26%).
Most women (79%) reported using at least one contraceptive method at the time of conception. Condoms were the most commonly reported method (91%), followed by the injectable and the implant (9% each); 22% of women reported dual contraceptive use. Three out of four women reported that they did not want any more children, and virtually all (99%) did not desire an additional pregnancy within two years. The most common method women planned to use postpartum was condoms (88%), followed by female sterilization (69%) and the implant (60%).
Multivariate analysis revealed that length of time on ART was not associated with having a mistimed pregnancy rather than an intended pregnancy or with having an unwanted pregnancy rather than an intended pregnancy. Number of living children was positively associated with having an unwanted pregnancy rather than an intended pregnancy (odds ratio, 1.2).
According to the researchers, the generalizability of their findings to other populations of HIV-positive women on ART is limited because they did not collect data on the health status of their participants; they note that the women enrolled in their study were likely healthier than HIV-positive women on ART in general, given the fact that they all had achieved pregnancy. Despite access to ART and prevailing cultural norms that promote childbearing, HIV-positive women in Malawi wish to limit childbearing, according to the researchers. They suggest that the high proportion of women in the study reporting an unintended pregnancy "underscores a need to ensure access to the most effective contraceptive methods as growing numbers of HIV-infected women continue to initiate lifelong ART in the Option B+ era."—L. Melhado
1. O’Shea MS et al., Reproductive intentions and family planning practices of pregnant HIV-infected Malawian women on antiretroviral therapy, AIDS Care, 2016, doi: 10.1080/09540121.2016.1140891.