Abstract
Background
The use of a dual contraception method (DCM) is recommended as an effective method to prevent Human Immunodeficiency Virus (HIV) transmission and the adverse consequences of pregnancy in people living with HIV infection. In developing countries like Ethiopia, contraception use is subjected to sociocultural, knowledge, and accessibility-related factors that influence consumption. Accordingly, this study aims to explore the magnitude of DCM use and factors related to consumption in HIV-positive women of reproductive age.
Methods
An institutional-based cross-sectional study was conducted at Hawassa University Comprehensive Specialized Hospital. The study used a systematic sampling technique to select 268 consenting participants. Data was collected using a semi-structured questionnaire via face-to-face interview. Descriptive statistics were used to present background information, and a hierarchical binary logistic regression was used to investigate DCM use and associated factors. Results with a p-value less than 0.05 are considered significant. All data analysis was performed using SPSS version 26.
Results
The magnitude of DCM use was 30% (95% CI; 24.0–35.0). After controlling for potential confounding variables women aged 15–36 years, (AOR = 8.65, 95% CI: 2.60, 28.75) and 37–40 years, (AOR = 6.25, 95% CI, 2.08, 18.82), women with no fertility desire (AOR = 8.34, 95% CI: 3.95, 17.61), women who have open discussions with their partners (AOR = 5.71, 95% CI: 2.15, 15.11), and women with knowledge of CD4 count (AOR = 2.94, 95% CI: 1.35, 6.38) were found to have a higher likelihood of DCM use.
Conclusions
The magnitude of DCM use among reproductive-age HIV-positive women was unsatisfactory. This provided an enormous window for counseling and reproductive health promotion measures. Interventional studies and strengthening of ART and family planning services must be customized to target the major social, cultural, and knowledge barriers identified in this study to enhance the practice of DCM use.
Keywords: Dual contraceptive method, HIV/AIDS, Pregnancy desire, Reproductive health, Hawassa, Ethiopia
Introduction
The human immunodeficiency virus/acute immunodeficiency syndrome (HIV/AIDS) continues to have disastrous economic, social, and physical impacts on individuals, nations, and the global community to the present day [1]. Globally, more than 2 million HIV-positive women become pregnant every year because of inadequate contraceptive use and risky sex behaviors. Out of these, 600,000 deaths are due to pregnancy-related complications [2].
Dual contraception method use (DCM) is the use of a barrier contraceptive (i.e., condoms) plus another effective family planning (FP) method that can prevent pregnancy (e.g., sterilization, hormonal methods, intrauterine devices, hormonal pills) [3]. The World Health Organization (WHO) recommends this method for people living with Human Immunodeficiency Virus (PLHIV) [4].
Several studies have evaluated the prevalence of DCM use worldwide. The prevalence of DCM in Africa ranges from 17 to 35.5% according to literature [5–12]. The knowledge and practice of DCM use by people with HIV/AIDS (PLHIV) in many developing countries, including Ethiopia, is unsatisfactory. A few systematic reviews and meta-analyses conducted in Ethiopia reported pooled prevalences of DCM use of 27.7% and 26.1% [13, 14]. Studies conducted in different regions of Ethiopia. For example, DCM use in Gondar (13.2%), Mekelle (15.7–45.2%), Borena (19.4%), Keffa (19.8%), Wolayta (28.6%), Fitche (32.0%), and Bahir-Dar (64.2%) showed significant variability, ranging from low to moderate consumption [15–22].
Determining the magnitude of DCM use and factors that favor or hinder utilization among women with HIV is valuable information that can reflect the existing reproductive health-related knowledge, quality of care, and effectiveness of counseling services provided by ART clinics, as well as sociocultural influencers of women’s behavior that need to be considered. Factors like age, marital status, place of residence, and educational and employment status were some of the sociodemographic influencers of the use of DCM [8, 13, 15–18, 20, 23, 24]. In addition, increasing parity, having no fertility desire, disclosure of serostatus, open discussion with partners about contraception use, higher CD4 count, and access to counseling services in ART clinics were among the sexual, reproductive, and HIV-related factors associated with DCM use [16, 19, 21–26].
The literature is lacking data on the magnitude, accessibility, and availability of DCM use among PLHIV in the Sidama region. The implementation of policy and the effectiveness of HIV and reproductive health counseling programs can only be evaluated considering the present data on consumption and practice at the regional level. Therefore, this study aimed to fill the knowledge gap by outlining the preferences for contraception use and identifying the prevalence and associated factors of DCM use among HIV-positive women of reproductive age at the Hawassa University Comprehensive Specialized Hospital (HUCSH) ART clinic.
Method
Study design and setting
An institutional-based cross-sectional study was conducted to assess the magnitude of DCM use and associated factors among HIV-positive reproductive-age women attending the ART clinic at HUCSH, in Hawassa, Ethiopia. This study was conducted from June to July 2022.
The Hospital is the largest tertiary hospital in the region and represents a catchment area of the entire region and surrounding areas estimated to be around 18 million people. The ART clinic provides regular follow-up, care, and counseling to 2800 patients diagnosed with HIV. Among them, 1,575 HIV-positive women of reproductive age were regularly followed up. In addition, the ART clinic collaborates with family planning services to address reproductive health issues, including the prevention of MTCT.
Study participants
All HIV-positive women of reproductive age who were regularly followed up at the HUCSH ART clinic were the source population for this study. The study recruited voluntary and consenting participants from the source population through a systematic sampling technique. The study excluded HIV-positive women who were pregnant during the study period.
Sample size determination and sampling technique
The single population proportion formula was used to estimate the sample size. The proportion of DCM use was drawn from a previous study conducted in Gebretsadik Shawo Hospital in Keffa, Ethiopia, which reported a DCM use rate of 19.8% [20]. After accounting for a 10% non-response rate, the final sample size was determined to be 268.
The list of all HIV-positive women of reproductive age was obtained from the ART clinic appointment roster, totaling 1,575 individuals. This list served as the sampling frame to determine the sampling factor (k = 6). Following informed consent, the study recruited every sixth individual during their visit.
Study variables
The primary objective of this study was to assess the prevalence of DCM use among HIV-positive women of reproductive age (15–49 years old). In this study, DCM use was the dependent variable for which exploratory analysis was conducted to determine factors that are associated with use.
The explanatory variables were categorized into three primary groups according to prior research: sociodemographic factors, sexual and reproductive factors, and clinical/HIV-related factors [15, 17]. Figure 1 shows factors considered under each classification that are to be used in the explanatory models.
Fig. 1.
Classes of DCM use determinant factors explored in this study
Operational definitions
DCM use was defined as the use of a barrier contraception along with another family planning method that can reduce the transmission of STIs/HIV and prevent pregnancy, within one month before the study period. DCM use was the [15, 17]. This was identified using the questionnaire item “Have you been using this method (DCM) in the past month “Yes” or “NO”.
In this study, age was categorized into three equal proportions given most of the participants were middle-aged women. Similarly, family income was categorized into three proportional parts.
The number of sexual partners was defined as either single or multiple, where multiple in this study implies concurrent relations with more than one partner. Sero-discordant status was defined as a partner with negative serostatus,
Data collection and ethical considerations
Data were gathered using semi-structured questionnaires adapted from publicly available instruments featured in a prior study [16]. Trained nurses conducted face-to-face interviews at the ART clinic to collect the information. The data collected did not contain any subject identifiers, and measures for data protection and confidentiality were maintained throughout the study.
Ethical clearance was obtained from the Institutional Review Board of Hawassa University College of Medicine and Health Sciences on 12/08/2022, with reference number IRB/041/14. A formal approval letter was obtained from the college’s ethical review committee. Since the survey aimed to explore sensitive and personal information, such as sexual history, the principal investigator and data collectors explained the significance of the study along with the secure data management and privacy protocol before obtaining informed consent from each participant.
Statistical analysis
Data were entered and analyzed using the Statistical Software for Social Sciences (SPSS) Version 26. Descriptive statistics were used to describe dependent and independent variables. Categorical variables are presented as frequencies and percentages, whereas continuous variables are presented as median and interquartile range. Crosstabulation was used to describe the magnitude of DCM use according to each category of predictive variables.
A stepwise multivariate binary logistic regression was performed to explore the association between DCM use and explanatory variables. An unadjusted model was used to identify associations with a significance level of less than 0.25 [15]. In the second model, these variables were adjusted for covariates found within the class of explanatory factors (i.e. SDC, sexual and reproductive factors, and clinical factors). The final model was constructed to adjust for strong confounders across the three classes of factors. Variables significantly associated with DCM use in the second model were included in the final model.
Variables dependent on the women’s relationship status, such as Partner’s desire to have children, having multiple sexual partners, sero-discordance, open discussion with partner, and partner’s involvement in ART counseling, were analyzed for the subgroup of women who indicated to be in a relationship (N = 166) during the study period.
Results are presented as odds ratios (OR) and 95% confidence intervals (CIs). The results presented were based on a significance-level α = 0.05. Furthermore, decisions to exclude variables that introduced poor model fit and imprecision were made while maintaining the logical framework. Model fit was assessed using the Hosmer–Lemeshow test (non-significant value was considered a good fit), and the positive predictive value of the final model was reported.
Result
Background characteristics of study participants
The study included 268 eligible and consenting participants, yielding a response rate of 100%. The median age of the participants was 38.0 (IQR 35.0–40.0). Nearly half, 146 (54.5%) were married; the majority, 230 (85.8%) reside in urban areas. The number of participants who completed secondary education was 94 (35.1%), whereas only 42 (15.7%) completed higher education. The median income for women in Ethiopian birr was 3000.00 (IQR 1500.00-5000.00).
All participants were interviewed about their sexual and reproductive health-related history. The study revealed that 166 (61.9%) women were in ongoing relationships, and 25 (15.1%) claimed to have multiple sexual partners; 84 (31.3%) women had more than three live children, 152 (56.7%) had a history of pregnancy or childbirth after HIV diagnosis, and 86 (32.1%) had experienced either abortion, stillbirth, or END. Among the participants, 119 (44.4%) indicated that they had no desire to have children.
Regarding information related to clinical factors, the median duration of HIV infection in years was 12 (IQR 8–14). Of all the respondents, 74 (26.9%) knew their CD4 count, and 26 (35.2%) reported a CD4 count less than 500. Of the women, 66 (24.6%) had STI history, and 204 (76.1%) reported having been counseled about DCM use. Within the subgroup of women who reported to be in a relationship, 30 (18.0%) were sero-discordant, 120 (72.3%) had an open discussion with their partners regarding contraception use, and 44 (33.4%) said their partners were involved in one of the counseling sessions (Table 1).
Table 1.
Background characteristics of study participants
| Variables (N) | Frequency (%) | Dual Contraception Method Use | |
|---|---|---|---|
| No | Yes | ||
| Sociodemographic characteristics | |||
| Age (268) | |||
| 15–36 | 92 (34.3) | 64 (69.6) | 28 (30.4) |
| 37–40 | 118 (44.0) | 72 (61.0) | 46 (39.0) |
| 41–49 | 58 (21.6) | 52 (89.7) | 6 (10.3) |
| Marital status (268) | |||
| Not married | 122 (54.5) | 106 (86.9) | 16 (13.1) |
| Married | 146 (55.5) | 82 (56.2) | 64 (43.8) |
| Education (268) | |||
| No formal education | 26 (9.7) | 20 (76.9) | 6 (23.1) |
| Primary education | 106 (39.6) | 66 (62.3) | 40 (37.7) |
| Secondary education | 94 (35.1) | 68 (72.3) | 26 (27.7) |
| Higher education | 42 (15.7) | 34 (81.0) | 8 (19.0) |
| Income (268) | |||
| < 1500 | 70 (26.1) | 46 (67.7) | 24 (34.3) |
| 1500–3000 | 96 (35.8) | 70 (72.9) | 26 (27.1) |
| > 3000 | 102 (38.1) | 72 (70.6) | 30 (29.4) |
| Place of Residence (268) | |||
| urban | 268 (85.8) | 158 (68.7) | 72 (31.3) |
| rural | 38 (14.2) | 30 (78.9) | 8 (21.1) |
| Religion (268) | |||
| Orthodox | 150 (56.0) | 98 (65.3) | 52 (34.7) |
| Muslim | 18 (6.7) | 14 (77.8) | 4 (22.2) |
| Nonorthodox Christian | 100 (37.3) | 76 (76.0) | 24 (24.0) |
| Sexual and Reproductive factors | |||
| Number of live children (268) | |||
| Less than three | 184 (68.7) | 136 (73.9) | 48 (26.1) |
| More than three | 84 (31.3) | 52 (61.9) | 32 (38.1) |
| Pregnancy or childbirth after HIV diagnosis (268) | |||
| no | 116 (43.3) | 98 (84.5) | 18 (15.5) |
| yes | 152 (56.7) | 90 (59.2) | 62 (40.8) |
| HIV positive children (268) | |||
| No | 178 (66.4) | 126 (70.8) | 52 (29.2) |
| Yes | 74 (27.6) | 48 (64.9) | 26 (35.1) |
| I don’t know | 16 (6.0) | 14 (87.5) | 2 (12.5) |
| History of abortion/stillbirth/END (268) | |||
| No | 182 (67.9) | 130 (71.4) | 52 (28.6) |
| Yes | 86 (32.1) | 58 (67.4) | 28 (32.6) |
| Pregnancy desire (268) | |||
| Yes | 149 (55.6) | 123 (82.6) | 26 (17.4) |
| No | 119 (44.4) | 65 (54.6) | 54 (45.4) |
| Partner’s desire to have children (166) | |||
| Yes | 82 (43.3) | 56 (68.3) | 26 (31.7) |
| no | 84 (50.6) | 44 (52.4) | 40 (47.6) |
| Sexual Partner (166) | |||
| Single | 138 (51.5) | 79 (57.2) | 59 (42.8) |
| Multiple | 28 (10.4) | 16 (57.1) | 12 (42.9) |
| Clinical Factors | |||
| Duration of HIV infection (268) | |||
| Median | 12 | ||
| IQR | 8–14 | ||
| HIV treatment Duration (268) | |||
| Median | 11 | ||
| IQR | 7–13 | ||
| Knowledge of CD4 count (268) | |||
| No | 194 (73.1) | 144 (73.5) | 52 (26.5) |
| yes | 74 (26.9) | 44 (61.1) | 28 (38.9) |
| CD4 (74) | |||
| > 500 | 48 (64.8) | 20 (41.7) | 28 (58.3) |
| < 500 | 26 (35.2) | 26 (100) | 0 |
| History of STI (268) | |||
| No | 202 (75.4) | 148 (73.3) | 54 (26.7) |
| yes | 66 (24.6) | 40 (60.6) | 26 (39.4) |
| Treatment for STI (66) | |||
| No | 6 (9.0) | ||
| yes | 62 (93.9) | ||
| Sero-discordance (166) | |||
| positive | 136 (81.9) | 76 (55.9) | 60 (44.1) |
| Negative | 30 (18.0) | 24 (80.0) | 6 (20.0) |
| Discussion with partner (166) | |||
| No | 46 (27.7) | 38 (79.2) | 10 (20.8) |
| yes | 120 (72.3) | 62 (52.5) | 56 (47.5) |
| Counselling about DCM by ART provider (268) | |||
| No | 64 (23.8) | 48 (75.0) | 16 (25.0) |
| yes | 204 (76.2) | 140 (68.6) | 64 (31.4) |
| Partner involvement in the counselling (132) | |||
| No | 88 (66.6) | 50 (58.1) | 36 (41.9) |
| Yes | 44 (33.4) | 24 (54.5) | 20 (45.5) |
Prevalence of DCM use
The magnitude of DCM use among HIV-positive reproductive-age women was 80 (30%), (95% CI; 24.0–35.0). The number of study participants who reported using any contraceptive method after HIV diagnosis was 192 (71.6%). Condom use was reported by 140 (52.2%) participants after HIV diagnosis. Implants (34.5%) and injectables (29.1%) were the most common additional contraception methods used with condoms. These women indicated that they received FP services at ART clinics (33.0%) and FP centers (19.1%), whereas the rest did not specify the location.
Factors associated with DCM use
In the unadjusted binary logistic regression model, young age (< 40 years) and marriage were associated with DCM use. In addition, women who have more than three children, have a history of pregnancy or childbirth after HIV diagnosis, and who had no desire to have children have increased use of DCM.
After controlling for potential confounding variables within the class of sexual and reproductive factors in model 2, women who had pregnancy or childbirth after HIV diagnosis had twice-greater odds and those who had no desire to have children had approximately six times increased odds of DCM use,, (AOR = 2.46, 95% CI: 1.21, 4.82) and (AOR = 5.95, 95% CI: 2.84, 2.49), respectively.
Similarly, among clinical and HIV-related factors, duration of HIV infection, sero-discordance, and open discussions with partners about contraception were significantly associated with DCM use in the unadjusted model. Further adjustment within the class of factors showed that knowledge of CD4 count was associated with increased DCM use (AOR = 2.35, 95% CI: 1.22, 4.53). Similarly, duration of HIV infection (AOR = 1.10, 95% CI: 1.00, 1.20) and open discussion with partners about contraception (AOR = 3.50, 95% CI: 1.49, 8.20) have statistically significant association with DCM use.
A final regression model was constructed to account for significant confounding among SDCs, sexual and reproductive factors, and clinical factors. The model included age, marital status, no desire to have children, pregnancy/childbirth after HIV diagnosis, open discussions with partners, and knowledge of CD4 count. This model explained 45.4% of the variability in DCM use and had a PPV of 71.2%. According to this model, women younger than 40 years (15–36 years, (AOR = 8.65, 95% CI: 2.60, 28.75) and 37–40 years, (AOR = 6.25, 95% CI, 2.08, 18.82), women with no desire to have children (AOR = 8.34, 95% CI: 3.95, 17.61), women who have open discussions with their partners (AOR = 5.71, 95% CI: 2.15, 15.11), and those with knowledge of their CD4 count (AOR = 2.94, 95% CI: 1.35, 6.38) have an increased frequency of DCM use. Table 2 details the results of all factors associated with DCM use in the logistic regression models.
Table 2.
Result of multivariable logistic regression models constructed to determine factors associated with DCM use
| Variables | N | Dual contraception method use | ||
|---|---|---|---|---|
| Unadjusted Model OR (95% CI) |
Model Ia OR (95% CI) |
Model IIb OR (95% CI) |
||
| Sexual and Reproductive factors | ||||
| Number of live children | 268 | |||
| Less than three | 1 | 1 | ||
| More than three | 1.74 (1.01–3.02) * | 1.24 (0.65–2.36) | ||
| Pregnancy or childbirth after HIV diagnosis | 268 | |||
| No | 1 | 1 | 1 | |
| Yes | 3.75 (2.06–6.82) *** | 2.46 (1.21–4.82) ** | 1.06 (0.49–2.31) | |
| HIV positive children | 268 | |||
| No | 1 | |||
| Yes | 1.31 (0.79–2.34) | |||
| History of abortion/stillbirth/END | 268 | |||
| No | 1 | |||
| Yes | 1.21 (0.69–2.10) | |||
| Pregnancy desire (Self) | 268 | |||
| Yes | 1 | 1 | 1 | |
| No | 3.93 (2.25–6.85) *** | 5.95 (2.84–2.49) *** | 8.34 (3.95–17.61) *** | |
| Partner’s desire to have children | 166 | |||
| Yes | 1 | 1 | ||
| no | 1.96 (1.04–3.68) * | 0.59 (0.24–1.41) | ||
| Sexual Partner | 166 | |||
| Single | 1 | |||
| Multiple | 1.00 (0.44–2.28) | |||
| Clinical and HIV related Factors | ||||
| Duration of HIV infection (For every 1-year) | 268 | 1.08 (1.01–1.17) * | 1.10 (1.00–1.20) * | 1.10 (0.98–1.22) |
| Knowledge of CD4 count | 268 | |||
| No | 1 | 1 | 1 | |
| yes | 1.76 (0.99–3.12) | 2.35 (1.22–4.53) ** | 2.94 (1.35–6.38) ** | |
| History of STI | 268 | |||
| No | 1 | 1 | ||
| yes | 1.78 (0.99–3.19) | 1.31 (0.67–2.57) | ||
| Sero-discordance (Partner’s HIV status) | 166 | |||
| positive | 1 | 1 | ||
| Negative | 0.32 (0.12–0.82) * | 0.37 (0.13–1.05) | ||
| Discussion with partner | 166 | |||
| No | 1 | 1 | 1 | |
| yes | 3.43 (1.57–7.52) ** | 3.50 (1.49–8.20) ** | 5.71 (2.15–15.11) *** | |
| Counselling about DCM by ART provider | 268 | |||
| No | 1 | |||
| yes | 1.37 (0.72–2.60) | |||
| Partner involvement in the counselling | 132 | |||
| No | 1 | |||
| Yes | 1.30 (0.61–2.75) | |||
| Sociodemographic characteristics | ||||
| Age | 268 | |||
| 15–36 | 3.79 (1.46–9.85) ** | 2.75 (1.01–7.50) * | 8.65 (2.60–28.75) *** | |
| 37–40 | 5.54 (2.20–13.93) *** | 4.48 (1.71–11.71) ** | 6.25 (2.08–18.82) ** | |
| 41–49 | 1 | 1 | ||
| Marital status | 268 | |||
| Not married | 1 | 1 | ||
| Married | 5.17 (2.78–9.60) *** | 5.12 (2.66–9.85) *** | 11.55 (2.99–44.68) *** | |
| Education | 268 | |||
| No formal education | 1 | |||
| Primary education | 2.02 (0.75–5.45) | |||
| Secondary education | 1.27 (0.46–3.53) | |||
| Higher education | 0.78 (0.24–2.59) | |||
| Income | 268 | |||
| < 1500 | 1 | |||
| 1500–3000 | 0.71 (0.36–1.39) | |||
| > 3000 | 0.79 (0.42–1.53) | |||
| Place of Residence | 268 | |||
| Rural | 1 | 1 | ||
| Urban | 1.71 (0.75–3.91) | 2.01 (0.81–4.97) | ||
| Religion | 268 | |||
| Orthodox | 1.68 (0.95–2.97) | |||
| Muslim | 0.90 (0.27–3.01) | |||
| Nonorthodox Christian | 1 | |||
ART: Antiretroviral therapy, DCM: Dual contraception method, END: Early neonatal death
a Model I Covariate adjustment was done within the classes of explanatory factors; namely sexual and reproductive characteristics, clinical and HIV related characteristics and SDC, variables with a p value of < 0.25 in the unadjusted model are included in model I
b Model II Variables with statistical significance (p value < 0.05) in model I were included in model II with further adjustment for age and marital status
* P value < 0.05 ** P value < 0.01 *** P value < 0.001
Discussion
In this study, 268 HIV-positive reproductive-age women were included, and the prevalence of DCM use was found to be low. This finding align with a recent meta-analysis that reported a pooled prevalence of 27.7% [13]. Additionally, studies conducted in various region, including Thailand (29.6%), southeast Nigeria (27%.), Malawi (26.5%), Gondar-Ethiopia (28.8%), Fitche (32.0%), and Wolaita zone-Ethiopia (28.6%) have reported comparable results [6, 10, 17, 21, 22, 25].
However, studies from other countries and regions in Ethiopia have reported much lower prevalence, compared to the present study. For instance, studies in India (23.0%), Zambia (17.7%), and Togo (16.9%) from Africa, as well as studies conducted in Mekelle (15.7%), Gonder University (13.2%), and Keffa (19.8%), all revealed lower percentages of DCM use [8, 12, 19, 20, 23, 24]. This disparity may be attributed to temporal differences, with older studies reporting lower rates [12, 24]. The increasing trend in DCM use over the years might indicate the effect of interventions that addressed underutilization and improved ART follow-up in recent years. Another possible explanation for this disparity might be sociodemographic variability and different study designs and data collection techniques [17, 24].
The prevalence of DCM use in this study was lower than that reported in other countries such as the USA (39%), Kenya (38.5%), and in Tigra region, Ethiopia (45.2%) [18, 26, 27]. These studies show that some countries have managed to improve DCM use years in advance compared to several other regions. It is evident that recognition of the effectiveness of DCM use and the presence of controlled studies may have encouraged health promotion services targeting PLHIV [27].
This study identified several factors significantly associated with DCM use among HIV-positive women. Younger age (less than 40), no desire to have children, and open discussions with partners about contraception were strong predictors of DCM use. Being married, having a CD4-count and pregnancy or childbirth after HIV diagnosis were also associated with DCM use, although this association was weaker.
The finding of increased DCM use among women younger than 40 years is supported by studies conducted in Gonder University and Fitche zone in Ethiopia and in studies conducted in Kenya, Tanzania, and Namibia in 2014 and in Zambia [5, 12, 21, 23], In contrast, studies in Cameron and in Keffa region, Ethiopia found a reversed association [9, 20]. In this study, women at the peak of their reproductive age (30s), who also represented most of the participants, showed stronger associations than older women, which may be explained by the decline in sexual activity and desire to have children at an advanced age. Marital status was significantly associated with DCM use in this study; however, the extremely wide CI found in this study, likely due to an inadequate sample size, allows no meaningful interpretation.
Furthermore, the lack of desire to have children was strongly associated with DCM use. This finding is in-line with studies conducted in Thailand, Kenya, Bahir-Dar, Borena, Fitche and Wolaita regions in Ethiopia [15, 16, 21, 22, 25, 26]. This association could be the consequence of having knowledge of increased pregnancy-associated complications in HIV-infected women and fear of MTCT, which, although not investigated in this study, may have a mediating effect on other factors that predict DCM use. In the present study, the association between parity, pregnancy/childbirth after HIV diagnosis, and marital status was significantly attenuated in the final model, independently leaving desire for having no children as a strong predictor.
The association between DCM use and CD4 count knowledge was also reported in a systematic review by Ayele et al. in 2021 [14]. A similar finding was evident in the Keffa zone, Ethiopia, and Zambia [12, 20]. This study also found that the proportion of women who had knowledge about their CD4 count was extremely low, which could contribute toward the low prevalence of DCM use in general. Sero-discrodant couples were found to have decreased DCM use in this study, the odds of which became insignificant during model adjustment. However, this is a concerning finding that may be related to women not disclosing their HIV status, which may not have been reported during this survey.
Open discussions about contraception use with partners showed a consistent association with DCM use across studies according to systematic reviews conducted in Ethiopia [13, 14]. Studies that reported similar finding were conducted in Gonder University, Tigray, Mekele, Keffa, and Wolaita [18–20, 22, 23]. Discussing contraception use is a marker of women’s freedom to negotiate safe sex and birth spacing. Unlike other studies, this study failed to detect an association between DCM use and counseling about DCM use by ART service providers and partners involved in counseling sessions [13, 16, 19, 23, 24]. Although the majority of women reported having been counseled, the absence of increased DCM use in this group may indicate disorganized and ineffective counseling regarding family planning and failure to encourage partners to participate in these sessions in HUCSH.
This study was conducted to address the knowledge gap regarding the practice of contraception use among HIV-positive women in Hawassa and surrounding areas in the Sidama region of Ethiopia. This study was institutional based, acquired the desired sample size, and used random sampling. All these attributes allow us to generalize the study findings to most HIV-positive reproductive-age women who receive ART services at HUCSH and grossly reflect explanatory factors that promote DCM use. However, since the analysis of associated factors was conducted in an exploratory manner, a study that provides accurate power is needed to confirm predictive ability. It is also noteworthy that due to the private nature of the queries in this survey the data is subject to reporting bias.
Nevertheless, the factors described and identified to have an association with DCM use provide directions on what sociocultural influencers require prudent intervention to promote women’s freedom to seek knowledge, counseling, healthcare, and access to family planning services. Accordingly, ART services and family planning counselors must be accountable for the initiation of DCM use once diagnosed and follow for sustained use throughout the reproductive period; They must strongly relay the relevance of DCM use, pregnancy risks, and must ensure that these women have their CD4 counts known. Equally significant is the provision of counseling and psychological support for women who wish to overcome fear, disclose their status, and discuss their desires and reproductive plans with their partners.
Conclusion
The prevalence of DCM use among reproductive-age HIV-positive women was unsatisfactory, providing an enormous window for counseling and reproductive health promotion measures. Fertility desire, knowledge of CD4 levels, and discussion of contraception use with partners were among the most significant determinant factors that explained dual contraceptive use. Interventional studies and strengthening of ART and family planning services must be customized to target the major social, cultural, and knowledge barriers identified in this study to enhance the use and practice of DCM.
Acknowledgements
Authors of this paper like to acknowledge the contributions obtained from the department of obstetric and gynecology, and HUCSH ART clinic staff who facilitated participant recruitment and data collection.
Abbreviations
- AOR
Adjusted Odds Ratio
- ART
Antiretroviral Therapy
- CI
Confidence Interval
- DCM
Dual Contraception Method
- END
Early Neonatal Death
- FP
Family Planning
- HIV/AIDS
Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
- HUCSH
Hawassa University Comprehensive Specialized Hospital
- IQR
Interquartile Range
- MTCT
Mother-to-child Transmission
- PLHIV
People Living with HIV Infection
- STI
Sexually Transmitted Infections
- WHO
World Health Organization
Author contributions
M.G. Conceptualized and designed the study, wrote parts of the paper and Performed data analysis Y.H. Supervised the study edited the manuscript, All authors reviewed and edited the manuscript.
Funding
No funding was received for conducting this study.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Study was approved by Hawassa University College of Medical and Health Sciences, Institutional Review Board and ethical clearance was provided by the college’s ethical review committee.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.