Contraceptive use and associated factors among women with HIV receiving care at a faith-based tertiary hospital in Northern Uganda: a cross-sectional study

Abstract

Background:

Preventing unintended pregnancies among reproductive-aged women with HIV (WWH) is crucial in combating mother-to-child transmission (MTCT) of HIV. We assessed the utilization of modern contraceptives and related factors among WWH attending the antiretroviral therapy (ART) clinic at a faith-based tertiary hospital in northern Uganda.

Objectives:

To determine the proportion of and factors associated with the utilization of modern contraceptives among WWH of reproductive age attending the ART clinic in St. Mary’s Hospital Lacor.

Design:

This cross-sectional study was conducted at the HIV clinic within St. Mary’s Hospital Lacor, from February to May 2023.

Methods:

Between February and May 2023, we conducted a cross-sectional study among randomly selected WWH of reproductive age attending the ART clinic at a faith-based health facility, St. Mary’s Hospital Lacor in Gulu city, northern Uganda. Quantitative data were collected using semi-structured questionnaires and analyzed using STATA version 16. Factors associated with the utilization of modern contraceptives were assessed using multivariable logistic regression. p < 0.05 was considered statistically significant.

Results:

Of the 385 enrolled participants, 94 (24.4%) reported current modern contraceptive use, and 58 (15.1%) were using natural methods. Being referred to another facility to access modern contraceptives (adjusted odds ratio (aOR): 2.60, 95% confidence interval (CI): 1.31–5.17, p < 0.01), prior use of modern contraceptive (aOR: 32.47, 95% CI: 3.56–300.94, p < 0.01), and age (aOR: 0.92, 95% CI: 0.87–0.98, p < 0.01) were all statistically associated with uptake of modern contraceptives.

Conclusion:

Only about one in every four WWH was currently using modern methods of contraceptives. There is a need to provide regular counseling to WWH on modern contraceptive methods to create awareness of the vital connection between modern contraceptive use and MTCT, as well as strengthen referral of clients opting to use modern contraceptives to facilities providing these services.

Plain language summary

Use of family planning methods among women living with HIV at a faith based facility in northern Uganda

This study examines the prevalence of contraceptive use among women receiving care for HIV in a faith based facility in Northern Uganda that does not routinely offer contraceptives. With a background of the need to prevent mother to child infection of HIV, we determined the proportion of and factors associated with the utilization of modern contraceptives among women with HIV of reproductive age attending ART clinic in Lacor hospital using a cross sectional study from February to May 2023 We found that about one in 4 women (24.4%) reported current use of modern contraceptives, while an additional 15% were using natural methods of family planning. Prior use of family planning, as well as referral to another facility for contraception increased the likelihood of using contraceptives by three folds. We recommend the strengthening of referral system, and increased awareness on contraception for prevention of vertical HIV transmission.

Introduction

The emergence of the human immunodeficiency virus (HIV) epidemic is regarded as one of the most significant public health challenges in recent times, with global implications. Globally, by the end of 2022, there were an estimated 39 million people with HIV (PWH). ¹ Notably, women of reproductive age constitute a substantial portion of this population, accounting for over 50% globally. ² The introduction of antiretroviral therapy (ART), characterized by its low cost and pharmacological effectiveness, has dramatically improved the health and longevity of women with HIV (WWH). Consequently, these women now aspire to achieve reproductive goals similar to those without HIV. ³

Despite the technological advancements in the provision of highly effective ART, the risk of mother-to-child transmission (MTCT) of HIV during pregnancy, labor, delivery, or breastfeeding remains a concerning challenge. Without interventions, this risk ranges from 15% to 45%. ⁴ In Uganda, a country with a substantially high HIV burden, the incidence of MTCT is still above 3%, translating to a case rate of about 466 per 100,000. ⁵ Achieving the goal of eliminating MTCT (eMTCT) in Uganda necessitates a significant reduction in the MTCT rate, aiming to bring it down from 7.9% to a mere 0.22%—an achievement dependent on preventing unintended pregnancies among WWH which is currently estimated to be at 45%.

One pillar of eMTCT is preventing unintended pregnancies, and its cornerstone lies in the provision of modern family planning services, recognized as a fundamental strategy. ⁶ The modern contraceptive methods include oral contraceptive pills, female and male sterilization, intrauterine contraceptive devices (IUCDs), injectable and implantable contraceptives, male and female condoms, diaphragms, and emergency contraception. The natural family planning methods include fertility awareness-based methods, the lactation amenorrhea method, and the withdrawal (coitus interruptus) method. ⁷

However, various sociodemographic factors like age, education level, and employment status, together with cultural, religious, and health system-based factors, continue to influence uptake and retention of modern contraceptive utilization among PWH across the contraceptive care cascade of accessibility, affordability, and availability.^8,9 Clients’ religious affiliations, or engagement of religious leaders, significantly influence the uptake of conventional contraceptives both in our setting and elsewhere.^{10 –14} Knowledge and beliefs of clients on prevention of mother-to-child transmission remain important determinants of modern contraceptive acceptance and utilization. In our setting, both the tradition and the church discourage the use of modern contraceptives because it contradicts the call for procreation, notably among Catholic, Anglican, and Moslem believers.^15,16

According to the report on international religious freedom, Catholics are the largest Christian group in Uganda (39%). ¹⁷ And as enshrined in 1968 Pope Paul VI’s landmark encyclical letter dubbed “Humanae Vitae” (Latin, “Human Life”), the Catholic Church’s constant teaching emphasizes that it is always intrinsically wrong to use contraception to prevent new human beings from coming into existence. ¹⁸ To date, Catholic-based health institutions continue to follow this rule and only encourage clients to utilize natural family planning methods. It is important to note that, as a contraceptive option, natural family planning has a typical failure rate of 24%, ²⁸ hence rendering it ineffective as a sole method in the prevention of MTCT.^7,19

In addition, HIV itself influences the use of modern contraceptives, with factors such as the WHO clinical stage, ART regimen, and contraceptive interactions being crucial considerations.^20,21 For example, women with advanced HIV disease may experience complications that potentially limit their choice of modern contraceptives, ART regimens like those containing protease inhibitors and Efavirenz affect the metabolism and efficacy of hormonal contraceptives. All these may warrant switching of either the ART regimen or contraceptive to suit the medical eligibility criteria.^22,23 The 2022 HIV consolidated guidelines for prevention and treatment of HIV and acquired immunodeficiency syndrome (AIDS) in Uganda recommend the use of a dolutegravir-based regimen as first line for WWH, just like in adult clients, since it has little impact on the medical eligibility criteria for contraceptives. However, some second- and third-line regimens have profound considerations on the choice of contraceptives. ²⁴ Among pregnant WWH, our ART policy recommends frequent viral load and CD4⁺ cell count monitoring to ensure suppression, hence reducing the risk of MTCT. ²⁵

Studies conducted in various regions of Uganda have consistently revealed low utilization rates of modern contraceptives among WWH.^26,27 A study among WWH in a hospital in Luwero district in central Uganda showed that religious views discouraging the use of modern family planning (p = 0.034) significantly affected the utilization of modern contraceptives. ²⁸ In the specific study context of St. Mary’s Hospital Lacor, a Catholic-founded hospital that prohibits direct provision of modern contraceptives (except for prescriptions for other medical indications) and runs a large HIV clinic, the prevalence of modern contraceptive use among WWH remains unknown. There is equally no clear information about the sexual activities the clients could be engaged in, and the possibility that spouses could have died or separated. Moreover, there is currently limited literature on the number of clients referred to the nearby government or private facilities providing modern contraceptives, such as Gulu Regional Referral Hospital, which is about 6 km from Lacor Hospital.

Therefore, we aimed to address this critical gap in knowledge by investigating the factors associated with contraceptive utilization among WWH of reproductive age attending the ART clinic in this faith-based hospital in northern Uganda.

Methods

Study design

We conducted a cross-sectional study, surveying women attending care at the HIV clinic within St. Mary’s Hospital Lacor, from February to May 2023. The study was conducted in line with the STROBE guidelines for cross-sectional studies (Supplemental Material). ²⁹

Study setting

St. Mary’s Hospital Lacor, located in Gulu city, northern Uganda, is a referral hospital that also serves as a teaching facility for Gulu University’s clinical year medical students. The hospital is in Layibi-Bardege Division, Gulu city, and offers HIV care services to approximately 7000 clients, 65% of whom are female. It houses a family planning unit providing health education and services, including natural family planning methods but does not provide modern contraceptives. ³⁰

Study population

We included women of reproductive age between 18 and 49 years, with a confirmed diagnosis of HIV registered in HIV care at the ART clinic of St. Mary’s Hospital Lacor, who provided written informed consent. We excluded clients who had undergone hysterectomy and those critically ill and required immediate medical attention.

Sample size estimation

The sample size was determined to be 385 WWH of reproductive age using the Kish Leslie formula (1965) for single population proportions, considering a 95% confidence, a 5% margin of error, and an assumed contraceptive use prevalence of 50% to maximize the sample size since there was a paucity of context-specific estimates.

According to the Uganda Demographic and Health Survey, ³¹ 47% of sexually active unmarried women use a modern contraceptive method. Therefore, a sample of 385 participants provided a prevalence estimate of 47% that was within a precision of 0.002 of the prevalence at a 5% significance level.

Sampling approach

A systematic random sampling method was employed to enroll a daily average of 15 participants. Given that the daily average number of clients was up to 60, every fourth client was selected. The first participant was selected using simple random sampling from among 4, then every fourth eligible woman was included in the study.

Data collection and instruments

The data collection tool was developed based on a literature review to capture all the crucial variables that influence the uptake of modern contraceptives among HIV clients. We included questions on sociodemographic factors like age, parity, education, and religion. We also inquired about the client’s knowledge of eMTCT, disclosure, and if they have ever been referred from St. Mary’s Hospital Lacor to another facility to access modern contraceptives. The tool was translated into the local Acoli dialect and administered secondarily by trained research assistants. The collected data were exported into EpiData version 3.1 (manufactured by the Epidata association) for sorting and cleaning to ensure completeness.

Operational definitions and study variables

The primary outcome variable was modern contraceptive use, defined as the use of long-acting reversible (Implanon and IUCD) and non-reversible methods (bilateral tubal ligation) or short-acting methods like condoms, contraceptive pills, and injectable (Sayana and Depo Provera) within 3 months of the study. Natural methods of family planning included the use of lactational amenorrhea, coitus interruptus, and the safe days method (calendar/rhythm method involving tracking the menstrual cycle and then avoiding sexual intercourse during ovulation). ³² The independent variables were sociodemographic (age, sex, marital status, religion), knowledge of MTCT, parity, and disclosure of serostatus to their husbands.

Statistical analysis

STATA version 16 (StataCorp, College Station, TX, USA) was used to analyze data, describing continuous variables (age) using median and interquartile range (IQR) and categorical variables using frequencies and percentages. Results were then displayed using tables and graphs. Bivariate-level association between contraceptive use and the independent factors was assessed using Chi-square or Fisher’s exact tests for categorical variables. Variables with p < 0.2 at bivariate analysis or biologically plausible to be associated with contraceptive use were forwarded to multivariable analysis. Using a stepwise forward modeling approach using binary logistic regression models, factors that were independently associated with contraceptive use after accounting for all important confounders were determined. Factors with p < 0.05 were considered to have a statistically significant independent association with contraceptive use. Results were presented as adjusted odds ratio (aOR) with their 95% confidence interval (95% CI) and p values.

Results

Sociodemographic characteristics

A total of 386 women were sampled for the study, and all (100%) consented to participate. The participants had a median age of 39 (IQR: 33–44) years. About two-thirds of the participants (n = 238, 61.7%) had attended primary education, 212 (54.9%) were married, 226 (58.55%) practiced peasant farming as the main source of income, and 246 (63.7%) were Catholics. Most of the participants (n = 112, 31.6%) had a parity between 3 and 4 and 114 (37.3%) had between 3 and 4 live children (Table 1).

Table 1.

Sociodemographic characteristics of women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda.

Variable	Total, N = 386		Contraceptive use
			Yes, n = 94		No, n = 292
Age in years, median (IQR)	39	(33–44)	38.0	(32.0–41.0)	39.5	(33.0–45.0)
Level of education, n (%)
No formal education	61	15.80	18	19.15	43	14.73
Primary	238	61.66	54	57.45	184	63.01
Secondary	67	117.36	20	21.28	47	16.10
Tertiary	20	5.18	2	2.13	18	6.16
Marital status, n (%)
Never married	38	9.84	4	4.26	34	11.64
Married	212	54.92	71	75.53	141	48.29
Previously married	136	35.23	19	20.21	117	40.07
Occupation, n (%)
Formal	105	27.50	27	28.72	78	26.71
Peasant farmer*	226	58.55	58	61.70	168	57.53
Unemployed	55	14.25	9	9.57	46	15.75
Religion, n (%)
Catholic	246	63.73	69	73.40	177	60.62
Protestant	68	17.62	12	12.77	56	19.18
Pentecostal	65	16.84	9	9.57	56	19.18
Moslem	7	1.81	4	4.26	3	1.03
Parity, n (%)
0–2	94	24.5	83	28.42	11	11.70
3–4	122	31.61	37	39.36	85	29.11
5–6	118	30.57	35	37.23	83	28.42
7+	52	13.47	11	11.70	41	14.04
Number of children alive, n (%)
0	33	8.55	1	1.06	32	10.96
1–4	228	59.07	61	64.89	167	57.19
5 and above	125	32.38	32	34.04	93	31.85
Age last child median (IQR) months**	72	24–132	45	24–72	96	24–156

^*This is the predominant source of livelihood in northern Uganda.

^**Data are available for only some of the respondents, who have had children.

ART, antiretroviral therapy; IQR, interquartile range.

Sociodemographic factors associated with modern contraceptive use among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda

Overall, 232 (60.1%) participants planned to have their last child, and 209 (54.1%) had no intentions to have the next child. Most of the participants (n = 214, 55.4%) expressed that it is the wife alone who decides on the family planning method. Most participants (n = 300, 84.3%) seeking care from this facility reported to have been referred at one point to others for contraception methods, 280 (72.5%) reported they had ever used a modern contraceptive method, and 273 (70.7%) reported that their first time to hear about family planning was from the health facility (Table 2).

Table 2.

Sociodemographic factors associated with modern contraceptive use among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda.

Variable	Total, N = 386		Contraceptive use				p Value
			Yes, n = 94		No, n = 292
Last child was planned, n (%)**							0.393
Yes	232	60.10	57	60.64	175	59.93
No	129	33.42	37	39.36	92	31.51
Not applicable	25	6.48	0	0	25	8.56
Intends next child, n (%)							0.630
Yes	164	42.49	43	45.74	121	41.44
No	209	54.15	50	53.19	159	54.45
Unsure	2	0.52	1	1.06	1	0.34
Not applicable	11	2.85	0	0.00	11	3.77
Who decides family size, n (%)							0.007
Wife alone	214	55.44	39	41.49	175	59.93
Husband	4	1.04	1	1.06	3	1.03
Both wife and husband	164	42.49	54	57.45	110	36.67
Other options	4	1.04	0	0	4	1.37
Referred from this facility, n (%)							<0.001
No	300	84.25	54	57.45	246	77.72
Yes	86	15.75	40	42.55	46	22.23
Ever used modern family planning, n (%)							<0.001
No	106	27.46	1	1.06	105	35.96
Yes	280	72.54	93	98.94	187	64.04
Partner knows HIV status**, n (%)							0.001
Yes	325	84.20	93	98.94	232	79.45
No	20	5.18	1	1.06	19	6.51
Unsure	24	6.22	0	0	24	8.22
Not applicable	17	4.40	0	0	17	5.82
Believes they are free to get contraception, albeit receiving ART care from a Catholic facility, n (%)							<0.001
Disagree	165	42.75	5	5.32	160	54.79
Agree	221	57.25	89	94.68	132	45.21
Believes FP can prevent HIV transmission to child, n (%)							<0.102
Disagrees	209	54.15	45	47.87	164	56.16
Agrees	164	42.49	43	45.74	121	41.44
Unsure	13	3.37	6	6.38	7	2.40

^**Data are available for only some of the respondents.

ART, antiretroviral therapy; FP, family planning.

Contraception use among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda

This study established that 206 (53.4%) participants received family planning counseling (if they were taken through the full process of counseling using the GATHER approach which gives details on methods, types, duration, mode of action, and side effects) while 384 (99.5%) received family planning information (basically what a participant has heard about family planning methods from whichever source without specification of details). Overall, 152 (39.4%) participants were using at least one form of family planning method, out of which 94 (24.4%) were on modern contraceptives and 58 (15.1%) were on natural methods, as shown in Figure 1.

Figure 1.

Family planning information and use among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda.

ART, antiretroviral therapy.

Of the 94 current modern contraceptive users, 42 (44.68%) used injectables, 28 (29.79%) implantable devices, 8 (8.51%) oral pills, 7 (7.45%) condoms, and 3 (3.19%) IUCDs, as shown in Figure 2.

Figure 2.

Types of modern contraceptive methods used by women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda.

ART, antiretroviral therapy.

Factors associated with modern contraceptive use among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda

At multivariable analysis shown in Table 3, age (aOR: 0.92, 95% CI: 0.87–0.98, p < 0.01), referral for family planning (aOR: 2.60, 95% CI: 1.31–5.17, p < 0.01), prior use of family planning (aOR: 32.47, 95% CI: 3.56–300.94, p < 0.01), and belief that one can get family planning services despite being in a Catholic facility (aOR: 21.60, 95% CI: 5.75–81.13) were independent predictors of modern family planning uptake.

Table 3.

Logistic regression analysis of factors associated with uptake of modern family planning methods among women of reproductive age with HIV attending the ART clinic at St. Mary’s Hospital Lacor, Uganda.

Variables	Crude association with contraceptive use			Adjusted association with contraceptive use
	cOR	95% CI	p Value	aOR	95% CI	p Value
Age in years	1.02	0.98–1.06	0.258	0.93	0.87–0.98	<0.01
Marital status
Single	1			1
Married	0.23	0.08–0.68	0.008	1.69	0.41–6.94	0.465
Previously married	0.54	0.30–0.98	0.043	0.71	0.15–3.30	0.662
Religion
Catholic	1			1
Protestant	0.55	0.28–1.09	0.086	1.00	0.41–2.43	0.99
Pentecostal	0.41	0.19–0.88	0.022	0.50	0.19–1.35	0.17
Moslem	3.42	0.75–15.68	0.113	9.72	0.73–128.77	0.09
Parity
0	1			1
1–4	3.28	1.57–6.87	0.002	2.43	0.85–695	0.10
5–6	3.18	1.51–6.68	0.002	2.87	0.73–11.39	0.13
7+	2.02	0.81–5.06	0.131	3.58	0.69–18.50	0.13
Number of children alive
0	1
1–4 children	11.69	1.56–87.40	0.02	12.28	0.43–352.28	0.14
4 or more children	11.01	1.45–83.88	0.02	9.30	0.28–314.09	0.21
Who decides family size
Wife alone	1			1
husband	1.50	0.15–14.76	0.73	0.26	0.01–8.09	0.44
Both wife and husband	2.20	1.37–3.55	0.001	1.11	0.58–2.13	0.76
Other options	Omit
Referred from this facility
No	1			1
Yes	3.96	2.36–6.64	<0.001	2.60	1.31–5.17	0.01
Ever used modern family planning
No	1			1
Yes	52.22	7.17–300.71	<0.01	32.473	3.50–300.94	<0.01
Believes they are free to get contraception, albeit receiving ART care from a Catholic facility, N (%)
Disagree	1			1
Agree	1.80	1.05–3.10	0.034	21.6	5.75–81.13	<0.01
Unsure	0.05	0.043–0.23	<0.001	69.28	4.45–1079.37	<0.01
Believes FP can prevent HIV transmission to the child
Disagrees	1			1
Agrees	1.30	0.80–20.9	0.29	0.85	0.44–1.64	0.63
Not sure	3.12	1.0–9.76	0.50	2.49	0.35–17.52	0.36

FP, family planning; cOR, crude odds ratio.

Bold values are statitically significant with p values <0.05.

Discussion

This study highlights the diverse patterns of contraceptive use among women living with HIV (WWH) receiving care at a catholic hospital in northern Uganda, demonstrating that modern contraceptive methods are being utilized despite limited availability at the facility level, with referrals playing a critical role in access. However, only a small proportion (24.4%) reported using modern contraceptives, with an additional 15.1% using natural methods. Injectable contraceptives and implants were the preferred modern contraceptive methods among those using them. In addition, previous use of a family planning method and being referred to another facility to access methods were significantly associated with current uptake of modern family planning. Our findings also underscore the fact that even when a facility does not offer modern family planning methods, it can still be accessed through appropriate referrals.

The intersection of faith and healthcare continues to influence contraceptive utilization, particularly in low- and middle-income countries.^10,11,33 Our findings, staged within a faith-based facility prohibiting prescription of modern contraceptives, underscore the urgent need to ensure that WWH, receiving care at faith-based institutions, are not left behind in access to modern contraception. This is crucial for achieving the eMTCT targets. While there is scant literature specifically focusing on contraceptive uptake in Catholic-based institutions, our study reveals a significantly lower proportion of clients utilizing modern contraceptives compared to national and regional rates. Given the fact that St. Mary’s Hospital Lacor does not provide modern contraceptives, it is likely that some clients did not consider other options for accessing the methods. Our findings are similar to those in Tanzania, where some Christians quoted Genesis 1:28 as a reason to multiply and fill the world, discouraging the use of modern family planning significantly.^28,34 Other African settings have also reported lower offering of long-acting family planning methods by faith-based health facilities. ³³

Comparison with other studies revealed interesting insights. In our study, the proportion of women using contraceptives was below the national modern contraceptive prevalence rate of 37% ³¹ and lower than rates reported in other government settings, such as the 36% reported by Bongomin et al. at Gulu Regional Referral Hospital and the 62% reported in eastern Uganda.^27,35 However, our prevalence rate is higher than the 16.8% found in Halibet, Eritrea, which has a developing health system. ³⁶ This comparison highlights the variability in contraceptive utilization rates across different settings and underscores the need for context-specific interventions. Our findings indicate that low contraceptive prevalence rates in a Catholic health-based hospital are similar to those in Rwanda, which established that uptake of family planning services was lower in Catholic facilities compared to non-Catholic facilities. ³⁷

The low prevalence of modern contraceptive use raises concerns about the potential for unwanted pregnancies among WWH, leading to unmet contraceptive needs and a risk of vertical transmission. Although natural family planning is emphasized by religious beliefs, our study shows that only a small proportion of participants in our setting utilize this option, similar to a case in Rwanda. ³⁸ It is worth noting that while ART influences the choice of modern contraceptives, our study did not delve into the medical eligibility criteria for contraceptive use in alignment with ART regimens.

Our findings underscore the importance of providing modern contraceptive counseling and referral services in faith-based institutions, similar to non-faith-based health facilities. Clients not referred for family planning services were less likely to use modern contraceptives, highlighting the importance of referral practices as indicated in Table 3. Improved inter-facility linkages and integration of family planning into HIV services have been shown to have a good impact on family planning uptake. ³⁹ Low referral rates observed in our study could be contributing to the overall low contraceptive utilization. Although the public facilities, such as Gulu Regional Referral Hospital and other lower-level government health centers within Gulu city, are within the reach of clients, it is crucial that healthcare workers at Lacor hospital continue to provide family planning counseling and a clear referral pathway and confirmed linkage to these facilities be developed to improve uptake.

Service providers in our institution do provide modern contraceptive counseling; however, the quality of contraceptive counseling, as indicated by a high method information index^40,41 (MII-plus) score, was beyond the scope of this paper, hence further qualitative studies are needed to understand other drivers of uptake and persistence on modern contraceptives among this population. Leveraging the experiences of previous contraceptive users as peer supporters could potentially improve uptake, as previous use was associated with better uptake in our study. Other studies previously found a prior contraceptive use influences current use. When faith leaders are engaged to provide information, uptake can increase, since some people have already had positive experiences.

In our study, age was a significant predictor of modern family planning use. For every yearly increase in age, there was an 8% reduction in the odds of using contraceptives among clients. It is true that the average age of the study participants was high (38 years); thus, older WWH might mean more perceived burden of having more children. The nature of sexual activity at the older ages is unclear, and the possibility that spouses could have died or separated could not be ruled out, but our study also observed that 54.1% of the participants had no intentions to have the next child. This, however, does not provide any clear insight into the sexual needs and activities that these WWH could be engaged in or intend to be engaged in. This is similar to the findings of Bongomin et al. where people aged 30 years or more attending an infectious disease clinic were less likely to use contraceptives in the same city as this study.

Finally, our study highlights the importance of client beliefs in the ability of modern contraceptives to prevent HIV transmission to the child. Clients who believed in this were more likely to use modern contraceptives, aligning with the role of contraceptives in aiding the eMTCT strategies. Our findings are similar to those of Terefe et al. (2024), where it was established that awareness and positive attitudes about MTCT were drivers to acceptance of modern contraceptive use. ⁴²

Limitations

Our study identified facility and client factors associated with contraceptive uptake among HIV clients. However, HIV factors such as regimen, duration on ART, and WHO clinical stage, which potentially influence uptake and choice of modern contraceptives, were beyond the objectives of this study, and future studies could delve into a deeper understanding of such factors. Similarly, this study did not specifically evaluate the use of modern contraceptives among WWH who had unintended pregnancies. In addition, the study was designed to maximize the use of modern contraceptives; thus, we missed cases where both natural and modern methods were used.

This was a cross-sectional study; hence, only associations other than causal inference around contraception use and associated factors among WWH receiving care in a faith-based hospital in northern Uganda can be provided.

The findings of this study may not be generalizable to all hospitals providing contraceptives to WWH.

Our study underscores the need for targeted interventions to improve modern contraceptive uptake among HIV-positive women attending care at faith-based institutions. Improving counseling, referral practices, and leveraging the experiences of previous contraceptive users could potentially enhance contraceptive utilization in this population.

Conclusion

Approximately one in every four WWH were currently using modern methods of contraceptives at a faith-based health facility in northern Uganda. Factors such as previous use of family planning, age, and referral to another facility for accessing family planning commodities were linked to contraceptive uptake. The low uptake suggests a substantial unmet need for family planning among these women, raising concerns about the risk of unintended pregnancies, which could culminate in a potential risk for vertical transmission. Future studies should explore these gaps further. Women of childbearing age with HIV should be prioritized in family planning service frameworks, regardless of their faith, to sustain the progress made in preventing MTCT.

We recommend that faith-based facilities consciously implement robust family planning services, with mass sensitization, counseling, and referral systems, particularly for WWH, to prevent unintended pregnancies and vertical transmission. In addition, further research involving more Catholic health facilities is essential to understand the dynamics of family planning services, including both natural and modern methods, for HIV-positive individuals.