Background: About 90% of unintended pregnancies among African women are attributed to non-use of effective family planning (EFP) methods (injectable, oral, intra-uterine device (IUD), implant, or tubal-ligation). Long acting reversible contraceptives (LARC), which include implants or IUDs, are the most effective reversible contraception for an extended period without requiring user action. We report frequency of unintended pregnancy and determinants of contraceptive choice among African women on life-long ART.
Methods: The US-PEPFAR PROMOTE is a long-term cohort study of HIV-infected women (n=1,986) and their children, enrolled from December 2016 to June 2017, as an extension to a completed mother-to-child transmission prevention trial from eight sites in Malawi, South Africa, Uganda, and Zimbabwe. Standardized questionnaires were used to collect demographic and reproductive health data. Baseline enrollment data were analyzed using chi square and Wilcoxon Rank-Sum tests for group comparisons, and multivariable logistic regression to identify determinants of contraceptive choice.
Results: Overall, among 1,984 women included in this analysis, 49.9% (n=990) reported that their last pregnancy was unintended (figure 1), and >50% had no desire for more children. Among sexually-active, non-pregnant women, 81.6% (1,050/1,287) reported EFP use; while 19.0% (227/1,197) without permanent contraception reported LARC methods. Injectables were the commonest method (39%) - especially at the South African sites (>50%), followed by implant (14.4%). Oral pills were popular in Zimbabwe and tubal-ligations were common in Malawi and South Africa. Non-pregnant women whose last pregnancy was unintended versus intended were more likely to report current EFP use, adjusted odds ratio (95% CI), 1.44 (1.10 -1.96), p=0.02; but not LARC use, 1.25 (0.92-1.70), p=0.15. Women with no formal employment were less likely to report LARC use, 0.64 (0.43-0.96), p=0.03, but not EFP-use, 0.92 (0.62-1.35), p=0.60. All multivariable models included age, marital-status, attained desired number of children, clinic travel-time, household water, and electricity, which were not associated with contraception choice.
Conclusions: Unintended pregnancy is common among HIV-infected African women. LARCs are acceptable contraceptive options in these settings, though under-utilized. Programmatic research should explore integrated ART and LARC delivery in consideration of the unique reproductive health challenges among HIV-infected African women on universal ART.

Fertility desire at last conception among HIV-infected women on Antiretroviral Therapy (ART) reported at study entry
[Fertility desire at last conception among HIV-infected women on Antiretroviral Therapy (ART) reported at study entry]