New study in OFID finds low rates of contraception use among women with HIV
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Jessica L. Castilho, MD, MPH, an assistant professor in the Division of Infectious Diseases and the Department of Health Policy at Vanderbilt University School of Medicine, recently spoke with Science Speaks about her new study in Open Forum Infectious Diseases, which found low rates of contraception use among women with HIV at a large HIV clinic in Tennessee from 1998 to 2018. She discussed why she and her co-authors explored this topic, the study’s main takeaways and clinical implications, and how IDSA’s G.E.R.M. Program supported the research effort.
Why is access to reproductive health services and effective contraception important for women with HIV?
Access to reproductive health services and family planning is important for all women and that includes women with HIV. They should not be excluded or thought that these services are less relevant to them.
We know that many women experience unintended pregnancies, and contraception allows women to plan and time their pregnancies should they desire them. This is important not only for pregnancy outcomes, but it’s also important for the health and wellbeing of the woman. All of these points are equally, if not more, applicable for women living with HIV who may also be living with multiple medical comorbidities and unique social stressors.
What motivated you and your co-authors to study contraceptive use in women with HIV?
Reproductive health and contraception have always been important topics in the care of women with HIV, but recently it was back in the spotlight following warnings back in 2018 about a potential link between dolutegravir, which was emerging as a first-line treatment for people living with HIV, and a potential birth defect — neural tube defects. That really helped bring everybody’s attention back to reproductive health among women living with HIV globally and also here in the U.S.
Between 2018 and 2019, when dolutegravir was not recommended for women of childbearing potential, we found ourselves reevaluating the contraception use of women in our clinic, and it caused us to focus on what contraception women were using or not using.
What are the main takeaway messages from the study?
Number one, despite advances in HIV treatment and advances in methods of effective contraception, rates of effective contraception use among women with HIV remained stable over time in our study, and rates were lower than what’s been reported in the general population over this same 20-year period. That surprised us. We need to look deeper into the reasons for this and ensure that we are providing adequate access and sufficient options to our patients who desire contraception.
Secondly, we found that women with comorbid psychiatric disease were less likely to initiate effective contraception and were more likely to experience pregnancy. More work is needed to understand the causes and implications of these findings, but this may help us identify important populations to focus on first to make sure that we’re meeting the needs for family planning for women living with HIV.
What are the clinical implications of this research for providers who care for women with HIV?
One important lesson that we found was that there was a real persistence of sterilization, particularly bilateral tubal ligation, as the most frequent form of effective contraception used in our clinic population. That was constant over the study period. There was also relatively low uptake of newer, reversible, long-acting forms of contraception. I think that highlights an area where we could potentially do better clinically. Just as HIV providers are excited about the newer forms of HIV therapies that are on the horizon, we need to make sure we’re talking with our female patients about all the different forms of family planning and contraception available to help support their choices and what’s best for them.
What are some of the current barriers that prevent women with HIV from accessing reproductive health services, and how can these be addressed?
That’s really the most important question, and it’s really where the study leaves us: What’s next, and what can we do in all of our clinics? We need to review how women access these services. Our clinic has been fortunate in that we've had family planning services really embedded within our clinic, and that helps to minimize the need for external clinic referrals. But we still need to look closer at who’s receiving the services, who isn’t, and why is that happening. We need more qualitative and mixed-method approaches to better understand the barriers that women face from the women themselves. We need to hear their voices, we need to understand their desires. We need to understand where we may be falling short and what opportunities there are to better meet their needs. Our group is starting to work on some of those next questions now.
I understand the study’s first author was a medical student at the time. Can you talk about her involvement?
At the time of the study, the lead author, Manasa Bhatta, was a medical student here at Vanderbilt and was engaged in an immersion research course. As part of that course, we developed this project together, and her involvement was also supported through an IDSA G.E.R.M. Program grant. That award was really fundamental and helped provide extra support for the study. It also gave her increased awareness of IDSA and infectious diseases in general. We’re appreciative of IDSA’s support and its efforts to help bring up the next generation of infectious disease providers and caregivers.
Is there anything else you would like to highlight about the study’s findings or about this topic more broadly?
I would just add that while this study focused on cisgender women living with HIV and contraception, family planning options and discussion of family planning desires are relevant for all people living with HIV. Understanding how we can support our patients’ family goals is an important component to what we do, as their health care providers, and this is a discussion we should be having with all of our patients.
Read the full study, "Low Rates of Contraception Use in Women With HIV," on OFID's website.
