Contraceptive Use Among Women Living with HIV and AIDS Receiving Care at Secondary and Tertiary Health Care Facilities in Ibadan, Nigeria

Contraceptive use is a form of family planning and it is one practice among the most important health decisions that many people make and this does not exclude women living with HIV/AIDS. Lack of adequate information on available contraceptive methods and restriction of choices are the major constraints for contraceptive users to obtain a method that suits their need. Consequently, this study was designed to assess contraceptive use among women living with HIV and AIDS receiving care at secondary and tertiary health care facilities in Ibadan, Nigeria. A cross-sectional study using systematic sampling technique was conducted to select 350 consenting women among HIV positive women receiving care in two health facilities in Ibadan, Nigeria. A pre-tested interviewer administered questionnaire was used to obtain information on respondent’s socio-demographic characteristics, contraceptive usage and level of satisfaction of modern contraceptive method. Data were analyzed using SPSS version 22. Chi-square statistic was used to test associations between categorical variables at a level of statistical significance of 5%. The mean age of respondents was 37.0±8.5 years and about 87.0% were currently married. The current prevalence of contraceptive was 67.7%. Condom was the most currently preferred contraceptive method (54.0%), followed by injectable (12.2%) and oral pills (11.0%). About 83.1% was satisfied with their current method of contraception. The most cited reason by those who were not satisfied with their current contraceptive method irregular menses (30.0%). The factors that were significantly associated with contraceptive use were maternal age, marital status, type of marriage, level of education and parity decision (P < 0.05). High level of contraceptive uptake and satisfaction was observed in this study. However, irregular menses was a common complaint of those who were not satisfied with their current method. Family planning programme should be incorporated as a component part of care for women living with HIV and AIDS.


Introduction
Contraceptive use is a form of family planning and it is one practice among the most important health decisions that many people make [1,2] and this does not exclude women living with HIV/AIDS. In 2015, about half of the 1.9 million new HIV positive infections worldwide were among women [3]. Although fertility and HIV rates in Nigeria are among the highest in the world as the country is rated second behind India with the number of HIV positive population globally, little is known about how HIV infection affects the met and unmet need for modern family planning [4]. Prevention of unintended pregnancies among HIV infected women is among the four key pillars for comprehensive prevention of mother to child transmission (PMTCT). This can only be achieved with the use of contraception to prevent unwanted pregnancy [5,6].
Every year, about 1.5 million women living with HIV/AIDS become pregnant, mainly in sub-Saharan Africa [7]. This category of women has higher unmet needs for family planning (FP) for their own health and for preventing mother-to-child transmission of HIV. Prevention of unintended pregnancies among women living with HIV is the second component of the World Health Organization's four-pronged approach to comprehensive prevention of mother-to-child transmission of HIV (PMTCT) [8]. Provision of appropriate counselling and support in addition with contraceptives, to women living with HIV to meet their need for family planning and spacing of births has been shown to be a cost-effective intervention to prevent MTCT [9].
Understanding the fertility desires of HIV-infected women who know their HIV status, their contraceptive choices and the pregnancy rates is critical in meeting their reproductive health needs and preventing unwanted pregnancies. This study was therefore designed to assess the level of utilization of contraceptives among women living with HIV in Ibadan, Oyo State of Nigeria.

Subjects and Method
This is a descriptive cross-sectional survey conducted among HIV positive women receiving care at the University College hospital, (UCH) and Adeoyo Maternity Hospital Ibadan, Oyo State, Nigeria during the period March 2015 to October 2015. The sample size was estimated using the formular: n = ² ² A systematic sampling technique was used to recruit women into this study. Participants were interviewed as they came into the clinic. A pretested questionnaire was used to obtained information on respondent's demographic characteristics, contraceptive use and level of satisfaction of current contraceptive choice.
Data were analyzed using the statistical Package for social Sciences version 22. All tests were carried out at 95% confidence interval with probability level of p < 0.05 accepted as being of statistical significance. ( = 0.05). Descriptive statistics was used to describe the general characteristics of the sample. Chi-Square test was used to determine the association between the dependent variables and some selected independent variables. The UI/UCH and Oyo State Ethical Review Board/Committee approved this study.

Results
Three hundred and fifty women were interviewed with mean age of 37.1±8.5 years. The majority 304 (86.9%) were currently married, 38 (10.9%) were previously married, 8 (2.3%) never married. About three-fourth of the women had secondary education, 55 (15.7%) had primary education, 26 (7.4%) had no formal education and 5 (1.4%) had tertiary education. Regarding occupation, 210 (60%) were traders, 44 (12.6%) civil servants, 41 (11.7%) Artisan and 13 (3.7%) ( Table 1). About 280 (80%) had sexual intercourse at least once a week. Two hundred and ninety-four (84.0%) had ever used contraceptives while about 237 (67.7%) are currently using contraceptive. Condom was the most commonly used contraceptive method (Figure 1 and 2). Out of the 346 (99.9%) who had ever been pregnant, 309 (89.3%) had live birth, 27 (7.8%) had induced abortion, 9 (2.6%) had still birth and 1 (0.3%) had spontaneous abortion. Nearly half of the decisions about parity were jointly made by the respondents and their spouses. Most of the respondents 203(58.0%) desired more children. (Table 2).   One hundred and ninety-seven (83.1%) of the women were satisfied with their current contraceptive method. Most women who were not satisfied with their current method complained of having irregular menses (30%) ( Table 3). Current usage of contraceptive is significantly associated with age, marital status, type of marriage, respondent's level of education and decision about parity (P < 0.05). Higher usage of contraceptive was evident among those aged 20-29 years, the never married, respondents from monogamous home, secondary education and made joint decision about parity.

Discussion
This study was conducted among HIV seropositive women receiving care in two health facilities in Ibadan metropolis revealed that most respondents were between age 30 and 39 years with mean age of 37.1 ± 8.5 years. This is consonance with the report of [10] among antiretroviral therapy patients in Ibadan, Nigeria. Nearly, nine out of every ten women in this study were currently married. This is in line with previous studies conducted among rural women in Ikeji, Arakeji, South West Nigeria [11] and among antenatal attendees in Uyo, South South, Nigeria [12]. The preponderance of married people in this study is higher probably because nearly all the women had ever been pregnant and are expected to have been married.
Most women in this study had ever or were currently using contraceptives as opposed to the existing evidence that contraceptive uptake has been abysmal in Nigeria [11,[13][14][15]. A plausible reason for the high contraceptive use in this study is the increased awareness campaign of contraceptives among people living with HIV and AIDS. The most common contraceptive used by respondents in this study was condom. This is similar with the report of previous studies [16]. Some authors have suggested that condoms are cheap, accessible, quick to use, with minimal side effects [17,18]. This could be a possible reason for the high prevalence of condom use in this study.
Interestingly, this study found a negative association between contraceptive use and age. This is similar with the findings of other authors [19]. The finding that utilization of contraceptive was higher among younger respondents than older respondents is an indication of the availability of a youth friendly contraceptive. Also, this finding suggest a higher prevalence of contraceptives among single women than ever married women. This finding substantiates the assertion that contraceptive usage is higher among unmarried sexually active women than married sexual active women [13,20,21]. Never married sexually active women were increasingly using contraceptives due to the recent increased awareness of HIV/AIDS in secondary schools, higher institutions and youth centres in the communities. Condom is most preferred contraceptives by this category of women because they may be ashamed of seeking health care in family planning clinics. Also, it is cheap and does not require complex medical prescription.
Surprisingly, this study found that women with tertiary education had the least contraceptive prevalence compared to others. This is in contrast to the pool of evidence established by previous studies that found a positive association between level of education attained by women and prevalence of contraceptives [13,[22][23][24][25]. This anomaly can be attributed to the low population of women with tertiary education in this study.
Furthermore, this study found that most women were satisfied with their current contraceptive method. This is in line with the study among women in Kumasi, Ghana [26] and Mozambique [27]. About one in ten women complained about irregular menses compared to one in five among women in Kumasi, Ghana [26].

Conclusion
Most respondents in this study had ever used and were currently using contraceptives. Condom was the most ever used and currently used method of contraception while implant was the least ever used method of contraception. Current contraceptive use was significantly associated with age, marital status, type of marriage, level of education and parity decision. Most women were satisfied with their current method of contraception. The most cited reason for nonsatisfaction with current contraceptive method was experience of irregular menses while fear of irregular menses was the least cited reason.
The questionnaire used for this study had some sensitive questions. Hence, social desirability bias was a major limitation of this study.