Provision of long‐acting reversible contraception in HIV‐prevalent countries: results from nationally representative surveys in southern Africa

Abstract

Objective To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings. Design Nationally representative survey of clinicians. Setting HIV-prevalent settings in South Africa and Zimbabwe. Population Clinicians in South Africa and Zimbabwe. Methods Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIV-prevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs. Main outcome measure Multivariable logistic regression of contraceptive provision and clinician training needs. Results Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians’ perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training. Conclusions Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and at-risk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.

Contraceptive use among HIV‐positive women in Enugu, southeast Nigeria

“…This finding may be due to low awareness of the safety of long‐acting reversible contraceptives among HIV‐positive women [18] and their health provider. Further studies are necessary to confirm this assumption; however, Morse et al [24] have reported that the clinician's perception that the IUD and implant are inappropriate for HIV‐positive women, despite evidence to the contrary, might affect usage.…”

Neurologist knowledge about interactions between antiepileptic drugs and contraceptive methods

“…Many practitioners who are unaware of WHO medical eligibility criteria for contraceptive use also make inappropriate contraception prescriptions for diseases other than epilepsy [3,5,6,24]. A cross‐sectional study using a UK general practice research database [5] demonstrated that the percentage of women with high cardiovascular risk using inappropriate contraception was only slightly reduced over time (from 8.1% in 2004 to 7.3% in 2010).…”

“…The rates of unplanned pregnancy among women with comorbidities—e.g. infection with HIV or a history of thrombosis—are even higher, because many doctors are unaware of WHO medical eligibility criteria for contraceptive use [2] and therefore prescribe inappropriate or poorly effective contraceptive methods for these women [3–6].…”

Clinicians' perceptions and provision of hormonal contraceptives for HIV-positive and at-risk women in Southern Africa: an original research article

“…Similarly, although IUDs are highly effective contraceptive methods, a previous analysis showed very few providers reported that either the copper or levonorgestrel-releasing IUD was appropriate for at-risk or HIV positive women [10], despite data showing they are safe and acceptable among both groups of women [15–17]. Encouragingly South Africa’s newly-released contraception guidelines emphasize long-acting methods, and the National Department of Health is moving forward with a national contraceptive implant introduction and revitalization of the IUD [18–20].…”

“…The surveys were pilot tested in each country for content and comprehension, and the final instrument covered professional training, practice setting, patient population, and provider knowledge, attitudes and clinical practices. The methods have been described in detail previously [8,10]. …”