AIDS is excellent.4,5 In the capital city, confidential ... lished in Kigali, the capital city, to study the predictors and ..... tent to prevent pregnancy. Despite a high.
Pregnancy and Contraception Use among Urban Rwandan Women after HIV Testing and Counseling
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Susan Allen, MD, Antoine Serufilira, MD, Valene Gnmber, PhD, Susan Kegeles, PhD, Phi4ppe Van de Perre, MD, Michel Carael PhD, and Thomas J. Coates, PhD
Introdudion Rwanda, a central African country with a population of 7.5 million, has an human immunodeficiency virus (HIV) seroprevalence of over 30% among 26- to 40-year-old men and women in urban areas.'-3 Nationwide information campaigns about acquired immunodeficiency syndrome (AIDS) have been under way since 1986 and knowledge about H[V and AIDS is excellent.4,5 In the capital city, confidential, voluntary HIV antibody testing and counseling with condom provision is available and is promoted by the National AIDS Control Program. Although condoms have become more popular since the advent of the AIDS epidemic, condom use overall is still infrequent.-6 Rwanda is the most densely populated country in Africa7 and its per capita annual income is less than $300. The average woman bears eight children in her lifetime and modern contraceptive use is infrequent, despite the efforts of the National Family Planning Program.8 Estimates of the risk of perinatal transmission of HIV range from 13% to 30%,9 and children born with HIV have little chance of surviving to adulthood.10 In central Africa, children who do escape the infection are often orphaned1' in a setting lacking the economic resources to provide for them, a problem that threatens to overwhelm extended family and community networks.12 In this context, it is important that HIV-infected women limit their fertility. The World Health Organization has advised that HIV counseling should include information about maternal transmission.13 There is little evidence to date, however, to indicate the effectiveness of this type of advice in preventing pregnancies among HIV-positive women.
In 1986, the Project San Francisco, a collaborative effort of the Rwandan Ministry of Health and the Center for AIDS Prevention Studies at the University of Califomia in San Francisco, was established in Kigali, the capital city, to study the predictors and natural history of HIV infection in Rwandan women. The demographic and behavioral correlates of HIV infection in Kigali have been previously described.4"14-'6 We present here the rates of hormonal contraceptive use and the incidence of pregnancy following an HIV antibody testing and counseling program provided to a large sample of childbearing urban women with a high prevalence of HIV infection.
Methods Sampling procedures have been described in detail elsewhere.316 Briefly, in 1986 and 1987, a consecutive, populationbased sample of 3702 women aged 18 to 35 Susan Kegeles and Thomas J. Coates are with the Center for AIDS Prevention Studies, Division of General Internal Medicine, University of California, San Francisco. Susan Allen is with the Department of Pathology, and she and Valerie Gruber are with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Susan Allen and Antoine Serufilira are with the Project San Francisco, Ministry of Health, Kigali, Rwanda. Philippe Van de Perre is with the BelgianRwandan Cooperation and the National AIDS Control Program, Ministry of Health, Kigali, Rwanda. Michel Carael is with the Global Programme on AIDS, World Health Organization, Geneva, Switzerland. Requests for reprints should be sent to Susan Allen, MD, 74 New Montgomery St, Suite 600, San Francisco, CA 94105. This paper was accepted January 12, 1993.
American Journal of Public Health 705
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years was drawn from the outpatient pediatric and prenatal clinics at the Centre Hospitalier de Kigali, the only community hospital in the city. The prevalence ofHIV infection in this initial sample was 29%. In 1988, 1458 of these women (460 HIV positive and 998 HIV negative), selected by stratified random sampling, were enrolled in a prospective study. The 1458 enrolled were similar to the 2244 women not enrolled with respect to the prevalence of HIV, age, marital status, and partner's profession. We consider this sample to be reasonably representative of childbearing urban women; the majority are literate and are in common-law or legal marriages, two thirds report only one lifetime sex partner, and almost three fourths are Catholic.16 At enrollment, the women saw a 10minute video explaining the goals and procedures of the study and gave written informed consent to participate. We administered a questionnaire addressing knowledge, attitudes, and behaviors relating to AIDS and HIV transmission; took a medical history including obstetric history and past contraceptive use; and performed a complete physical examination on each woman. All instruments were administered in Kinyarwanda, the local language, by Rwandan nurses and social workers. Participating subjects were obligated to receive their HIV antibody test results, as required by the US National Institutes of Health-Office of Protection from Research Risks, and as stated in the informed consent. Pretest counseling consisted of a 35-minute AIDS educational video (produced in the local language), followed by a group discussion led by a social worker and physician. HIV antibody test results, with posttest counseling, were given individually and confidentially 3 weeks later. At the request of the study subjects, interested male sex partners were invited to participate in the video and group discussion sessions. They were free to request the HIV antibody test but were not required to have it, and no data were collected from them. At enrollment and during each subsequent contact, participants were offered condoms and spermicides at no cost. In the video, following an introduction by the director of the National AIDS Control Program, a gynecologist responds to questions posed by three women of varying ages and social circumstances. The questions concem the manifestations of AIDS, the meaning of the HIV antibody test, and routes of transmission of HIV, including heterosexual transmission, 706 American Journal of Public Health
maternal-child transmission, and contaminated transfusions or unsterilized needles. The second scene shows the three women sitting with a nurse, who demonstrates the use of condoms and spermicide. Condoms are reinforced as the method of choice for prevention of HIV transmission, and the lack of clear evidence as to the efficacy of spermicide is emphasized. The women discuss the difficulty of initiating a discussion about AIDS with their sex partners ("He will think that I don't trust him, or that I have been unfaithful") but reinforce each other's intentions to do so. In the final scene, four men in a bar discuss the HIV blood test and condoms. During the group discussion that followed the video, participants had the opportunity to ask questions, and condoms and spermicides were again demonstrated. Subjects could elect to receive their test results alone or with their sexual partner. Risk reduction was emphasized for HIV-negative subjects, who were warned that a negative test did not imply immunity from infection. HIV-positive subjects were advised to use condoms to avoid transmitting the virus to their sex partners and to avoid reinfection themselves. In keeping with the level of knowledge at the time (1988), the counselor clarified that it was not yet known what the chances were of HIV infection's progressing to AIDS. Avoidance of other infections (particularly sexually transmitted diseases), early treatment of symptoms, and a healthy diet were advised to maintain good health. At that time, precise data were also lacking regarding the probability that an HIVpositive African mother would transmit the virus to her baby. Women were advised that because of the (unknown but probably high) risk of bearing an infected child, and because of the increased risk to the woman's health that might be imposed by the stress of pregnancy, continued
childbearing was discouraged. They were also told that although condoms and spermicide were contraceptives as well as AIDS prevention measures, more effective means of preventing pregnancy were available at the National Family Planning Program. The overall emphasis of the counseling session was on preventing heterosexual transmission and providing moral support for HIV-positive women; unless the patient initiated further discussion, the issues of conception and contraception were not pursued. Our previous research indicated that even before view-
ing the educational video, 97% of the women knew about maternal-child transmission of HIV. HIV serologies were performed in the Rwanda National AIDS Control Program Laboratory. All sera were screened with an enzyme immunoassay (Wellcome Diagnostics, England). Positive results were confirmed either with Western blot (DuPont, United States) or indirect immunofluorescence (Virion, Switzerland) for HIV-1. Pregnancy and hormonal contraceptive use by the sample were recorded for 2 years. Use of injectable or oral contraceptives was noted during the yearly physical and gynecological exams. Women who elected to use condoms or spermicide were given calendars in which they recorded sexual contacts with and without their chosen method of contraception. They returned to the clinic every 3 months for compliance evaluation and received more condoms and spermicide as needed. The incidence of pregnancy was recorded every 6 months on a medical questionnaire completed at the clinic (for more than 85% ofthe women at each visit) or at home (for women who could not come to the clinic). Of the 1458 women who enrolled in the cohort study, 106 did not have complete information available at 2 years, and 204 did not complete the 12-month physical exam at the clinic and thus data on their contraceptive use at that time are missing. A cross-sectional analysis was used to identify baseline correlates of pregnancy and hormonal contraceptive use in the 1458 women enrolled. Changes in hormonal contraceptive use in the year after HIV antibody testing were evaluated for the 1254 women (373 HIV-positive and 881 HIV-negative) who completed the 12month physical exam at the clinic. Predictors of pregnancy in the 2 years after HIV antibody testing were evaluated in the 1352 women (407 HIV-positive and 945 HIV-negative) who had completed 2-year follow-up or were known to have become pregnant in that time. The method of data collection did not allow calculation of incidence of pregnancy per person-month of susceptibility, an analysis thatwould eliminate anovulatory person-months from the denominator. In lieu of this measure, baseline pregnancy, lactation, and hormonal contraceptive use are related to the incidence of pregnancy in the subsequent 2years. Statistical significance is indicated by a P value of
