Background. Dual protection is recommended for prevention of unwanted pregnancies and protection against sexually transmitted infections, including HIV. It is critical for HIV-negative women to prevent seroconversion and HIV transmission to their infants during pregnancy and breastfeeding.
Methods. Women were followed up after delivery, monthly for the first 9 months and then 3-monthly to 24 months, in a cohort study investigating postnatal HIV transmission. Study nurses discussed family planning, including condom use, at each visit. Contraceptive methods used since the last visit were recorded. All women knew their HIV status, and most women breastfed for a minimum of 6 months. 
Results. Among 1 137 HIV-positive and 1 220 HIV-negative women the most common contraceptive method was the hormonal injectable; few women used condoms alone or as
dual contraception (0 - 3 months 6.8%; 7 - 12 months 16.3%; 19 - 24 months 14.4%). Compared with uninfected women, HIV-positive women were more likely to use condoms in years 1 and 2 after delivery (adjusted odds ratio (AOR) 1.72, 95% confidence interval (CI) 1.38 - 2.14, 

Bland, R M

Coovadia, H M

Coutsoudis, A

Newell, M L

Ngubane, N

Patel, D

Rollins, N

English

AJOL - African Journals Online

ORIGINAL ARTICLES209March 2008, Vol. 98, No. 3  SAMJSouth Africa is one of the countries in sub-Saharan Africa hardest hit by the HIV pandemic, with women more likely to be infected than men of the same age.1 HIV prevalence among pregnant women attending antenatal clinics has reached its highest level to date: 29.5% (95% confidence interval (CI) 28.5 - 30.5) of women were HIV positive in 2004 (95% CI 36.8 - 41.4), with the prevalence reaching 40% in KwaZulu-Natal.2 While much attention is paid to reduction of vertical HIV transmission from mother to child during the antenatal period and delivery, with modified obstetric techniques and the use of antiretroviral regimens,3,4 the postpartum period is also critically important.5 Exclusive breastfeeding is recommended for the first 6 months of life for infants of HIV-negative women, and for infants of HIV-positive women who do not have the resources for safe and sustainable replacement feeding.6 It is crucial for HIV-negative women to prevent seroconversion and HIV transmission to their infant during breastfeeding. We present data on the use of contraceptives, in particular dual protection (i.e. the use of a condom, plus another contraceptive method, to simultaneously reduce the risk of unwanted pregnancies and sexually transmitted infections (STI) including HIV), in the first 2 years after delivery, in HIV-infected and uninfected women, in an area of South Africa with a high HIV prevalence.7-9Population and methodsThe data presented here are from a non-randomised intervention cohort study examining postnatal transmission of HIV and infant feeding in KwaZulu-Natal, South Africa.10 Pregnant women were enrolled at 7 rural, 1 peri-urban, and 1 urban government clinic. All women received HIV counselling and testing from lay HIV counsellors, and all women received post-test counselling and were aware of their HIV results. Maternal sociodemographic data were recorded antenatally. Women were followed up at clinics, postnatally, for a maximum period of 24 months: monthly for the first 9 months, and every 3 months from 10 to 24 months. At each clinic visit the mother was interviewed by a dedicated study nurse, known to the mother, who had received training in family planning, and was aware of the full medical history and HIV Messages about dual contraception in areas of high HIV prevalence are not heededN Ngubane, D Patel, M L Newell, H M Coovadia, N Rollins, A Coutsoudis, R M BlandAfrica Centre for Health and Population Studies, University of KwaZulu-Natal, DurbanN Ngubane, MPHM L Newell, PhDR M Bland, MDCentre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College, LondonD Patel, PhDCentre for HIV/AIDS Networking, University of KwaZulu-NatalH M Coovadia, PhDDepartment of Paediatrics and Child Health, University of KwaZulu-NatalN Rollins, MDA Coutsoudis, PhDBackground. Dual protection is recommended for prevention of unwanted pregnancies and protection against sexually transmitted infections, including HIV. It is critical for HIV-negative women to prevent seroconversion and HIV transmission to their infants during pregnancy and breastfeeding.Methods. Women were followed up after delivery, monthly for the first 9 months and then 3-monthly to 24 months, in a cohort study investigating postnatal HIV transmission. Study nurses discussed family planning, including condom use, at each visit. Contraceptive methods used since the last visit were recorded. All women knew their HIV status, and most women breastfed for a minimum of 6 months. Results. Among 1 137 HIV-positive and 1 220 HIV-negative women the most common contraceptive method was the hormonal injectable; few women used condoms alone or as dual contraception (0 - 3 months 6.8%; 7 - 12 months 16.3%; 19 - 24 months 14.4%). Compared with uninfected women, HIV-positive women were more likely to use condoms in years 1 and 2 after delivery (adjusted odds ratio (AOR) 1.72, 95% confidence interval (CI) 1.38 - 2.14, p<0.001; AOR 1.61, 95% CI 1.15 - 2.25, p=0.006 respectively). Compared with women with a flush toilet, those with a pit latrine were less likely to use condoms in years 1 and 2 (AOR 0.22, 95% CI 01.7 - 0.28, p<0.001; AOR 0.27, 95% CI 0.19 - 0.39, p<0.001). Older women were more likely to use condoms in the first postpartum year (AOR 1.78, 95% CI 1.03 - 3.09, p=0.040).Conclusions. More creative ways of promoting condoms and dual contraception need to be found if new HIV infections, in women and children, are to be prevented.S Afr Med J 2008; 209-212.Corresponding author: R Bland (rbland@africacentre.ac.za)Pg 209-212.indd   209 2/20/08   12:26:22 PMMarch 2008, Vol. 98, No. 3  SAMJORIGINAL ARTICLES210status of the mother. At each visit the mother was specifically asked about her contraceptive use since the last clinic visit. If more than one contraceptive method had been used during this period, all were documented. Most women opted to breastfeed for at least the first 6 months of the infant’s life.11 An integrated mother and child health service, including family planning, was provided by the study nurses.Contraceptive methods were classified as: none, injectable, oral contraception, male condom, female sterilisation or dual contraception. Contraceptive use was described over five time periods: 0 - 3, 4 - 6, 7 - 12, 13 - 18 and 19 - 24 months after delivery. The characteristics of mothers who did, or did not, use male condoms were examined over two time periods: 0 - 12 and 12 - 24 months after delivery.  Data were captured using optical imaging recognition software (Teleform, Cardiff, and San Diego) into a Microsoft SQL server database. Statistical analyses used were performed using SPSS, version 13 (SPSS Inc., Chicago, Ill.). Univariable comparisons for categorical variables were assessed with a chi-square test or chi-square test for linear trend. Univariable comparisons for continuous variables were assessed using either a two-tailed unpaired t-test or the Mann-Whitney test. Determinants of condom use were assessed in a multivariable logistic regression analysis.ResultsA total of 1 137 HIV-positive and 1 220 HIV-negative Zulu women were followed up postnatally. HIV-positive women were more likely to have had a previous pregnancy, have paid employment, be older and have better toilet facilities than HIV-negative women (Table I).Injectable contraceptives were the most common method of contraception used, although a significant number of women did not use any form of contraceptive, particularly during the first 6 months after delivery (Fig. 1). Condom use in women was low, but increased during the first year from 6.8% in the period 0 - 3 months after delivery to 11.9%, 16.3%, 15% and 14.4% in the periods 4 - 6, 7 - 12, 13 - 18 and 19 - 24 months after delivery respectively.Maternal factors associated with condom use are presented in Table II. Women who were HIV positive and those who had better toilet facilities were more likely to use condoms in both the first and second years after delivery. In addition, older women were more likely to use condoms compared with younger women in the first year after delivery.DiscussionThese results provide information about the choice of contraceptives by a large cohort of mostly rural African, women in the first 2 years after delivery. Few women used condoms, or dual contraception, despite regular counselling from the same study nurse and the ready availability of condoms at the clinics. The clinics used had a comprehensive range of family planning methods available and women could be seen at any time by the study nurse or HIV counsellor. Table I. Characteristics of women by HIV statusVariablesHIV-negative  women(N=1 220)HIV-positive women(N=1 137) p-valueMaternal age (yrs)14 - 2021 - 35>35Missing data5495621072244824681<0.001Education levelNoneSome primary Some secondary Missing data584227221860420643140.381Paid employmentNoYesMissing data1 0951196976148130.008Toilet  typeFlush/ventilated pitlatrinePit latrine/bucketchemicalNoneMissing data18340309648213492476280.008Previous pregnancy01 - 23 - 45 or moreMissing data5474251429412299583184638<0.001Number of live births 01 - 23 - 4≥5Missing data6114041306312377560154388<0.001Mode of deliveryVaginalCaesarean sectionForceps/vacuumMissing data1 058152829561544130.437EpisiotomyNoYesMissing data847357689822019<0.001Vaginal tearNoYesMissing data98921417916190310.068Pg 209-212.indd   210 2/20/08   12:26:23 PMORIGINAL ARTICLES211March 2008, Vol. 98, No. 3  SAMJTable II. Factors associated with condom use                                                                            Condom use 0 - 12 months after delivery                      Condom use 13 - 24 months after deliveryVariable   NORp-valueAOR (95% CI)p-value   NORp-valueAOR (95% CI)p-valueMaternal age (years)14 - 2021 - 35>351  7551 323  1721.001.481.21<0.0010.351.001.38 (1.04 - 1.85)1.78 (1.03 - 3.09)0.0270.040  367  677  1101.001.680.890.0040.7281.001.53 (0.96 - 2.44)1.24 (0.53 - 2.92)0.0710.614Maternal HIV statusNegativePositive1 1671 0831.001.80<0.0011.001.72 (1.38 - 2.14)<0.001  617  5371.001.84< 0.0011.001.61 (1.15 - 2.25)0.006Highest maternal educationNoneSome primarySome secondary  114  8151 3211.001.221.660.450.0511.001.08 (0.62 - 1.88)1.33 (0.75 - 2.33)0.7850.323   58  431  6651.000.851.330.670.441.000.68 (0.3 - 1.54)0.88 (0.38 - 2.01)0.3540.763Paid employmentNoYes1 991   2591.000.9390.7001.000.72 (0.51 - 1.01)0.0591 018   1361.000.870.5721.000.77 (0.45 - 1.3)0.32EpisiotomyNoYes1 699   5511.000.930.531.000.95 (0.72 - 1.26)0.734  868  2861.000.650.031.000.66 (0.42 - 1.03)0.07Number of live births01 - 23 - 4>5  946  931  273  1001.001.061.060.520.560.720.031.000.78 (0.59 - 1.03)0.88 (0.58 - 1.35)0.52 (0.25 - 1.08)0.0840.5730.081  461  463  166    641.001.150.950.420.4090.8460.0691.000.73 (0.47 - 1.12)0.79 (0.42 - 1.49)0.44 (0.14 - 1.41)0.1460.4740.169Toilet typeFlush/ventilated pit latrinePit latrine/bucket/chemicalNone  4651 247  5381.000.210.20<0.001<0.0011.00 0.22 (0.17 - 0.28)0.22 (0.16 - 0.30)<0.001<0.001  260  617  2771.000.260.20<0.001< 0.0011.000.27 (0.19 - 0.39)0.23 (0.14 - 0.38)<0.001<0.001Mode of deliveryCaesarean sectionVaginal   2941 9561.000.720.021.000.884 (0.65 - 1.2)0.433  171  9830.580.0031.000.74 (0.48 - 1.14)0.173OR = odds ratio; AOR = adjusted odds ratio.Pg 209-212.indd   211 2/20/08   12:26:25 PMMarch 2008, Vol. 98, No. 3  SAMJORIGINAL ARTICLES212Furthermore, all women knew their HIV status, most women breastfed and all HIV-negative women were counselled on the risks of seroconversion during lactation. This finding is in line with other studies showing low use of condoms or dual contraception by sexually active women.12,13A known HIV-positive status was an important determinant of condom use in this area. Interestingly, women with flush toilets, used as a proxy for socio-economic status, were also more likely to use condoms. The finding that older women were more likely to use condoms suggests that appropriate health messages about dual contraception should be designed to target younger age groups. Many studies examining contraceptive use are cross-sectional. Strengths of this study include longitudinal follow-up of a large cohort of rural women in the postpartum period, and data on their HIV status. Limitations of this study include a lack of detailed information on the date of resumption of sexual intercourse after delivery, and no information on their current partners’ HIV status. Nevertheless, it is of concern that condom use was low in all women, but particularly HIV-negative breastfeeding women. It is clear that more creative ways of promoting the use of condoms and dual contraception need to be found if postnatal HIV transmission is to be reduced and new HIV infections are to be prevented in this community.Grant support: Wellcome Trust supported this study (Grant #063009/Z/00/2) and the Africa Centre (Grant #050534).References  1.  Pettifor A. Young people's sexual health in South Africa. HIV prevalence from nationally representative household survey. AIDS 2005; 19: 1525-1534.  2.  Department of Health Report. National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa. 2005. http://www.doh.gov.za/docs/reports/2005/hiv.pdf (last accessed 21 September 2007).  3.  Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354: 795-802.  4.  Shaffer N, Chuachoowong R, Mock PA, et al. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok Collaborative Perinatal HIV Transmission Study Group. Lancet 1999; 353: 773-780.  5.  WHO, UNICEF, UNAIDS, UNFPA. HIV Transmission through Breastfeeding: A Review of Available Evidence. Geveva: World Health Organization, 2004.  6.  Bland R, Rollins N, Coovadia H, Coutsoudis A, Newell M. Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice. Bull World Health Organ 2007; 85: 289-296.  7.  De Bruin M. Living with HIV: challenges in reproductive health care in South Africa. Afr J Reprod Health 2004; 8: 92-98.  8.  Maharaj P. Reasons for condom use among young people in KwaZulu Natal: Prevention of HIV pregnancy or both? Int Fam Plan Perspect 2006; 32(1): 28-34.  9.  Morroni C, Smit J, McFadyen L, Mqhayi M, Beksinska M. Dual protection against sexually transmitted infections and pregnancy in South Africa. Afr J Reprod Health 2003; 7(2): 13-19.10.  Coovadia H, Rollins N, Bland R, et al. Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding: the first six months of life. Lancet 2007; 369: 1607-1616.11. Bland RM, Little KE, Coovadia HM, Coutsoudis A, Rollins NC, Newell ML. Intervention to promote exclusive breastfeeding for the first 6 months of life in a high HIV prevalence area. AIDS 2008 (in press).12.  Morroni C, Tibazarwa K, Myer L. Combined condom and contraceptive use among South African women. S Afr Med J 2006; 96: 620-622.13.  Rehle T, Shisana O, Pillay V, Zuma K, Puren A, Parker W. National HIV incidence measures - new insights into the South African epidemic. S Afr Med J 2007; 97: 194-197.Accepted 21 May 2007.Fig. 1. Women’s reported use of contraception at different time periods postnatally.10Fig. 1. Women’s reported use of contraception at different time periodspostnatally.0%10%20%30%40%50%60%70%80%90%100%0 - 3 mths4 - 6 mths7 - 12 mths13 - 18 mths19 - 24 mthsDual contraceptionFemale sterilisationMale condomOral contraceptiveInjectableNone10Fig. 1. Women’s reported use of contraception at different time periodspostnatally.0%10%20%30%40%50%60%70%80%90%100%0 - 3 mths4 - 6 mths7 - 12 mths13 - 18 mths19 - 24 mthsDual contraceptionFemale sterilisationMale condomOral contraceptiveInjectableNone10Fig. 1. Women’s reported use of contraception at different time periodspostnatally.0%10%20%30%40%50%60%70%80%90%100%0 - 3 mths4 - 6 mths7 - 12 mths13 - 18 mths19 - 24 mthsDual contraceptionFemale sterilisationMale condomOral contraceptiveInjectableNoneSAMA supports  National Polio Eradication Week6 - 12 April 2008Pg 209-212.indd   212 2/20/08   12:26:30 PM

Messages about dual contraception in areas of high HIV prevalence are not heeded

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Messages about dual contraception in areas of high HIV prevalence are not heeded

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