Modern family planning use among people living with HIV/AIDS: a facility based study in Ethiopia

Introduction Despite increasing efforts to address the reproductive health needs of persons living with Human Immuno-Deficiency Virus (HIV), a high unmet need for contraception exists among HIV+ women in sub-Saharan Africa. Currently, Ethiopia promotes integration of family planning (FP) services in to HIV chronic care. Yet the contraceptive prevalence rate among clients remains low. The objective of the study was to assess the role of socio-cultural factors on modern family planning use among HIV+ clients attending Anti-Retroviral Therapy clinics in Addis Ababa sub-cities. Methods The study involved a facility based cross sectional survey. The ten sub cities were initially categorized/stratified into 5 based on direction (East, West, South, North and Central) and from each category one sub city was randomly selected. The total sample size was proportionally allocated to the selected health facilities according to previous monthly average client load per health center. Participants were selected using simple random sampling technique during their routine visit at the health centers. Data were collected through a semi-structured interviewer administered questionnaire. Both descriptive and inferential statistics were generated and results considered significant at 95% confidence level using STATA version 14.0. Results Six hundred and thirty-six clients participated in the study. Majority of them were age between 30-39 years. Though majority, 607 (95.4%) participants approved the use of modern FP method, current use rate stood at 39%. Condom was the most (14.5%) commonly used single method. The odds of FP use by participants who disclosed their HIV status were almost twice that of their counterparts (AOR= 1.84; 95% CI: 1.14, 2.95). Participants who held discussion with their spouse/partners concerning FP, irrespective of the frequency had an odd of more than four when using FP than their counterparts (AO= 4.35; 95% CI: 2.69, 7.04). Conclusion This study revealed that 6 out of every 10 HIV+ clients are not currently using FP methods. Disclosure of HIV status as well as open discussion with spouse/partner were positively associated with family planning use. These study findings call for comprehensive and client focus FP education and counseling in line with disclosure of HIV status and dialogue with spouse/partner in order to increase uptake and utilization of FP among clients. Partners have a great influence on the use and choice of FP methods, so their views are paramount.


Introduction
Globally, there are an estimated 36.7 million people living with HIV/AIDS. The pandemic burden lies in Africa where it disproportionally affects Sub-Sahara Africa (SSA) inhabitants. Greater than half (58%) of persons living with HIV are of reproductive age and slightly more than half (53%) of all adult deaths is related to HIV in this region [1]. Despite increasing efforts to address the reproductive health needs of people living with HIV, 80% unmet need for family planning (FP) exists among HIV+ clients in sub-Saharan Africa [2]. HIV positive clients who do not use modern FP have a higher risk of unwanted pregnancies and hence increase chance of MTCT [3] and unsafe abortion. Ethiopia, annually expects 3 million pregnancies of which 602 births per 100,000 pregnancies are prone to MTCT of HIV with a large majority of this pregnancies been unwanted [4]. A cross-sectional study conducted in Ethiopia including both HIV-positive and HIV-negative women reported that 69.2% of their most recent pregnancy was unwanted [5]. Besides the benefits in averting HIV positive births and preventing unwanted pregnancies, FP is also a cost effective strategy. For instance, providing family planning to HIV positive women in Ethiopia is expected to save annually US $360,000 than providing ARV prophylaxis [6]. Undesired pregnancies have also both maternal and child consequences including unsafe abortion, maternal and infant morbidity and mortality.
The Ethiopian national plan for the elimination of MTCT of HIV is in line with the global comprehensive PMTCT strategies. It advocates the four pronged strategies to keep the mother alive and prevent new pediatric HIV infections [7]. The four pillars of the strategy are primary prevention of HIV infection, preventing unintended pregnancy among HIV-infected women, preventing HIV transmission from HIV-infected women to their infants, and care of HIV-infected women and their children [8]. In Ethiopia currently, the Ministry of Health (MOH) policies promote integration of FP services in HIV/AIDS prevention, care and treatment services [8]. Yet a large number (65-72%) of HIV positive women still have unintended (unwanted or mistimed) pregnancies [9]. Several studies conducted in many African countries have indicated that individual, reproductive, societal expectation, medical intervention (Highly Active Anti-Retroviral Therapy [HAART] and Prevention of Mother to Child Transmission [PMTCT]), health services, and cultural and belief factors influence family planning use among HIV positive clients [10][11][12][13][14][15][16]. Socio-cultural factors like disclosure of HIV status to spouse [17], open discussion about family planning method and use [12], decision making about family planning use [13,18], as well as partner support and approval of FP method use were found to be positively associated with current family planning use. However, there are limited studies conducted in Ethiopia following literature reviews that have looked into sociocultural factors influencing Modern family planning utilization among People Living with HIV/AIDS (PLWHA); an area advocated by many researchers to explore. Hence, the aim of this study was to address the knowledge gap with regards to factors influencing family planning use among PLWHA, in a bid to help program managers and stakeholders better plan for this target population in terms of decision making and policy development. This study, therefore, sought to assess socio-cultural factors that influence modern family planning utilization in the context of ART service provision among sexually active PLWHA enrolled at governmental health centers of Addis Ababa.

Methods
Study area and period: the study was conducted in Addis Ababa, the capital of Ethiopia. Its population is totally urban with population projection of 3,048,632 million; 1,595,968 females in 2017 [6]. Addis Ababa City Administration is made up of 10 sub cities and 116 woredas harboring 52 Hospitals (public and private owned), 84 Health Centers (80 government owned and 4 by NGOs) and more than 760 health clinics from low to higher (all Private) [19]. There are 112 ART sites in the city; 75 health centers, 8 NGOs facilities, 11 government hospitals and 18 private hospitals [19]. Public and private health facilities are offering ART services in the city since the free ART lunched in 2005 in Ethiopia [20]. In 2015, in Addis Ababa, there were 129,143 people who have ever started ART and 82,498 currently on treatment [3]. In 2014, 42% of married women of reproductive age  were using FP methods [7]. Amharic is a commonly spoken language in the study area. This study was conducted at health centers having an ART clinic providing FP services in five randomly selected sub-cities in Addis Ababa from August 2016 to June 2017.
Study design: this is a facility based cross-sectional study design aimed to gather data of PLWHA who were seeking services from Addis Ababa City Administration health centers. Medical chart/file was reviewed to confirm the HIV status of each participant before inviting to participate in the study.
Eligibility criteria: to be eligible to participate in the study, participants were sexually active PLWHA; female and male aged 18-49 years who accepted to participate in the study and were able to give informed consent; attending the randomly selected health centers ART clinics during the study period. We considered a participant to be ART user if he/she was taking ART at the time of interview.
Sample size: the sample size was calculated using single population proportional formula. We assume proportion of modern FP use among PLWHA (both males and females)= 50%= 0.5 (No study to the knowledge of the authors report proportion of FP use among both male and female HIV sero-positive clients and also needed the largest possible sample size for a cross sectional study); Absolute precision of 5% and 95% level of confidence yielding 384 participants. Due to the multi-stage random sampling nature of the study design, a design effect of 1.5 was used giving a minimum sample of 578 participants.
Assuming a 10% non-response rate, the final sample size for the study was 636 participants.
Sample selection: study participants were selected using multistage random sampling technique. Addis Ababa has 10 sub-cities hosting 75 health centers (HCs). Fifty percent of these sub-cities were selected with simple random sampling technique using lottery method after been stratified into north, west, east, south and central. All HCs in the selected sub-cities providing ART services were listed. The numbers of HCs in each selected sub-city were determined proportionally considering the total number of HCs in each sub-city.
Eleven HCs were selected. The numbers of study participants in each HC was determined using proportion to population size where the total sample size was proportionally allocated to the selected HCs according to client load (the number of PLWHA receiving ART services) in each facilities to meet up the study sample size (Figure 1). At the level of the HCs, participants were selected using simple random sampling; knowing the HIV codes of all the patients, a random selection was done and the selected clients were interview on a daily basis as they came to pick their medications after ensuring they meet the inclusion criteria stated above. It was repeated until the sample size of each facility was reached. If the client does not meet or is not willing to participate or a sample client does not show up to pick up his/her ARV, the client next to him/her was sampled and enrolled for the study. (male condom) and use of a hormonal or permanent contraceptive method [22]. Ever used FP methodany participant who said has used a modern FP method before and who is either using or not using at the time of the interview. FP servicesa health services that help individuals and couples decide whether to have children and if so, when and how many, and to achieve the desired spacing and timing of their births. Contraceptive Prevalence rate-Is the proportion of women of reproductive age who are using (or whose partner is using) a modern FP method at a given point in time. Sexual intercoursewas defined to refer specifically to vaginal-penile penetrative sex between a man and a woman. Sexually Active-A client who has had sexual intercourse at least once in the last 3 months. We define ART user as any PLWHA who is receiving ART in the study facilities at the time of interview. and confidentiality and right to prevention from any type of harm was taken into consideration. All participants were informed that their participation is on voluntarism bases and they have the right to stop or withdraw should they feel discomfort during the interview. The interview lasted no more than 30 minutes per participants. Data were kept confidential by locking in a cupboard with key and by password in the computer to avoid access of the data by a third party.

Discussion
The current study was done to assess the role of socio-cultural factors on modern family planning use among HIV+ clients attending Anti-Retroviral Therapy clinics in Addis Ababa sub-cities. In the study, 39% of PLWHA used modern family planning at the time of the survey.
This contraceptive prevalence rate (CPR) among this group was low compared to the target set by the Federal HIV/AIDS Prevention and Control Office (FHAPCO) of Ethiopia that target modern FP use among sexually active clients as 50% [5]. The study showed a similarly low abortions, morbidity and mortality [1,3,9]. Consequences of low FP uptake was not investigated in our study. This low usage could be improved through an urgent need of making various methods available, as well as the education of PLWHA so that they can use any of the modern FP methods [22] and more specifically counseling on the true side effects of each method. However, some studies done in Uganda and South Africa reported a high proportion of use 78% [23] and 89.8% [24] respectively compared to ours. This high levels of usage could be due to the high level of integration of FP services with HIV/AIDS prevention, care and treatment services in these countries.
Suggestively, the high burden of the disease in the aforementioned countries had probably made health education a cornerstone of all disease programs [18].
Findings from a cross-sectional study done in Baringo North District in Kenya was slightly lower than ours (32.3%) [18]. This could have been a result of the difference in the study time, the method acceptance among the two societies, the weakness of the health care services as well as the nature of the study area (subsistence farming rural community). Addis Ababa being an urban setting, participants probably had more exposure to information via TV and radios where knowledge and awareness about FP could be obtained as well as easy access to Health facilities compared to the rural Baringo community.
Respondents who disclosed their HIV status to spouse/partner were more likely to use FP than their counterparts. This result was consistent with reports from other studies which stated that 'respondents who did not disclose their HIV status to their spouse/partners where less likely to use FP methods' [13,20,23].
This is because HIV is nowadays less seen as a taboo in many societies and stigmatization has reduced among most communities [23].