Health workers in the southwestern district of Insigiro, Uganda are calling for more research to study why contraceptive implants failed to be effective on women taking antiretroviral drugs.
Dozens of cases have been recorded by health workers in centres in Ngarama, Birere, Nyamuyanja, Rugaaga and Rwekubo in Insingiro district. Now health workers - especially midwives - say something must be done fast to find out what is leading to this. More information is needed so that they can give informed advice to their patients.
Rose Tumusiime, the health worker in charge at Birere Health Centre III, said: "We are surprised why these mothers get pregnant even after we have administered the implants."
Family planning for women with HIV
Preventing unplanned or mistimed pregnancy allows a woman with HIV to optimise her own health and has the potential to decrease mother-to-child transmission of HIV. The World Health Organization (WHO) reports that approximately 90 per cent of children living with HIV acquired the infection during pregnancy, birth, or breastfeeding.
Studies have shown that contraception rather than antiretroviral treatment to prevent mother-to-child transmission is more effective in reducing HIV. For example, increased use of contraception prevents 28.6 per cent more HIV positive births than using the antiretroviral (ARV) nevirapine. Yet, such interventions can only be effective if mothers taking ARVs are enrolled on a family planning programme.
Dr Justus Agaba of St Augustine Medical Centre said: "When a client informs a health worker that she is on ARVs, she or he will be able to look at her regimen and decide which family planning method is appropriate for a client to use."
However, there are already some known interactions between contraceptive implants and certain types of ARVs which cause a problem, and this can have serious consequences, which is why more research on this issue is vital to ensure women living with HIV can get the right family planning advice to prevent unplanned pregnancies.
An urgent need for counselling and space
Some health workers already advise women living with HIV, to use alternative methods of contraception. Lilian Kyosimire, a midwife at Ngarama Health Centre III in Insigiro southwestern of Uganda said: "If a mother is on ARVs, they are advised to use other methods of family planning like IUD or an injection other than implants." This is because progestogen injections, for example, and intra uterine devices are not affected by HIV drugs.
However, another issue is that many mothers living with HIV often fail to open up to the medical personnel administering the contraceptive implant because of stigma around HIV. During prior counselling sessions, health workers encourage mothers to disclose their HIV status to other health workers elsewhere, but mothers often do not feel able to do so.
HIV-positive women taking ARVs should always be offered careful counselling on the full range of family planning methods. Joan Kilande, a programme officer with Health Promotion for Social Development-HEPS, said: "Their right to free, full and informed choice is violated if thorough counselling is not carried out during family planning sessions."
Understaffing and the lack of space for such sessions are also issues which contribute to an increase in mothers not opening up about their status. Lillian Aturidde, a patient at Rwekubo Health Centre 4, expressed the need for a space for family planning at the health center and the need to recruit a health worker dedicated to family planning.
She said: "A midwife is busy attending to a woman about to give birth and she is the same midwife enrolling women on family planning. She does not have enough time to give us more information on family planning enabling us to make an informed choice."
Women living with HIV need to have better access to information about the relationship between contraceptive implants and ARVs. Health workers and women taking ARVs need to know what their family planning options are, based on evidence. Women need the right kind of environment to access services, free from fear of stigma and discrimination. This will prevent unwanted pregnancies, as well as preventing more cases of HIV.