Birth control counseling may reduce AIDS transmission in Africa, say researchers

BY RUTHANN RICHTER

Family planning counseling could prove to be a cost-effective way to help minimize the number of children born HIV-positive in sub-Saharan Africa, a new study by School of Medicine researchers suggests.

"If you can help prevent HIV-positive women from having unplanned children, obviously you're going to prevent unnecessary HIV transmission," said Clea Sarnquist, DrPH, MPH, a senior research scholar in pediatrics at Stanford and first author of the new study, which was presented today at the International AIDS Conference in Washington, D.C.

According to Sarnquist and her colleagues, about 40 percent of pregnancies in sub-Saharan Africa are unplanned. Such unwanted pregnancies could be prevented if women relied on long-acting forms of contraception — such as the intra-uterine device, or IUD, or hormonal implants — rather than birth control pills or diaphragms. Indeed, the researchers found that after receiving group counseling almost 90 percent of the HIV-positive women in the study chose a long-acting form of contraception.

The women in the study, which was conducted in a suburban region of Zimbabwe, also said they felt a greater sense of power in negotiating sexual activity, including condom use, and were more open with their partners about their HIV status, the researchers reported.

Every year, hundreds of thousands of babies are born HIV-positive in sub-Saharan Africa. While there are medications that can prevent transmission of the virus during pregnancy or breastfeeding, many of the women are unable to get them. In Zimbabwe, for instance, fewer than half of all HIV-positive women who are pregnant have access to these medications, though the numbers have been on the rise in recent years, Sarnquist said.

By contrast, studies have shown that providing family planning counseling is more cost-effective than providing anti-AIDS medications; according to one study, annual cost savings to prevent unwanted births ranged from $26,000 in Vietnam to more than $2.2 million in South Africa. Moreover, family planning has other benefits that help improve women's overall health and well-being, Sarnquist said. For maximum prevention, both drugs and counseling should be available, she added.

In the study, Sarnquist and her colleagues worked with a group of 98 HIV-positive women in the village of Chitungwiza, about 30 miles from the Zimbabwean capital of Harare. Yvonne Maldonado, MD, professor of pediatrics at Stanford and senior author of the study, has established a study site there and done research over the last two decades on preventing HIV transmission from mother to child. About 16 percent of the women in Chitungwiza are HIV-positive.

The researchers invited two-thirds of the study participants, all of whom had recently given birth, to attend three 90-minute group sessions with trained counselors. The women learned about family planning, sexual negotiation and HIV prevention and did exercises in self-esteem building and communication. The other one-third served as a control group, receiving the standard information on family planning.

The majority of the women in the region use the pill for contraception, which isn't consistently reliable as women are not always able to get to the clinic for drug refills or to afford purchasing them even if they can get there, Sarnquist said. In the sessions, the women were introduced to implants and intrauterine devices, which can protect against pregnancy for three to 10 years, depending on the device.  Fifteen nurses also were trained to install IUDs and implants, matchstick-sized cylinders that are inserted under a woman's arm and secrete hormones into the bloodstream.

Within three months, almost 90 percent of the women had opted for either the implants or IUDs, up from 13.5 percent that had used them previously, the researchers reported.
"The implants were extremely popular, which we didn't necessarily expect," Sarnquist said.
Because implants provide highly effective pregnancy prevention for four to five years, it could help women prevent unplanned pregnancies during that time. The World Health Organization recommends that women wait at least two years between pregnancies. For HIV-positive women, this spacing allows women an opportunity to maximize their own health and reduce the amount of virus in their system, which decreases the risk of passing the virus on to their unborn children, Sarnquist said.

In the study, the women were also far more inclined to talk to their partners about their HIV status, likely because of improved communication and knowledge about HIV, Sarnquist said.

"That was an unexpected finding, which does have ramifications for HIV transmission and stigma," she said.

In addition, the women in the counseling group reported feeling more power in their relationships, particularly with regard to negotiating sexual activity. For instance, more of the women felt they were able to persuade their partners to use condoms or to talk about condom use, Sarnquist said.

Sarnquist said the researchers are hoping to expand the study to a much larger population of women who could be followed over a longer period of time, with a goal of determining whether the approach can reduce the number of unplanned pregnancies, and in turn, the number of children born HIV-positive.

The approach could be easily replicated in other regions of sub-Saharan Africa to reach many more women, she said.

Researchers from the University of Zimbabwe-UCSF Collaborative Research Programme joined in conducting the study. Jennifer Kang, MPH, the former project manager, was also involved in the study.

The work was supported by U.S. President's Emergency Plan for AIDS Relief and the National Institutes of Health.