An estimated 2.6 million people become infected with HIV annually. Women are particularly affected, making up 60 percent of people living with HIV in sub-Saharan Africa (while women make up 50% of the global epidemic) [1]. Females constitute 58% (about 1.72 million) of persons living with HIV in Nigeria. In Nigeria, the prevalence of HIV infection among young women aged 15-24 years is estimated to be three times higher than among men of the same age. Each year, 55% of AIDS deaths occur among women and girls [2]. UNAIDS/WHO estimates that 42 million people are living with HIV/AIDS worldwide and 50% of all adults with HIV infection are women predominantly infected via heterosexual transmission [3].

Fifty-three million women in this region want to prevent pregnancy, but are not using contraception [4]. Contraceptive choice for an HIV positive individual living in poverty in a resource poor country with inadequate healthcare services is very challenging compared with woman in a developed country receiving highly active antiretroviral therapy (HAART) with a wide range of contraceptive methods available. Contraceptive use and compliance is related to the range of methods available, patient choice, prevalent health and religious beliefs, perceptions of method effectiveness, and side effects [5,6]. Correct use of contraceptive methods requires a basic knowledge of contraception and skills to follow written instructions [7]. In many countries women are unable to make autonomous decisions about their sexual and reproductive health because of political instability within society, lack of economic independence, and prevailing cultural or religious attitudes to women’s rights [8].

In studies of women with HIV infection approximately 70% are sexually active, effective contraception use is variable, and unplanned pregnancy frequently reported [9]. In a cohort of HIV positive women only 57% of the sexually active women used a reliable method of contraception. A study on the impact of HIV diagnosis on sexual and contraceptive behaviour found that in the sexually active women, 20% were using no contraception, 24% became pregnant, and 63% of conceptions ended in abortion [10-12]. In the African DITRAME Project 39% of women with HIV infection used contraceptives; factors significantly related to contraceptive use were marital status and level of education [13]. The incidence of further pregnancy was 16.5 per 100 women years at risk; 50% of these pregnancies were unplanned and one third terminated by abortion, significant determinants of pregnancy were death of the previous child and cessation of breast feeding [13-15].

A high degree of protection against HIV sexual transmission is provided by consistent correct condom use [16]; Dual protection, the simultaneous use of an effective contraception method with consistent condom use, has been advocated to reduce the risk of unplanned pregnancy, horizontal transmission of HIV to a non-infected partner, transmission of resistant virus to an partner with HIV infection, and the risk of acquisition of other STIs including high risk human papillomavirus (HPV) types [17-19]. Obstacles to greater use of male condoms include lack of availability, fear of being perceived as having multiple partners and being unfaithful to a regular partner, opposition on religious grounds, and male dominance in decision making [19-21]. Women living with HIV infection may feel unable to disclose their HIV status and negotiate condom use with new sexual partners for fear of abandonment, domestic violence, loss of economic support, and social isolation.

Fertility is not affected by HIV infection; lower conception rates may occur as a result of behavioural change, existing subfertility, low body mass index, AIDS, and intercurrent illness particularly pulmonary tuberculosis [22-24]. Despite the high rates of sexual activity and unplanned pregnancy among people living with HIV as well as the associated risk of HIV transmission, there has been very little research that has explored the determinants of family planning among people living with HIV especially between males and females in the study area. This study aimed at determining the predictor of current use of barrier method of family planning among people living with HIV/AIDS attending clinic at State Specialist Hospital, Akure, South West Nigeria.

Study population and sampling

This study was conducted among people living with HIV/AIDS attending clinic at State Specialist Hospital, Akure, South West Nigeria. The Hospital serves as a major secondary health facilities for the people of Akure and its environ. The study employed a descriptive cross-sectional design. Three hundred and eighty five (385) people both male (age 15-59 years) and female (age 15-49 years) living with HIV/AIDS were selected using systematic sampling technique. A total of 2696 people living with HIV/AID were registered at the HIV clinic for the preceding year (2012). Every seventh respondent was selected after randomly selecting the first respondent to arrive at the total sample size of 385. All male (age 15-59 years) and female (age 15-49 years) living with HIV/AIDS attending HIV clinic in State Specialist Hospital, Akure were eligible for the study.

Data collection

A semi-structured questionnaire was used to interview people living with HIV/AIDS. Trained interviewers administered the pre-tested questionnaires. The instrument included measures of socio- demographic variables, knowledge and practice of family planning and HIV related factors of the respondents. During the interview, respondents were asked their age, marital status, education, ethnicity, area of residence, no of living children and death of any child (ren). The respondents also answered questions on methods of family planning, source of information, ever use any method of family planning, current use of any family planning method and current use of barrier method of family planning, desire for more children and partner desire for more children. Other questions included when diagnosed HIV positive, if on HAART, period on HAART, partner’s HIV status, having any HIV positive child, partner disclosure of HIV status and ever receive training on PMTCT.

Measures

The dependent variable was current use of barrier method of family planning, while independent variables grouped into three categories – socio-demographic, family planning knowledge and practice and HIV related factors. Socio-demographic factors consisted of age, gender, marital status, education, occupation, area of residence. Family planning practice factors include methods of family planning, source of information of family planning methods, ever discussed family planning with health worker, ever use any method of family planning, current use of any form of family planning. Measures of HIV related factor included when the patient was HIV diagnosed, whether patient is on HAART, Period on HAART, partner’s HIV status, ever received training on PMTCT and HIV status of Child (ren).

Ethical issues

The study received the approval of the Hospital Management Board, Ondo State in Nigeria before implementation. Furthermore, the written consent of individual participants was obtained after being fully informed of the study purpose and procedures. Specifically, the questionnaire had a front page marked "confidentiality and consent" which informed respondents of the objectives of the study and requested their voluntary consents. No name or other identifying information was maintained.

Data analysis

Data analysis was undertaken using SPSS (version 16.0). Family planning knowledge was scored based on the knowledge of family planning methods. For presentation of descriptive statistics, the distribution of the socioeconomic variables, family planning methods and practices and HIV related factors were reported. We examined the influence of independent variables on dependent variable (current use of barrier method of family planning) through both bivariate (cross tabulation and chi-square) and multivariate analysis (logistic regression model). Odd ratios (OR), 95% confidence interval (CI) and p-values were obtained and statistically significance was determined at an alpha level of 0.05.

Our study sample consisted of 289 (75.4%) respondents within the age range of 25-44 years. The mean age was 37+1.0. The majority (284 or 73.8%) of the respondents were female gender.

Two hundred and thirty seven (61.6%) respondents were married while only 16.4 percent of the respondents were single. Only 19% of the respondent had completed tertiary education. Nearly all (361 or 93.8%) the respondent were Christians; 33% of them were of catholic denomination. A large proportion of people living with HIV/AIDS reside in urban area. Two hundred and thirty-four (71.2%) respondents had four or fewer children. About one-quarter (24.1%) of the respondents had reported the death of one or more children (Table 1). Barrier method of contraceptives (149 or 38.7%) was frequently known and the major source of information was electronic media/print media (92 or 23.9%) (Table 2).

Table 1: Socio-demographic characteristics of respondents

Table 2: Percentage distribution of knowledge of family planning methods among respondents (n=385).

Slightly more than one-fifth (21.8%) of the respondents had good to fair knowledge of method of contraception (Figure 1). Barrier method of contraception use during the last sexual act was reported by 28.8%. Although, 52.2% and 48.3.2% of the respondents reported desire for more children and their partner desire for more children respectively but only 22.1% of them had ever discussed family planning with the health worker (Figure 2). About two-fifth (146 or 37.9%) of the respondents had been diagnosed for HIV/AIDS for 24 months or less, only 313 (81.3%) of them were on HAART. Overall, about 43% of the respondent reported HIV negative sexual partner and ever receive training on PMTCT respectively. Six-one percent of the respondents had disclosed their HIV status to their sexual partner (Table 3).

Table 3: Distribution of HIV related factors among the respondents.

Figure 1: Percentage distribution of knowledge of family planning methods among respondents (n=385).

Figure 2: Family planning practices among people living with HIV/ AIDS in SSH Akure, Nigeria (n=385).

Bivariate analysis

As shown in Table 4, significant associations were found between non-use of barrier method of contraceptives and some sociodemographic factors with regards to none living child (p=0.015), low level of education (p=0.001), being married (p<0.001) and death of any child (p<0.001). Also, non-use of family planning was found to be significantly associated with poor knowledge of family planning (<0.001), never discussed family planning with health workers (p<0.001) and never discussed family planning with spouse (p<0.001) (Table 4).

Table 4: Bivariate analysis of current non-use of family planning method.

Multivariate analysis

At multivariate level, adjusting for the effect of age, gender, religion, education and fertility desire, poor knowledge of family planning (odd ratio [OR]=10.17, 95% confidence interval [CI]=2.21-46.71), never discussed family planning with sexual partner (OR=0.40, CI=0.01-0.12), death of children (OR=7.47, CI =2.16-21.85) and low level of education (OR=9.40, CI=2.95-29.94) remained significantly associated with the non-use of contraceptive. Living in rural areas (OR=7.45, CI =2.67-20.79) was also significantly associated with non-use of contraceptive (Table 5).

Table 5: Binary logistic regression of determinants of non-use of barrier method of family planning.

In this study, we examine the predictors of current use of barrier method of family planning among people living with HIV/AIDS attending clinic at State Specialist Hospital, Akure, South West Nigeria. Factors found to determine the current use of barrier method family planning included having living children, good knowledge of family planning methods, high level of education, urban area of residence and lack death of any child. Poor knowledge and very low current use of contraception among people living with HIV/AIDS have been reported in this study. Although, contraceptive use and compliance is related to the range of methods available, patient choice, prevalent health and religious beliefs, perceptions of method effectiveness, and side effects [5,6] but correct use of contraceptive methods requires a basic knowledge of contraception and skills to follow written instructions [7].

In this study, the prevalence of contractive use was 29.9%. This is lower than the African DITRAME Project of 39% of people living with HIV infection who used contraceptives; factors significantly related to contraceptive use were marital status and level of education [13]. However, studies have shown that 50% of pregnancies among people living with HIV/AIDS were unplanned and one third terminated by abortion; significant determinants of pregnancy were death of the previous child and cessation of breast feeding [13]. Barrier method of contraception use during the last sexual act was very low in this study. A high degree of protection against HIV sexual transmission is provided by consistent correct condom use [16]; Dual protection, the simultaneous use of an effective contraception method with consistent condom use, has been advocated to reduce the risk of unplanned pregnancy, horizontal transmission of HIV to a non-infected partner, transmission of resistant virus to any partner with HIV infection, and the risk of acquisition of other STIs including high risk human papillomavirus (HPV) types [17-19]. Studies have shown that obstacles to greater use of include lack of availability, fear of being perceived as having multiple partners and being unfaithful to a regular partner, opposition on religious grounds, and male dominance in decision making [19,21]. Only sixty-one percent of the respondents had disclosed their HIV status to their sexual partners. Disclosure of HIV status to the sexual partner has been identified as an important factor in determining the use of condoms and enhancing partner’s involvement in making crucial sex practices [25].

One limitations of this study is the cross-sectional design which does not allow for causality to be determined. Inability to validate the accuracy of the responses of the respondents also limited this study. People living with HIV/AIDS may over report the socially acceptable activities and underreport socially undesirable ones; the extent of bias is difficult to assess. The generally low level of contraception use in this study may be explained by the high level of desire for children in this population which may arise from esteem associated with large families size [26] especially with a fertility rate of 5.6% in Nigeria [27]. The strong desire to have children in this population may also be influenced by the death of any child. In this study, respondents from rural areas were more than four times less likely to use contraceptives. The rural-urban disparity could be explained by the fact that contraceptive services were not readily available in rural health centers apart from the fact that health facilities were less common in rural areas and if such health facilities were present they may have inadequate resources with regard to health workers and facilities to provide good quality health services including family planning.

There is a need to improve the knowledge of respondents on family planning through campaigns and access to family planning and HIV/AIDS. Respondents in rural areas at low educational level with death of child (ren) need to be specifically targeted. It is therefore important that family planning programs should be provided with full access and full choice to those who wish to limit their family size as well as those who wish to have more children with the aim of achieving better health outcomes for people living with HIV. Findings from this study revealed an overwhelming need to increase access to family planning and HIV/AIDS care practices through integration. Such integration has potential not only to improve reproductive health outcomes [28], but also to ultimately reduce paediatric HIV infections, and hence reduce the amount of antiretroviral therapy needed.

We appreciate the support of the Organizers of the third international family planning conference for their sponsorship to present this work at family planning conference in November, 2013 at African Union Conference Center in Addis Ababa, Ethiopia.