Childbearing and Contraceptive-Use Plans Among Women at High Risk for HIV Infection -- Selected U.S. Sites, 1989 - 1991

From September 1990 through August 1991, 2655 (49%) of the 5457 women reported with acquired immunodeficiency syndrome (AIDS) in the United States had been injecting-drug users (IDUs), and 1136 (21%) had had sexual intercourse with men who were IDUs (1). During the same period, 413 (56%) of the 735 children (aged less than 13 years) reported with AIDS were born to mothers who were either IDUs (38%) or sex partners of IDUs (18%) (1). Even though messages and services regarding prevention of human immunodeficiency virus (HIV) infection and pregnancy planning for women at high risk for HIV infection should be tailored to their specific needs, information regarding pregnancy history, plans for childbearing, and contraceptive use among such women is limited. This report characterizes the childbearing and contraceptive-use plans of women at high risk * for HIV infection interviewed during 1989-1991 in three settings--methadone-maintenance programs, drug-free outpatient programs, and detention facilities -- in Florida, New Jersey, New York, and Pennsylvania.

Since 1988, CDC has collaborated with seven state and local health departments, hospitals, and family-planning organizations, including those described in this report, to implement and evaluate perinatal HIV-prevention programs for women in a variety of settings (2). These women, who are at high risk for HIV infection, are provided HIV-prevention, reproductive-health, family-planning, and/or educational services. Upon participants' enrollment in the perinatal HIV-prevention program, investigators use a standardized questionnaire to obtain information including demographic attributes, pregnancy history, childbearing plans, contraceptive use, sexual behavior, and drug use. The findings in this report are based on interviews with women in four states (Florida: detention and drug-treatment programs in Broward and Dade counties; New Jersey: drug-treatment programs in Newark, Paterson, and Jersey City; Pennsylvania: drug-treatment programs in Philadelphia; and New York: drug-treatment programs in New York City, including Harlem and Brooklyn).

A total of 736 women aged 18-44 years who were not pregnant were interviewed. These women were from methadone-maintenance clinics (103 (30%) from New York City, 103 (30%) from New Jersey, and 137 (40%) from Philadelphia); drug-free outpatient clinics (36 (21%) from Florida, 11 (6%) from New Jersey, and 126 (73%) from Philadelphia), and detention facilities (220 from Florida). Women who reported no sexual intercourse during the 8 weeks before the enrollment interview, who were surgically sterilized, or who reported being HIV seropositive were excluded from this analysis.

Most respondents (412 (56%)) were aged 25-34 years, and 507 (69%) were members of racial/ethnic minorities (Table 1). Women in methadone-maintenance clinics were more likely to have histories of injecting-drug use and to have a primary sex partner ** who was at risk for HIV infection, while women in drug-free outpatient clinics were more likely to have histories of exchanging sex for drugs or money and less likely to have a primary sex partner. Most women (54%-60%) reported they did not want to become pregnant ever or for at least 3 years.

Of women who had been pregnant at some time since 1986, less than one fourth (range: 0-24%) reported that their most recent pregnancy was planned (Table 2). From 26% to 38% of women used contraceptives consistently during their most recent 4-week period of sexual activity; however, 37%-49% of the women reported never having used contraceptives. ***

Most women (55%-81%) indicated that for pregnancy prevention during the next 12-month period they planned to use contraceptives; however, substantial percentages of women in methadone-maintenance clinics (21%-31%) and detention facilities (25%) reported they did not plan to actively prevent pregnancy in the next year. From 41% to 64% of women reported that they wanted a child sometime in the future, although fewer women (11%-28%) wanted one within the next year.

Reported by: M Fordyce, MPH, M Jones, PhD, RS Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. G Halpin, MD, A Kline, PhD, K McNally, KC Spitalny, MD, State Epidemiologist, New Jersey State Dept of Health. J Mitchell, MD, P Namerow, PhD, Harlem Hospital/Columbia University, New York City; J Mantell, PhD, K Ong, MD, City Epidemiologist, New York City Dept of Health; DL Morse, MD, State Epidemiologist, New York State Dept of Health. KA Armstrong, MS, L Samost, Family Planning Council of Southeastern Pennsylvania Dept of Health, Inc, Philadelphia; DR Tavris, MD, State Epidemiologist, Pennsylvania Dept of Health. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: In this assessment, pregnancy history, contraceptive use, plans for childbearing, and plans for pregnancy prevention were similar for women at increased risk for HIV infection in each of the three settings. Contraceptive use, specifically condom use, and sexual behavior changes (e.g., abstinence and nonpenetrative sex) are effective for preventing both HIV infection and pregnancy and may be acceptable prevention strategies for many women at risk. Therefore, women who wish to delay childbearing should be encouraged to use contraceptives consistently and should be informed that condoms are a contraceptive method that will preserve their capacity for future childbearing by reducing their risk for sexually transmitted diseases.

The findings in this report have at least two limitations. First, because data were obtained from women who volunteered to participate in programs in four locations, the findings cannot be readily generalized to women in other settings and locations. Second, the findings may not be helpful in tailoring HIV-prevention and reproductive-service programs for women aged less than 25 years because of the limited representation of such women in the survey.

Despite these limitations, these findings and results from a recent study of three federally funded community-health centers (3) underscore the opportunities for providing women (primarily aged greater than 25 years) at high risk for HIV infection with services for HIV prevention, reproductive health, and family planning. Special efforts to reach minority women, who are disproportionately affected by the AIDS epidemic, may be especially effective in these settings (1). Through increased understanding of decisions regarding childbearing and contraceptive use among women at risk for HIV infection, public health agencies may improve HIV-prevention programs and identify additional settings where women at risk for both HIV infection and perinatal transmission can be offered prevention services. To improve access to these women, HIV-prevention and family-planning services may be extended--through outreach and through the provision of on-site services--to drug-treatment centers, sexually transmitted disease clinics, detention facilities, and shelters.

References

1. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, September 1991:8.

2. CDC. Division of STD/HIV Prevention annual report, 1990. Atlanta: US Department of Health and Human Services, Public Health Service, 1991:159-64.

3. Salomon P, O'Neill J, Holloway J, et al. Reaching high risk women by placing HIV services at customary sites of primary care (Abstract). Vol I. VII International AIDS Conference. Florence, Italy, June 16-21, 1991:452.

• Women were defined as being at high risk because of their past or current drug use (including trading sex for drugs or money) or because a sex partner was at high risk. For this study, a high-risk partner was defined as a man who was HIV-antibody-positive, had ever used injecting drugs, had ever had sex with another man, or had ever been incarcerated. ** Respondents indicated whether they considered any particular sex partner a primary sex partner. *** When women who reported they were sterilized or practiced abstinence were included in the analysis (as everytime users of contraceptives) the percentage of inconsistent use of contraceptives remained substantial; 48%-62% of women who did not want to become pregnant within the next 3 years and 21%-26% of women who did not ever want to become pregnant used contraceptives inconsistently.

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