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Role of menstruation in contraceptive choice among HIV-infected women in Soweto, South Africa
Contraception 81 (2010) 547 – 551
Original research article
Role of menstruation in contraceptive choice among HIV-infected women in Soweto, South Africa☆ Fatima Lahera,⁎, Catherine S. Toddb , Mark A. Stibichc , Rebecca Phofaa , Xoliswa Behanea , Lerato Mohapia , Neil Martinsona,d , Glenda Graya a Perinatal HIV Research Unit, Soweto, Johannesburg, Gauteng Province, 1864 South Africa Columbia University, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA c Lacuna Projects, Houston, TX 77019, USA d Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA Received 19 October 2009; revised 9 December 2009; accepted 10 December 2009
b
Abstract Background: Contraceptive preferences of HIV-infected women must be considered in efforts to integrate HIV and reproductive health services. In South Africa, contraception is often discontinued due to bleeding pattern changes. It is unknown whether HIV-infected women are more sensitive to menstrual changes and how this affects contraceptive choice. This study describes perceptions toward menses and contraceptive-induced amenorrhea among HIV-infected women. Study Design: A convenience sample of 42 HIV-infected women aged 15 to 45 years was purposively recruited for three focus groups and 15 in-depth qualitative interviews which were conducted at the Perinatal HIV Research Unit, South Africa. Transcripts were coded and emergent themes grouped. Results: One third of women reported HIV-related menstrual changes, unchanged by antiretroviral use. Menstruation was believed to purge the body of “dirty blood.” Women perceived that menstruation had a negative effect on male partner sexual desire, with concern about higher HIV transmission during menstruation. Ninety-six percent of injectable contraceptive users experienced amenorrhea, regarded as troublesome and a reason for discontinuation. Conclusion: In Soweto, HIV diagnosis may accentuate linking menstruation with health, leading to avoidance or discontinuation of methods causing amenorrhea. Providers should intensify education on the safety of contraceptive-induced oligo/amenorrhea. © 2010 Elsevier Inc. All rights reserved. Keywords: Contraception; menstruation; HIV
1. Introduction Highly active antiretroviral therapy (HAART) is becoming more accessible and has extended survival and reduced morbidity [1]. Because most HIV-infected women in high HIV prevalence areas are in their reproductive years, there has been a call for improved integrated reproductive health care within HIV services and appeals for more data in this ☆ This is an original manuscript and is not under concurrent consideration elsewhere. Partial results of this study have been accepted for oral presentation at the International Conference on Family Planning: Research and Best Practices in Kampala, Uganda, on November 16, 2009. ⁎ Corresponding author. Tel.: +2711 989 9946; fax: +2711 989 9762. E-mail address: [email protected] (F. Laher).
0010-7824/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2009.12.010
field [2]. The need for female-controlled, non-coitally dependent contraceptive methods is evident: women may not be empowered to control reproduction but must bear the burden of care for ill children, partners and family. Planned pregnancies conceived at optimal viral load suppression will additionally assist preventing vertical HIV transmission [3,4]. Contraceptive preference among HIV-infected women may be influenced by biomedical concerns such as possible interactions with HAART [5]. Systemic hormonal methods are available and popular in many countries, largely due to availability, high contraceptive efficacy, tolerable side effects and ability for women to control method utilization. However, some methods can alter menstrual bleeding patterns. Progestin-only long-acting injectable contraceptives, such as norethisterone enanthate
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F. Laher et al. / Contraception 81 (2010) 547–551
and depot medroxyprogesterone acetate, commonly cause oligo- or amenorrhea. Amenorrhea-inducing contraceptive methods have been noted to be unpopular in some settings because of the perceived need to remove “dirty blood” through menses [6,7] but are highly acceptable in other settings where menses is regarded as inconvenient [8]. In South Africa, injectable and oral hormonal and barrier contraceptive methods are freely available through government sources and widely utilized, but the rate of consistent use over 1 year is 27.8% [9]. Systemic injectable hormonal methods are the most popular utilized methods nationally, but also have high rates of discontinuation, largely due to bleeding pattern alterations [10,11]. The effect of HIV infection on menstruation is unclear. Some studies have noted a higher prevalence of menstrual abnormalities in HIV-infected women (particularly those with lower CD4 counts) such as amenorrhea, prolonged, irregular, or skipped menses, or spotting or bleeding between menses [12,13]. However, other studies concluded that HIV status had little effect on menstrual abnormalities, which were common regardless of HIV status [14–16]. It is uncertain whether and how HIV-infected women factor menstrual changes into contraceptive decision-making. The objective of this study was to describe perceptions toward menses and contraceptive-induced amenorrhea, and to describe their impact on contraceptive choice and discontinuation among HIV-infected women in Soweto, South Africa.
2. Materials and methods 2.1. Setting We conducted this study at the Perinatal HIV Research Unit (PHRU), a clinical care and research site located within the Chris Hani Baragwanath Hospital (Soweto, Gauteng Province, South Africa). In Soweto, two tertiary medical centers and multiple primary health care clinics provide free family planning (male condoms, intrauterine devices, injectable and oral systemic hormonal contraceptives), elective termination of pregnancy up to 12 weeks gestation and HAART to patients with CD4 counts less than 200 cells/μL or WHO Stage 4 illness. PHRU provides HAART to eligible patients through a program funded by the Presidents Emergency Plan For AIDS Relief and has on-site free family planning services. In 2007, the Gauteng Province had an antenatal HIV prevalence of 28.0% (95% CI 26.9–29.1%) [17]. 2.2. Participants Eligibility criteria for this qualitative study were HIVinfected women aged 15 to 45 years accessing services at PHRU and able to provide voluntary written informed consent. Using convenience sampling, 42 potential participants were identified during clinic visits through screening for age and purposively selected into three age strata: 15–22,
23–30 and 31–45 years. Age stratification was done to ensure equal representation across the reproductive age span, due to effects of age on fertility intentions and contraceptive choices [18]. Further, grouping women of similar ages in focus groups limited the effect of age as a factor in voicing contributions [19]. A screening questionnaire collected medical and obstetric history, current HAART use, civil status, childbearing desires and contraceptive use. 2.3. Interview content and conduct The question guide was assessed for face and content validity through a pilot focus group discussion (FGD) with three participants. To determine main themes, 3-h-long FGDs comprising eight participants for each age stratum were audio-recorded and moderated by an interviewer and a sessions recorder. Discussions were conducted in a mixture of local languages (e.g., English, Sotho and Zulu) with the moderators fluent in all three languages. Investigators reviewed English-translated transcripts. FGD guide content included women's understanding of menses and its relation to health and HIV diagnosis, the significance of amenorrhea outside of pregnancy, participant and partner attitudes toward menstruation, and whether there was any effect of HIV disease on menstruation. Perceptions of contraceptive amenorrhea were probed with these questions: “What contraceptive methods have you used? What did you like/dislike about them?” “What would be the advantages and disadvantages of a contraceptive method that stopped menstruation?” “Do you think women in your community would use a contraceptive method that stopped menstruation? Why or why not?” Following preliminary FGD analysis, 15 further participants (five per age stratum) were recruited by similar means for individual in-depth interviews (IDIs) which were conducted to explore themes and provide contextual information. IDIs were approximately 45 min duration, conducted in the primary language of the participant, and audio-recorded with only the interviewer and participant in the room. Interview tapes were translated from local languages to English. The IDI field guide began with two broad questions (“the grand tour” approach) employed to define topics while still encouraging detailed responses [20]. These two questions assessed beliefs about menstruation and contraception: “Tell me everything you can about menstruation” and “Tell me everything you think about what a perfect contraceptive method should be like.” If participants did not raise specific issues of interest spontaneously, interviewers asked a series of probe questions such as, “Since being notified that you are HIV-infected, has menstruation changed for you in any way?” Other IDI questions invited participants to share their perceptions on the meaning, significance, and feelings regarding contraception and amenorrhea; what they thought men's perceptions are about contraception and menstruation; and how HIV status affects contraceptive choice. All FGD facilitators and IDI interviewers were appropriately trained female staff.
F. Laher et al. / Contraception 81 (2010) 547–551
Participants were provided transport reimbursement not advertised before informed consent. Ethical approval for this study was obtained from the institutional review boards of Witwatersrand University in South Africa, the University of California, San Diego, and Columbia University. 2.4. Data analysis Transcripts were coded using a grounded theory approach and then grouped into themes. Coded quotations were analyzed for effect of demographic factors on themes. Analysis was performed with ATLAS-ti (ATLAS-ti Center, Berlin). 3. Results Of the 42 participants, 50% were receiving HAART. The mean prior pregnancies was 1.90 (range 0–4) with 1.64 mean live births (range 0–4). Mean time since HIV diagnosis was 3.24 years (range 0–12 years). Injectable contraception was utilized by 25 participants, of whom 24 experienced contraceptive amenorrhea. We were unable to discern an impact of age or parity on these qualitative findings. There was consistency of data between FGDs and IDIs, and three common themes were elicited, which are presented here. 3.1. Menstruation as an indicator of female vitality In every FGD, there was unopposed agreement among participants about the significance of menstruation: it served as a marker of health, vitality, womanhood and fertility. Ten of 15 IDI participants noted that menstruation was a way for “dirty blood” to leave the body, and that if menstruation did not occur (in the absence of pregnancy), it was believed illness would ensue. Women reported mixed feelings toward menstruation — it was something necessary for health, but they did not like the associated “dirtiness,” inconvenience and discomfort. These perspectives changed with HIV diagnosis for two women, who became anxious about blood due to its symbolic reminder of infection and the need to protect uninfected members of the household from touching any menses-soiled items. Women perceived that their partners did not react favorably to them during menses, and this seemed to be emphasized by HIV diagnosis. While 2 IDI participants thought that male partners were unaffected by menstruation, 13 participants believed that men were “disgusted” by blood to the extent that it was prohibitive to sexual intercourse. A concern was raised that sex during menses may result in HIV transmission to a sero-discordant partner from contact with HIV-infected menstrual blood. 3.2. Effect of HIV on menstruation Most participants reported no menstrual changes since HIV diagnosis. In FGDs, a few women mentioned increased
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discomfort, cramping and change in bleeding pattern since diagnosis. In IDIs, 5/15 (33%) HIV-infected women reported menstrual changes after HIV diagnosis, ranging from change in the color of blood (2/15), skipped menses (2/15), prolonged bleeding (1/15) and shorter bleeding time (1/ 15). There was no difference between HAART and nonHAART-taking participants in perceived menstrual changes. 3.3. Contraception amenorrhea as a reason for method discontinuation In FGDs, the query whether women would initiate a method which causes amenorrhea generally elicited evenly split responses between preferring amenorrhea and preservation of menses. In the IDIs, participants were asked general questions about menstruation and contraception. When specifically asked about injectable hormonal contraceptives, the method most frequently associated with menstrual changes by participants, oligo/amenorrhea was reported to be a troublesome side effect by 6 of 15 participants. However, 3 of 15 found this effect advantageous because sanitary pads were no longer needed and because of the reduction in menstrual discomfort and pain. Three participants attributed a wide variety of symptoms to contraceptive amenorrhea, including nosebleeds, bad skin, headaches, illness, nausea, anorexia and frustration. Though not specifically asked, 4 of 15 IDI participants offered that menstrual changes were the reason for method discontinuation. Six of 15 women were vexed by the question of where the “dirty blood” of menstruation would go to in the circumstance of contraception-induced amenorrhea. 4. Discussion This study finds that menstrual bleeding pattern changes play a role in contraceptive choice and discontinuation for HIV-infected women, similar to findings from women in other settings, regardless of HIV status [6,7]. However, a notable finding from our study is that most women have a limited understanding of the menstrual cycle and its function, evidenced by multiple expressed misconceptions, which translated to misapprehension and misinformation about contraceptive amenorrhea. Furthermore, HIV diagnosis seems to emphasize the connection between menstruation and health for HIV-infected women. We think that these findings particularly affect HIVinfected women on HAART who have no childbearing desire. Use of combined oral contraceptives, which allow for menstrual preservation by the mechanism of withdrawal bleeds, may not be suitable in combination with HAART, due to variations in ethinyl estradiol levels possibly diminishing contraceptive effect [21]. Injectable systemic hormonal contraception is generally endorsed for HIVinfected women based on lack of potential HAART interaction and scheduling convenience [22]. However, concerns around amenorrhea are known to impede injection
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continuity [23]. At PHRU between 2004 and 2008, 26% of 117 pregnant women receiving HAART terminated their unwanted pregnancies; despite free on-site availability of oral and injection methods, only 10% of these women had used a systemic hormonal method, signifying the unmet need for acceptable contraception [24]. A Cochrane review noted that structured counseling decreased the likelihood of discontinuation of methods causing amenorrhea [25]. It is possible that structured counseling, elucidation of contraceptive amenorrhea may improve method acceptability and adherence, and in doing so, may reduce unwanted pregnancies among HIV-infected women. For this reason, the authors recommend that upfront explanations of the harmlessness of contraceptive amenorrhea be offered from health care workers and educational materials. Previous quantitative studies assessing menstrual irregularities in HIV-infected women noted that menstrual irregularities were reported by less than 20% to 31% of surveyed women [12,13]. While our methodology and sample differ immensely, our study findings similarly noted that about a third of women reported some change with their menses after HIV diagnosis. In this context, contraceptive methods that alter menstrual bleeding patterns further were deemed suspicious and undesirable by many women. HIV affected the perception of menstruation by heightening concern for transmission to partners, especially in sero-discordant pairs, and this perception was unchanged by HAART. This worry expressed by women in the study is borne out through data which support the possibility of increased risk of HIV transmission during menstruation [26]. In combination with our finding of women's perception of male revulsion toward menses, contraceptive amenorrhea may be an advantage to be promoted for HIV-infected women in relationships. Anemia is common in African settings owing to the high prevalence of nutritional deficiencies and may be compounded in women by menstrual blood loss [27]. For HIVinfected individuals, anemia may further be exacerbated by HIV and opportunistic infections [28,29]. When discussing anxieties surrounding childbearing desire, HIV-infected women in this setting often mentioned blood loss at delivery as a major health concern for HIV-infected women in particular [30]. However, no woman in this study spoke of the plausible health advantage of contraceptive-induced amenorrhea to minimize blood loss, as noted in a European study assessing levonorgestrel intrauterine system efficacy [31]. Our study has several limitations, including lack of comparative groups of HIV-uninfected women and a small sample limited only to clinic attendees; we attempted to reduce the effects of these limitations by asking participants not only about their experiences and thoughts, but also about how they thought others in their community would respond to the questions. The non-random sampling technique was employed to represent women across the reproductive span, thereby limiting any effect of age. The cross-sectional nature may have limited recall of menstrual irregularities. To
attempt to control for the possible limitation of social desirability bias, we employed female staff to lessen inhibition and non-disclosure bias. Of note, individual interviews provided data consistent with FGD findings. In Soweto, the association between menstruation and health may be accentuated by HIV diagnosis, leading to avoidance or discontinuation of methods causing menstrual changes. Providers should provide method choice at each encounter and discuss concerns surrounding menstrual changes by explaining the harmlessness and possible advantages of oligo/amenorrhea to ensure continuous contraceptive coverage. Acknowledgments The authors wish to thank the Morris S. Smith Foundation, the Doris Duke Charitable Foundation, USAID/Presidents Emergency Plan For AIDS Relief, and the participants. References [1] Lima VD, Hogg RS, Harrigan PR, et al. Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy. AIDS 2007;21:685–92. [2] Burr CK, Fry RS, Weber S, Armas-Kolostroubis LN, Lampe MA. Integrating reproductive health into HIV care of women in the United States: it is time. AIDS 2009;23:1928–30. [3] Reynolds HW, Janowitz B, Wilcher R, Cates W. Contraception to prevent HIV-infected births: current contribution and potential cost savings in PEPFAR countries. Sex Transm Infect 2008;84:ii49–ii53. [4] Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of HIV-1. Rakai project study group. New Engl J Med 2000;342:921–9. [5] Myer L, Morroni C, El-Sadr W. Reproductive decisions in HIVinfected individuals. Lancet 2005;366:698–700. [6] World Health Organisation Task Force on Psychosocial Research in Family Planning. Special Programme of Research, Development and Research Training in Human Reproduction. A cross-cultural study of menstruation: implications for contraceptive development and use. Stud Fam Plann 1981;12:3–16. [7] Berer M, Ravindran TKS, Cottingham J, editors. Beyond acceptability: users perspective on contraception. London: Reproductive Health Matters; 1997. p. 1–124. [8] Glasier AF, Smith KB, van der Spuy ZM, et al. Amenorrhea associated with contraception — an international study on acceptability. Contraception 2003;67:1–8. [9] Health Systems Trust. Health statistics — reproductive health. Accessed at: http://www.hst.org.za/healthstats/index.php?indtype_ id=003006002. [10] Baumgartner JN, Morroni C, Mlobeli RD, et al. Timeliness of contraceptive reinjections in South Africa and its relation to unintentional discontinuation. Int Fam Plann Perspect 2007;33:66–74. [11] Beksinska ME, Rees HV, Smit J. Temporary discontinuation: a compliance issue in injectable users. Contraception 2001;64:309–13. [12] Massad LS, Evans CT, Minkoff H, et al. Effects of HIV infection and its treatment on self-reported menstrual abnormalities in women. J Womens Health 2006;15:591–8. [13] Greenblatt RM, Hilton J, Palacio H, et al. Menstrual irregularity among HIV-seropositive women. Program and Abstracts of the HIV Infection in Women Conference; Feb 22–24, 1995; Washington, DC; 1995. p. S51.
F. Laher et al. / Contraception 81 (2010) 547–551 [14] Cohen MH, Greenblatt R, Minkoff H, et al. Menstrual abnormalities in women with HIV infection. Program and abstracts of the XI International Conference on AIDS; July 7–12, 1996; Vancouver, British Columbia; 1996. Abstract Mo.B.540. [15] Harlow SD, Schuman P, Cohen M, et al. Effect of HIV infection on menstrual cycle length. JAIDS 2000;24:68–75. [16] Ellerbrock TV, Wright TC, Bush TJ, Dole P, Brudney K, Chiasson MA. Characteristics of menstruation in women infected with human immunodeficiency virus. Obstet Gyn 1996;87:1030–4. [17] Department of Health SA. National HIV and syphilis prevalence survey, South Africa 2006. South Africa: Pretoria: Department of Health; 2007. Retrieved September 1, 2009, from http://www.doh.gov.za. [18] Chen JL, Phillips KA, Kanouse DE, Collins RL, Miu A. Fertility desires and intentions of HIV-positive men and women. Fam Plann Perspec 2001;33:144–65. [19] Hesse-Biber SJN, Leavy PL. The practice of qualitative research. Thousand Oaks (Calif): Sage Publications, Inc.; 2005. p. 213. [20] Bernard HR. Unstructured and semi-structured interviewing. In: Bernard HR, editor. Research methods in anthropology: qualitative and quantitative approaches. 3rd ed. Walnut Creek (Calif): AltaMira Press; 2001. p. 208–36. [21] Oesterheld JR, Cozza K, Sandson NB. Oral contraceptives. Psychosomatics 2008;49:168–75. [22] World Health Organization. Special Programme of Research, Development and Research Training in Human Reproduction. Hormonal contraception and HIV: science and policy. Africa Regional Meeting. Nairobi 19-21 September 2005; 2005. Accessed 08 September 2009 at http://www.who.int/reproductivehealth/topics/ family_planning/nairobi_statement.pdf.
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[23] Konje JC, Ladipo OA. Barriers to uptake and use of modern methods of contraception in developing countries. Int J Gynecol Obstet 1999;65:287–94. [24] Laher F, Lephoto C, Forrest J, Cheyip M, Mohapi L. The impact of parallel HAART and contraception service provision on elective terminations of pregnancy in Soweto, South Africa. Abstract #754th South African AIDS Conference. 2009. Durban, South Africa; 2009. [25] Halpern V, Grimes DA, Lopez L, Gallo MF. Strategies to improve adherence and acceptability of hormonal methods for contraception. Cochrane Database Syst Rev 2006(1):CD004317, doi:10.1002/ 14651858.CD004317.pub2. [26] Kalichman SC, Simbayi LC. Sexual exposure to blood and increased risks for heterosexual HIV transmission in Cape Town, South Africa. Afr J Reprod Health 2004;8:55–8. [27] Ramakrishnan U. Prevalence of micronutrient malnutrition worldwide. Nut Rev 2002;60(suppl 5):S46–S52. [28] Belperio PS, Rhew DC. Prevalence and outcomes of anemia in individuals with human immunodeficiency virus: a systematic review of the literature. Am J Med 2004;116:27–43. [29] Antelman G, Msamanga GI, Spiegelman D, et al. Nutritional factors and infectious disease contribute to anemia among pregnant women with human immunodeficiency virus in Tanzania. J Nutr 2000;130: 1950–7. [30] Laher F, Todd CS, Stibich MA, et al. A qualitative assessment of decisions affecting contraceptive utilization and fertility intentions among HIV-positive women in Soweto, South Africa. AIDS Behav 2009;13(Suppl 1):47–54. [31] Andrade A, Wildemeersch D. Menstrual blood loss in women using the frameless FibroPlant LNG-IUS. Contraception 2009;79:134–8.
Original research article
Role of menstruation in contraceptive choice among HIV-infected women in Soweto, South Africa☆ Fatima Lahera,⁎, Catherine S. Toddb , Mark A. Stibichc , Rebecca Phofaa , Xoliswa Behanea , Lerato Mohapia , Neil Martinsona,d , Glenda Graya a Perinatal HIV Research Unit, Soweto, Johannesburg, Gauteng Province, 1864 South Africa Columbia University, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA c Lacuna Projects, Houston, TX 77019, USA d Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA Received 19 October 2009; revised 9 December 2009; accepted 10 December 2009
b
Abstract Background: Contraceptive preferences of HIV-infected women must be considered in efforts to integrate HIV and reproductive health services. In South Africa, contraception is often discontinued due to bleeding pattern changes. It is unknown whether HIV-infected women are more sensitive to menstrual changes and how this affects contraceptive choice. This study describes perceptions toward menses and contraceptive-induced amenorrhea among HIV-infected women. Study Design: A convenience sample of 42 HIV-infected women aged 15 to 45 years was purposively recruited for three focus groups and 15 in-depth qualitative interviews which were conducted at the Perinatal HIV Research Unit, South Africa. Transcripts were coded and emergent themes grouped. Results: One third of women reported HIV-related menstrual changes, unchanged by antiretroviral use. Menstruation was believed to purge the body of “dirty blood.” Women perceived that menstruation had a negative effect on male partner sexual desire, with concern about higher HIV transmission during menstruation. Ninety-six percent of injectable contraceptive users experienced amenorrhea, regarded as troublesome and a reason for discontinuation. Conclusion: In Soweto, HIV diagnosis may accentuate linking menstruation with health, leading to avoidance or discontinuation of methods causing amenorrhea. Providers should intensify education on the safety of contraceptive-induced oligo/amenorrhea. © 2010 Elsevier Inc. All rights reserved. Keywords: Contraception; menstruation; HIV
1. Introduction Highly active antiretroviral therapy (HAART) is becoming more accessible and has extended survival and reduced morbidity [1]. Because most HIV-infected women in high HIV prevalence areas are in their reproductive years, there has been a call for improved integrated reproductive health care within HIV services and appeals for more data in this ☆ This is an original manuscript and is not under concurrent consideration elsewhere. Partial results of this study have been accepted for oral presentation at the International Conference on Family Planning: Research and Best Practices in Kampala, Uganda, on November 16, 2009. ⁎ Corresponding author. Tel.: +2711 989 9946; fax: +2711 989 9762. E-mail address: [email protected] (F. Laher).
0010-7824/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2009.12.010
field [2]. The need for female-controlled, non-coitally dependent contraceptive methods is evident: women may not be empowered to control reproduction but must bear the burden of care for ill children, partners and family. Planned pregnancies conceived at optimal viral load suppression will additionally assist preventing vertical HIV transmission [3,4]. Contraceptive preference among HIV-infected women may be influenced by biomedical concerns such as possible interactions with HAART [5]. Systemic hormonal methods are available and popular in many countries, largely due to availability, high contraceptive efficacy, tolerable side effects and ability for women to control method utilization. However, some methods can alter menstrual bleeding patterns. Progestin-only long-acting injectable contraceptives, such as norethisterone enanthate
548
F. Laher et al. / Contraception 81 (2010) 547–551
and depot medroxyprogesterone acetate, commonly cause oligo- or amenorrhea. Amenorrhea-inducing contraceptive methods have been noted to be unpopular in some settings because of the perceived need to remove “dirty blood” through menses [6,7] but are highly acceptable in other settings where menses is regarded as inconvenient [8]. In South Africa, injectable and oral hormonal and barrier contraceptive methods are freely available through government sources and widely utilized, but the rate of consistent use over 1 year is 27.8% [9]. Systemic injectable hormonal methods are the most popular utilized methods nationally, but also have high rates of discontinuation, largely due to bleeding pattern alterations [10,11]. The effect of HIV infection on menstruation is unclear. Some studies have noted a higher prevalence of menstrual abnormalities in HIV-infected women (particularly those with lower CD4 counts) such as amenorrhea, prolonged, irregular, or skipped menses, or spotting or bleeding between menses [12,13]. However, other studies concluded that HIV status had little effect on menstrual abnormalities, which were common regardless of HIV status [14–16]. It is uncertain whether and how HIV-infected women factor menstrual changes into contraceptive decision-making. The objective of this study was to describe perceptions toward menses and contraceptive-induced amenorrhea, and to describe their impact on contraceptive choice and discontinuation among HIV-infected women in Soweto, South Africa.
2. Materials and methods 2.1. Setting We conducted this study at the Perinatal HIV Research Unit (PHRU), a clinical care and research site located within the Chris Hani Baragwanath Hospital (Soweto, Gauteng Province, South Africa). In Soweto, two tertiary medical centers and multiple primary health care clinics provide free family planning (male condoms, intrauterine devices, injectable and oral systemic hormonal contraceptives), elective termination of pregnancy up to 12 weeks gestation and HAART to patients with CD4 counts less than 200 cells/μL or WHO Stage 4 illness. PHRU provides HAART to eligible patients through a program funded by the Presidents Emergency Plan For AIDS Relief and has on-site free family planning services. In 2007, the Gauteng Province had an antenatal HIV prevalence of 28.0% (95% CI 26.9–29.1%) [17]. 2.2. Participants Eligibility criteria for this qualitative study were HIVinfected women aged 15 to 45 years accessing services at PHRU and able to provide voluntary written informed consent. Using convenience sampling, 42 potential participants were identified during clinic visits through screening for age and purposively selected into three age strata: 15–22,
23–30 and 31–45 years. Age stratification was done to ensure equal representation across the reproductive age span, due to effects of age on fertility intentions and contraceptive choices [18]. Further, grouping women of similar ages in focus groups limited the effect of age as a factor in voicing contributions [19]. A screening questionnaire collected medical and obstetric history, current HAART use, civil status, childbearing desires and contraceptive use. 2.3. Interview content and conduct The question guide was assessed for face and content validity through a pilot focus group discussion (FGD) with three participants. To determine main themes, 3-h-long FGDs comprising eight participants for each age stratum were audio-recorded and moderated by an interviewer and a sessions recorder. Discussions were conducted in a mixture of local languages (e.g., English, Sotho and Zulu) with the moderators fluent in all three languages. Investigators reviewed English-translated transcripts. FGD guide content included women's understanding of menses and its relation to health and HIV diagnosis, the significance of amenorrhea outside of pregnancy, participant and partner attitudes toward menstruation, and whether there was any effect of HIV disease on menstruation. Perceptions of contraceptive amenorrhea were probed with these questions: “What contraceptive methods have you used? What did you like/dislike about them?” “What would be the advantages and disadvantages of a contraceptive method that stopped menstruation?” “Do you think women in your community would use a contraceptive method that stopped menstruation? Why or why not?” Following preliminary FGD analysis, 15 further participants (five per age stratum) were recruited by similar means for individual in-depth interviews (IDIs) which were conducted to explore themes and provide contextual information. IDIs were approximately 45 min duration, conducted in the primary language of the participant, and audio-recorded with only the interviewer and participant in the room. Interview tapes were translated from local languages to English. The IDI field guide began with two broad questions (“the grand tour” approach) employed to define topics while still encouraging detailed responses [20]. These two questions assessed beliefs about menstruation and contraception: “Tell me everything you can about menstruation” and “Tell me everything you think about what a perfect contraceptive method should be like.” If participants did not raise specific issues of interest spontaneously, interviewers asked a series of probe questions such as, “Since being notified that you are HIV-infected, has menstruation changed for you in any way?” Other IDI questions invited participants to share their perceptions on the meaning, significance, and feelings regarding contraception and amenorrhea; what they thought men's perceptions are about contraception and menstruation; and how HIV status affects contraceptive choice. All FGD facilitators and IDI interviewers were appropriately trained female staff.
F. Laher et al. / Contraception 81 (2010) 547–551
Participants were provided transport reimbursement not advertised before informed consent. Ethical approval for this study was obtained from the institutional review boards of Witwatersrand University in South Africa, the University of California, San Diego, and Columbia University. 2.4. Data analysis Transcripts were coded using a grounded theory approach and then grouped into themes. Coded quotations were analyzed for effect of demographic factors on themes. Analysis was performed with ATLAS-ti (ATLAS-ti Center, Berlin). 3. Results Of the 42 participants, 50% were receiving HAART. The mean prior pregnancies was 1.90 (range 0–4) with 1.64 mean live births (range 0–4). Mean time since HIV diagnosis was 3.24 years (range 0–12 years). Injectable contraception was utilized by 25 participants, of whom 24 experienced contraceptive amenorrhea. We were unable to discern an impact of age or parity on these qualitative findings. There was consistency of data between FGDs and IDIs, and three common themes were elicited, which are presented here. 3.1. Menstruation as an indicator of female vitality In every FGD, there was unopposed agreement among participants about the significance of menstruation: it served as a marker of health, vitality, womanhood and fertility. Ten of 15 IDI participants noted that menstruation was a way for “dirty blood” to leave the body, and that if menstruation did not occur (in the absence of pregnancy), it was believed illness would ensue. Women reported mixed feelings toward menstruation — it was something necessary for health, but they did not like the associated “dirtiness,” inconvenience and discomfort. These perspectives changed with HIV diagnosis for two women, who became anxious about blood due to its symbolic reminder of infection and the need to protect uninfected members of the household from touching any menses-soiled items. Women perceived that their partners did not react favorably to them during menses, and this seemed to be emphasized by HIV diagnosis. While 2 IDI participants thought that male partners were unaffected by menstruation, 13 participants believed that men were “disgusted” by blood to the extent that it was prohibitive to sexual intercourse. A concern was raised that sex during menses may result in HIV transmission to a sero-discordant partner from contact with HIV-infected menstrual blood. 3.2. Effect of HIV on menstruation Most participants reported no menstrual changes since HIV diagnosis. In FGDs, a few women mentioned increased
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discomfort, cramping and change in bleeding pattern since diagnosis. In IDIs, 5/15 (33%) HIV-infected women reported menstrual changes after HIV diagnosis, ranging from change in the color of blood (2/15), skipped menses (2/15), prolonged bleeding (1/15) and shorter bleeding time (1/ 15). There was no difference between HAART and nonHAART-taking participants in perceived menstrual changes. 3.3. Contraception amenorrhea as a reason for method discontinuation In FGDs, the query whether women would initiate a method which causes amenorrhea generally elicited evenly split responses between preferring amenorrhea and preservation of menses. In the IDIs, participants were asked general questions about menstruation and contraception. When specifically asked about injectable hormonal contraceptives, the method most frequently associated with menstrual changes by participants, oligo/amenorrhea was reported to be a troublesome side effect by 6 of 15 participants. However, 3 of 15 found this effect advantageous because sanitary pads were no longer needed and because of the reduction in menstrual discomfort and pain. Three participants attributed a wide variety of symptoms to contraceptive amenorrhea, including nosebleeds, bad skin, headaches, illness, nausea, anorexia and frustration. Though not specifically asked, 4 of 15 IDI participants offered that menstrual changes were the reason for method discontinuation. Six of 15 women were vexed by the question of where the “dirty blood” of menstruation would go to in the circumstance of contraception-induced amenorrhea. 4. Discussion This study finds that menstrual bleeding pattern changes play a role in contraceptive choice and discontinuation for HIV-infected women, similar to findings from women in other settings, regardless of HIV status [6,7]. However, a notable finding from our study is that most women have a limited understanding of the menstrual cycle and its function, evidenced by multiple expressed misconceptions, which translated to misapprehension and misinformation about contraceptive amenorrhea. Furthermore, HIV diagnosis seems to emphasize the connection between menstruation and health for HIV-infected women. We think that these findings particularly affect HIVinfected women on HAART who have no childbearing desire. Use of combined oral contraceptives, which allow for menstrual preservation by the mechanism of withdrawal bleeds, may not be suitable in combination with HAART, due to variations in ethinyl estradiol levels possibly diminishing contraceptive effect [21]. Injectable systemic hormonal contraception is generally endorsed for HIVinfected women based on lack of potential HAART interaction and scheduling convenience [22]. However, concerns around amenorrhea are known to impede injection
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continuity [23]. At PHRU between 2004 and 2008, 26% of 117 pregnant women receiving HAART terminated their unwanted pregnancies; despite free on-site availability of oral and injection methods, only 10% of these women had used a systemic hormonal method, signifying the unmet need for acceptable contraception [24]. A Cochrane review noted that structured counseling decreased the likelihood of discontinuation of methods causing amenorrhea [25]. It is possible that structured counseling, elucidation of contraceptive amenorrhea may improve method acceptability and adherence, and in doing so, may reduce unwanted pregnancies among HIV-infected women. For this reason, the authors recommend that upfront explanations of the harmlessness of contraceptive amenorrhea be offered from health care workers and educational materials. Previous quantitative studies assessing menstrual irregularities in HIV-infected women noted that menstrual irregularities were reported by less than 20% to 31% of surveyed women [12,13]. While our methodology and sample differ immensely, our study findings similarly noted that about a third of women reported some change with their menses after HIV diagnosis. In this context, contraceptive methods that alter menstrual bleeding patterns further were deemed suspicious and undesirable by many women. HIV affected the perception of menstruation by heightening concern for transmission to partners, especially in sero-discordant pairs, and this perception was unchanged by HAART. This worry expressed by women in the study is borne out through data which support the possibility of increased risk of HIV transmission during menstruation [26]. In combination with our finding of women's perception of male revulsion toward menses, contraceptive amenorrhea may be an advantage to be promoted for HIV-infected women in relationships. Anemia is common in African settings owing to the high prevalence of nutritional deficiencies and may be compounded in women by menstrual blood loss [27]. For HIVinfected individuals, anemia may further be exacerbated by HIV and opportunistic infections [28,29]. When discussing anxieties surrounding childbearing desire, HIV-infected women in this setting often mentioned blood loss at delivery as a major health concern for HIV-infected women in particular [30]. However, no woman in this study spoke of the plausible health advantage of contraceptive-induced amenorrhea to minimize blood loss, as noted in a European study assessing levonorgestrel intrauterine system efficacy [31]. Our study has several limitations, including lack of comparative groups of HIV-uninfected women and a small sample limited only to clinic attendees; we attempted to reduce the effects of these limitations by asking participants not only about their experiences and thoughts, but also about how they thought others in their community would respond to the questions. The non-random sampling technique was employed to represent women across the reproductive span, thereby limiting any effect of age. The cross-sectional nature may have limited recall of menstrual irregularities. To
attempt to control for the possible limitation of social desirability bias, we employed female staff to lessen inhibition and non-disclosure bias. Of note, individual interviews provided data consistent with FGD findings. In Soweto, the association between menstruation and health may be accentuated by HIV diagnosis, leading to avoidance or discontinuation of methods causing menstrual changes. Providers should provide method choice at each encounter and discuss concerns surrounding menstrual changes by explaining the harmlessness and possible advantages of oligo/amenorrhea to ensure continuous contraceptive coverage. Acknowledgments The authors wish to thank the Morris S. Smith Foundation, the Doris Duke Charitable Foundation, USAID/Presidents Emergency Plan For AIDS Relief, and the participants. References [1] Lima VD, Hogg RS, Harrigan PR, et al. Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy. AIDS 2007;21:685–92. [2] Burr CK, Fry RS, Weber S, Armas-Kolostroubis LN, Lampe MA. Integrating reproductive health into HIV care of women in the United States: it is time. AIDS 2009;23:1928–30. [3] Reynolds HW, Janowitz B, Wilcher R, Cates W. Contraception to prevent HIV-infected births: current contribution and potential cost savings in PEPFAR countries. Sex Transm Infect 2008;84:ii49–ii53. [4] Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of HIV-1. Rakai project study group. New Engl J Med 2000;342:921–9. [5] Myer L, Morroni C, El-Sadr W. Reproductive decisions in HIVinfected individuals. Lancet 2005;366:698–700. [6] World Health Organisation Task Force on Psychosocial Research in Family Planning. Special Programme of Research, Development and Research Training in Human Reproduction. A cross-cultural study of menstruation: implications for contraceptive development and use. Stud Fam Plann 1981;12:3–16. [7] Berer M, Ravindran TKS, Cottingham J, editors. Beyond acceptability: users perspective on contraception. London: Reproductive Health Matters; 1997. p. 1–124. [8] Glasier AF, Smith KB, van der Spuy ZM, et al. Amenorrhea associated with contraception — an international study on acceptability. Contraception 2003;67:1–8. [9] Health Systems Trust. Health statistics — reproductive health. Accessed at: http://www.hst.org.za/healthstats/index.php?indtype_ id=003006002. [10] Baumgartner JN, Morroni C, Mlobeli RD, et al. Timeliness of contraceptive reinjections in South Africa and its relation to unintentional discontinuation. Int Fam Plann Perspect 2007;33:66–74. [11] Beksinska ME, Rees HV, Smit J. Temporary discontinuation: a compliance issue in injectable users. Contraception 2001;64:309–13. [12] Massad LS, Evans CT, Minkoff H, et al. Effects of HIV infection and its treatment on self-reported menstrual abnormalities in women. J Womens Health 2006;15:591–8. [13] Greenblatt RM, Hilton J, Palacio H, et al. Menstrual irregularity among HIV-seropositive women. Program and Abstracts of the HIV Infection in Women Conference; Feb 22–24, 1995; Washington, DC; 1995. p. S51.
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