|Year : 2016 | Volume
| Issue : 4 | Page : 251-259
Changes in sexual behavior and contraceptive use after HIV acquisition and factors associated with risky sexual practices among people living with HIV in selected Indian cities
Beena Joshi1, Sanjay Chauhan2, Hiranya Das3, Rosangluaia Luaia4, Nitya Sunil5
1 Scientist E, Department of Operational Research, National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
2 Scientist - F and Head, Department of Operational Research, National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
3 Scientist - D, Regional Medical Research Center, Dibrugarh, Assam, India
4 Head, Department of Medicine, Incharge ART Center, Civil Hospital, Aizawl, Mizoram, India
5 Project Research Officer, Department of Operational Research, National Institute for Research in Reproductive Health, Mumbai, Maharashtra, India
|Date of Web Publication||15-Dec-2016|
Department of Operational Research, National Institute for Research in Reproductive Health, Indian Council of Medical Research, J. M. Street, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Sexual behavior and contraceptive use among HIV-infected persons are a neglected issue in public health programs. Objectives: To understand sexual practices and contraceptive use of people living with HIV (PLHIV) before and after being diagnosed with the infection and assess the providers' perspectives on provision of contraceptives to PLHIV, the quality of services provided and linkages between reproductive health and HIV services. Methods: A mix method design study using a purposive sampling was undertaken enrolling PLHIV from ART centers and PLHIV networks across three cities in India. Doctors and counselors providing HIV services at public hospitals were also interviewed. Results: Use of condoms increased from 35% to 81% after being diagnosed with HIV. Consistent condom use was 69% compared to only 8.7% before being diagnosed with HIV. Nearly 41% (297) of participants indulged in one or more forms of risky sexual behaviors. Significant correlates of risky sexual practices were: participants who were middle-aged (25–33 years), formerly married, currently not on antiretroviral therapy, and received negligible information on contraception from service providers leading to poor knowledge on safe sex and dual protection. Information from service providers reveals a lack of specific program guidelines to comprehensively address family planning (FP) issues through HIV programs. Conclusion: The study throws light on missed opportunities to address contraceptive needs of PLHIV and recommends training service providers and operationalizing a strategy to link HIV and FP services.
Keywords: Contraception, dual methods, HIV/AIDS, sexual behavior
|How to cite this article:|
Joshi B, Chauhan S, Das H, Luaia R, Sunil N. Changes in sexual behavior and contraceptive use after HIV acquisition and factors associated with risky sexual practices among people living with HIV in selected Indian cities. Indian J Public Health 2016;60:251-9
|How to cite this URL:|
Joshi B, Chauhan S, Das H, Luaia R, Sunil N. Changes in sexual behavior and contraceptive use after HIV acquisition and factors associated with risky sexual practices among people living with HIV in selected Indian cities. Indian J Public Health [serial online] 2016 [cited 2017 Mar 27];60:251-9. Available from: http://www.ijph.in/text.asp?2016/60/4/251/195854
| Introduction|| |
HIV epidemic in India is heterogeneous in its distribution and slowly declining. The estimated adult prevalence of HIV is 0.26% in 2015, a little higher among males (0.30%) compared to females (0.22%). HIV prevalence varies between 2.67% among female sex workers to 8.82% among transgenders. Estimates reveal that about 38,000 HIV-positive women need Prevention of Parent to Child Transmission (PPTCT) services and every year 14,500 new HIV infections are reported among children. It is well known that HIV transmission in India is mainly through heterosexual route. In a single, random, unprotected sex act, the probability of pregnancy is higher than the probability of HIV infection. The probability of pregnancy is 3.5 percent  whereas the probability of HIV infection is 0.04% for male to female transmission and 0.08% for female to male transmission. Substantial investments have been made in condom promotion and other HIV prevention and in risk reduction programs through targeted interventions among high-risk groups. However, the program does not reach to nonhigh risk HIV-positive groups representing general population. Little is being done to address their sexual and reproductive health (RH) needs. The PPTCT program in India focuses mainly on prong 3 - providing antiretroviral (ARV) prophylaxis to pregnant women and to neonates. With the scaling up of PPTCT program, the proportion of women receiving ARV prophylaxis increased from 18% in 2007 to 32% in 2011, and a 35% reduction of new HIV infection among children was achieved. However, efforts to reduce new infections by focusing on prong 2, i.e., prevention of unintended pregnancies by providing effective contraception, have been weak.
Very few studies in India have explored the family planning (FP) practices of HIV-positive people who do not belong to the high-risk groups. A study covering six countries in Asia showed that among HIV positives, 27% of the pregnancies are unplanned and 37% are unwanted. Another study in India reported that 70% of the repeat pregnancies among women living with HIV were both unplanned and unwanted. Increase in condom use up to 92% has been reported but inconsistent use has persisted. Increase in condom use up to 92% has been reported but inconsistent use has persisted. Barriers to consistent use included lack of sexual satisfaction, seroconcordant among couples, husband's alcohol abuse, desire to have children, and nondisclosure of HIV status. The prevalence of dual-contraceptive method use was only 23% after diagnosis of HIV  as programs fail to provide comprehensive services resulting in poor uptake of the dual method of contraception.
Considering these reported dynamics affecting the contraceptive practices among HIV positive from limited data sources, a study with a mixed deign was undertaken to understand sexual practices and contraceptive use of people living with HIV (PLHIV) before and after being diagnosed with the infection and assess the providers perspectives on provision of contraceptives to PLHIV, the quality of services provided, and linkages between RH and HIV services.
| Materials and Methods|| |
The current study was carried out among PLHIV using a mixed method study design between February 2010 and August 2011. This involved interviewing both PLHIV and also the health providers using semi-structured questionnaires. The study was conducted in three cities, namely Mumbai, Dibrugarh, and Aizawl belonging to three states Maharashtra, Assam, and Mizoram, respectively, of which two were from North East (Assam and Mizoram) based on the operational feasibility of the investigators and the requirements of the funding source. Assuming a low prevalence of 2.3% condom use in Assam, with confidence interval (CI) of 95% within 1% point of the true value, the sample size was calculated as 863 ≈ 900. Three hundred participants were enrolled from each center. The three states from which the sites were chosen were very heterogeneous with varying transmission rates and routes of transmission, fertility rates, and contraceptive prevalence as per the NHFS 3 data  and National AIDS Control Organization estimates 2006 at the time of project initiation. Maharashtra was a high HIV prevalence state (0.55%), with heterosexual route as the main route of transmission, with low total fertility rate (TFR) of 2 and low unmet need for contraception of 9.6%. Mizoram, where the main route of transmission was through intravenous drug use, had high HIV prevalence of 0.81%, high TFR of 2.9, and high unmet need for contraception of 17.4%. In comparison, Assam (heterosexual route of transmission) had TFR of 2.4 and high unmet need for contraception of 10.8%, with low HIV prevalence of 0.08%. This scenario covered PLHIV residing in heterogeneous demographic situations with respect to HIV prevalence and FP needs.
The inclusion criteria were HIV positive males and females above 18 years of age, who are aware of their HIV status for last 6 months or more. HIV-positive commercial sex workers were excluded from the study. The participants attending ART centers at public hospitals who fulfilled the above criteria and were willing to participate in the study were enrolled in the study. Participants were also approached through PLHIV networks. Participants attending these centers who fulfilled eligibility criteria were serially enrolled after administering an informed consent form. Necessary technical and ethical approvals were obtained from participating centers before study initiation. Data pertaining to ever married, sexually active participants are considered for the present analysis.
Key informant interviews were conducted among counselors (n = 12) and medical officers (n = 12), two each from ICTC and ART centers of public hospitals at each site to assess the quality of services provided and linkages between RH and HIV services.
Data collection and techniques
An interviewer administered, pretested structured questionnaire was used to elicit information from the study participants, after obtaining informed written consent in local language. Interviewers with a social science background (both males and females) were trained in the conduct of the interviews, especially regarding sensitive information on sexual practices that they would elicit from the participants. Responses were checked for the validity by a data management team who were not a part of the interview process. Information about dual protection was provided to each respondent after the interview. Key informant interviews were conducted using semi-structured questionnaires.
Dual method use was defined as sexual partners using a condom along with any other modern method of contraception. Dual protection was defined as the use of any method of contraception for protection against both HIV/sexually transmitted infections and pregnancy. Fertility desire was defined as men or women who are currently sexually active with their spouse and have desire to have children in future. Unmet need was defined as participants who are currently married, sexually active, who did not want to have any child at all or immediately, and yet did not use any method of contraception. For the purpose of analysis, adapting from the WHOs definition  of risky sexual behaviors, we defined risky sexual practices as the irregular use of a condom or not using any spacing or limiting method of modern contraception irrespective of a number of partners.
Data were entered and analyzed in IBM - SPSS version 19 (IBM, Bangalore, Karnataka). Frequencies and percentages were used for categorical data. Mean and standard deviation were calculated for continuous variables and McNemar test to compare sexual behavior and contraceptive use before and after being diagnosed with HIV. The dependent variable was self-reported risky sexual practices at the time of interview. Pearson's Chi-square test was used to assess the association between risky sexual practices and independent variables (demographic characteristics, sexual behavior, knowledge, and access to contraceptives). A multivariate logistic regression model with forward selection (using P < 0.01 as the entry criterion) was used to calculate odds ratios (ORs) and corresponding 95% CIs for potential demographic, lifestyle, and health seeking behavior correlates of risky sexual practices. A P value (significance) of < 0.05 is considered statistically significant.
Knowledge of three or more safe sex practices was considered as good knowledge and similarly correct knowledge on dual contraception (condom alone or along with any other method) was considered good knowledge. All other responses were coded as poor.
| Results|| |
Sociodemographic characteristics of people living with HIV
Data of 726 ever married participants were included in the final analysis of which 411 were males and 315 females. The mean age of the participants in the study was 32.6 ± 4.4 years with majority of them in the age group of 24–32 years. More than 90% of the study participants were literate. About 80% of the participants were currently married, and 20% were formerly married (3.9% widowed and 13.4% divorced and 2.3% separated). Overall, 93% of the cases had disclosed their HIV status to some close associate mainly spouse. About, 55% of the participants were seroconcordant, and only 5.5% of the participants were aware about the HIV status of a spouse before marriage.
Overall, 75% of the study participants had at least one living child, and 16% of the children were HIV-positive. About 16% of participants had future intentions to have children despite knowing their HIV status for reasons such as “family pressure” and “wanting to have a boy child to raise family.” The overall unmet need of contraception among study participants was 13% [Table 1].
Awareness on contraceptives and services availed by people living with HIV
Awareness regarding one or more methods of contraception was 95%. Majority of the participants were aware of condoms (93%). All the study participants had knowledge regarding safe sex. Knowledge regarding usage of condom for dual protection among participants was about 80%. Advice provided by service providers on dual methods was only 26% restricting mainly to permanent sterilization.
Only 21% were counseled on issues related to pregnancy planning and 27% on FP methods other than condoms [Table 2]. Overall 8.3% of the married study participants had problems with the quality of condoms available at the health facility. Overall 11% of the participants experienced breakage/slipping of condoms and only 14% among them used emergency contraception (EC) pills. Discrimination at referral department is reported by 7.4% of the study participants in the form of “indifferent attitude of staff,” “preference to non-HIV person,” “delay in getting medicines,” “trying to avoid,” and “verbal abuse.” Only 16% of the participants who underwent abortion (n = 118) received postabortion counseling.
|Table 2: Experiences of people living with HIV in utilization of health-care delivery services (n=726)|
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Change in sexual behavior and contraceptive use post-HIV
About 32% had a sexual partner other than spouse and 20% reported using alcohol/drugs before indulging in any sexual act. Anal and oral sex activities reduced post HIV compared to a marginal increase in penovaginal sex. Condom use increased from 34.7% before being diagnosed with HIV to 81% after acquiring HIV infection [Table 3]. Consistent use also increased from 9% to 69%. Use of dual contraceptive method increased from 5.7% before being diagnosed with HIV to 19.4% after being diagnosed with HIV mainly among women who had undergone tubal ligation. Stratified analysis of condom use with spouse and partner revealed increase in condom use with a spouse from 24% before being diagnosed with HIV to 82% after being diagnosed with HIV, regular partner (21.6%–74.9%), and casual partner (52.4%–68.6%). Use of contraceptive methods other than condom was low (oral contraceptive pills – 9.8%, tubectomy – 8.5%) as an emphasis on contraception was always on the usage of condoms by the service providers (70.6%) mainly for infection control and less on dual protection.
|Table 3: Sexual practices among participants before and after HIV infection|
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There was a minimum discussion among married participants regarding safe sex with spouse/partner before being diagnosed with HIV (10.4%) compared to after being diagnosed with HIV (46.5%).
Providers' perspectives on providing contraceptives to people living with HIV, quality of care, and existing linkages between HIV and family planning services
Data revealed a lack of comprehensive service integration of FP counseling at most HIV services delivery sites (except ANC OPDs) or referrals to FP clinics. Although no significant increase in pregnancies and abortions was observed among PLHIV, service providers felt that due to easy access to free ART/PPTCT prophylaxis, there is a feeling of good health and sometimes PLHIV engage in unprotected sex. None of the medical officers had received in-service training on FP. Most of the counselors reported that the focus of HIV and FP counseling training is exclusively on condoms mainly for infection control, with very little discussion on its use for dual protection. Majority of the medical officers opined that no contraceptive method was contraindicated among HIV positive but was apprehensive on advising intrauterine device. They mentioned that there is enough stock of condoms; however, no other contraceptives were available at ICTC/ART centers. No IEC material is available on contraception other than a condom at HIV service facilities. All the key informants reported a lack of separate Management Information System (MIS) for recording the use of condom or other FP methods, abortions, fertility desires, sexual, or menstrual history of PLHIV.
Key informants agreed that no clear policy guidelines exist for linking FP and ICTC/ART services. All the key informants felt that it is important to strengthen the linkages between HIV and FP both at the policy level and by training and sensitizing service providers of both programs for effective functioning of linkages. A separate manual of guidance on contraception for PLHIV was a demand from the service providers for uniform service delivery.
Factors associated with risky sexual practices post-HIV
Nearly 41% (297) indulged in one or more forms of risky sexual behaviors. We explored various demographic, lifestyle, and program-related issues related to risky sexual practices post-HIV [Table 4]. About 41% (297) of the participants were found to be indulging in risky sexual practices among demographic and lifestyle factors. Younger age group 25–33 years (OR: 1.446, P = 0.014), sexually active widows/separated (OR: 2.382, P < 0.001), unemployed (OR: 1.397, P = 0.025), substance use by spouse/partner before sex (OR: 1.531, P = 0.015), and spouse not tested for HIV (OR: 1.559, P = 0.013) were predictors of risky sexual practices post-HIV. Participants not on ARV therapy (OR: 1.603, P = 0.002) and having illness (OR: 1.375, P = 0.034) were factors related to drug intake and overall health. Currently having one or no child (OR: 1.551, P = 0.008), future intentions for fertility (OR: 1.911, P = 0.002), and having a partner other than spouse (OR: 1.755, P < 0.001) were associated with risky sexual practices. Factors related to program and delivery of FP services were inadequate spouse counseling (OR: 2.048, P > 0.001), FP method not advised by service provider (OR: 2.181, P = 0.001), lack of counseling on FP (OR: 1.531, P = 0.015), poor knowledge on dual protection (OR: 1.710, P = 0.004), contraception (OR: 1.706, P = 0.008), safe sex (OR: 1.685, P = 0.007), and better awareness on PPTCT (OR: 1.568, P = 0.013).
|Table 4: Factors associated with risky sexual behavior among enrolled people living with HIV-univariate analysis (n=297)|
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After controlling for interactions and confounding in the multivariate analysis [Table 5], significant correlates of risky sexual practices were participants who were in the age group of 25–33 years, formerly married, currently not on ARV therapy, contraceptive method not advised by service provider, poor knowledge on prophylaxis for mother to child transmission, safe sex, and dual protection.
|Table 5: Factors associated with risky sexual behavior among enrolled people living with HIV-multivariate analysis|
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| Discussion|| |
The current study provides insight on awareness, attitudes, and use of contraception among HIV-positive people. Use of condom among PLHIV compared to general population  was high (75% vs. 5%). Only 16% PLHIV had undergone female sterilization in contrast to the national trend. As reported in few Indian studies,, less than a quarter of PLHIV used dual methods (18.6%); however, these figures were better compared to the figures reported by studies in African settings (5%).,, The unmet need for contraception is almost similar to that reported among general population. Inconsistent condom use reported breakage or slippage of condoms (11%) coupled with nonuse of EC (80%) would result in pregnancies that would be unwanted or mistimed as has been reported in a limited number of studies. These pregnancies are many times continued due to inability to terminate pregnancy and family obligations.,
As a consequence, there would be an increased morbidity risk on the already compromised health of women. As PPTCT prophylaxis reaches to only 32% of women who need it, there would be more number of HIV-infected children born to the mothers who do not receive PPTCT prophylaxis. This would further increase the burden on the cost of health services too. Women may resort to abortions, but the possibility of not accessing these services at public hospitals due to discrimination (7.4% referral department and 1.5% during abortion) cannot be ignored. They would avail of these services at other facilities paying huge costs.
The study also reveals that the focus of HIV program is mainly on infection control and increasing access to ARV prophylaxis with poor emphasis on FP as these issues are less discussed by counselors. A comprehensive programmatic focus can be achieved by addressing these issues in the training of service providers and advocacy through IEC messages on dual protection either by consistent use of condom use or by use of the dual method. There is a need to improve the quality of counseling on these issues and counselors must explore the fertility desires and contraceptive use of PLHIV. This could be made as a routine screening by recording this information and mainstreaming these aspects in the MIS. Service providers at the referral sites need to be sensitized, and services should be made friendly to these vulnerable population. The health-care providers need to be sensitized to the issues of sex and sexuality and be able to understand their sexual behaviors and the influencing environment on those behaviors. As reported in one of the review, counseling and providing information do not change behaviors. It must be coupled with proactive testing of spouse and sexual partners  which our study reported to be about 67% for spouse and only 14% of other partner.
Factors affecting contraceptive use as reported in our study must be identified at the individual level when PLHIV access HIV service delivery sites; they must be informed and counseled about safe sex and advantages of dual protection. Necessary referral linkages must be developed between HIV and RH services, especially the FP services.
Selection of study sites was based on the mandate of the funding source and capacity of institutes to implement the research project. Thus, our findings may not be generalizable. Self-reported data on contraceptive use, disclosure of HIV status may not be accurate due to social desirability bias, which might have persisted despite trained external investigators. Further studies are warranted to assess the burden of unwanted pregnancies and abortions after the detection of HIV and test different strategies to promote dual protection among PLHIV.
| Conclusion|| |
The unmet need of contraception, poor use of dual contraception and negligible counseling on the contraceptive and family planning issues by health providers to PLHIV, highlight the need of the program to address these issues comprehensively, by identifying the missed opportunities during provision of HIV services. Prevention of unwanted pregnancies among HIV positive people would definitely reduce the disease burden and will turn out to be a cost effective strategy compared to the prophylactic provision of ART regimen to the infected mother during pregnancy and management of maternal and child morbidities later.
Authors acknowledge the support extended by ICMR (NIRRH/RA/08-2014) and the authorities and staff of the centers participating in the study. Authors thank the entire research team involved in data collection. The cooperation extended by PLHIV enrolled in the study for sharing information and sparing time during participation in the study is duly acknowledged. We also thank Dr. Seshagiri Rao, President FPAI Mumbai Branch, for reviewing the article.
Financial support and sponsorship
This study was supported by the Indian Council of Medical Research, (NE budget) New Delhi, Department of Health Research, Government of India.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]