LAUSR

BACKGROUND Integrating family planning interventions with HIV studies in developing countries has been shown to prevent mother-to-child HIV transmission and simultaneously reduce HIV and unintended pregnancy in high-risk populations. As part of a prospective cohort study on HIV incidence and risk factors in Zambian women having unprotected sex, we also offered family planning counseling and immediate access to long-acting reversible contraceptives. Although long-acting reversible contraceptives are the most effective form of contraception, many Zambian women are limited to oral or injectable methods due to lack of knowledge or method availability. This project offers single mothers enrolled in a cohort study information about and access to long-acting reversible contraceptives at enrollment and at each follow-up visit. OBJECTIVE This study evaluates how fertility intentions affect long-acting reversible contraceptive utilization in HIV-negative single mothers in Zambia. Our primary outcome was long-acting reversible contraceptive use throughout study participation. We also estimated rates of long-acting reversible contraceptive uptake and discontinuation. We specifically studied single mothers because they are at high risk for unintended pregnancy, which can have significant negative ramifications on their financial, social and psychological circumstances. STUDY DESIGN From 2012-2017, Zambia Emory HIV Research Project recruited 521 HIV-negative single mothers between the ages of 18-45 years from government clinics in Lusaka and Ndola, Zambia's two largest cities. Participants were followed every three months for up to five years. At each visit, we discussed fertility goals and contraceptive options and offered a long-acting reversible method to any woman who was not pregnant or already using a long-acting reversible or permanent contraceptive method. Data was collected on demographic factors, sexual behavior and reproductive history. Multivariable logistic regression was used to model baseline fertility intentions with long-acting reversible contraceptive use. RESULTS We enrolled 518 women, and 57 women did not return for any follow-up visits. There was a significant increase in long-acting reversible contraceptive use during the study. At baseline, 93/518 (18%) of women were using a long-acting reversible method, and 151/461 (33%) women used a long-acting reversible method at the end of follow-up (p-value < 0.0001). Four women chose an intrauterine device and ninety-one chose an implant for their first uptake event. Women who did not desire any more children in Ndola were more likely to use a long-acting reversible contraceptive after adjusting for other confounders (aPOR = 2.02, 95% CI 1.88-3.42). During follow-up, 37/183 (20%) of long-acting reversible contraceptive users discontinued their method, and women who desired future children at baseline were more likely to discontinue earlier (p-value = 0.016). CONCLUSIONS This study demonstrates that integrated family planning services can successfully increase long-acting reversible contraceptive use among Zambian single mothers, a vulnerable population disproportionately affected by unintended pregnancy. A steady increase in use over time confirms the importance of repeated messaging about these unfamiliar methods. Thus it is imperative that family planning interventions target single mothers in developing countries to promote effective contraceptive use.