Status of family planning integration to HIV care in Amhara regional state, Ethiopia

Background Preventing unintended pregnancies among HIV positive women is one component of HIV prevention strategies. However, programs to prevent mother-to-child transmission (PMTCT) of HIV started in antenatal care. The objective of this study was to examine the status of family planning integration to HIV care from client and facility perspectives and identify factors associated with current family planning use. Methods A facility-based cross-sectional study was conducted from December 2017 to April 2018. Data were coded and double entered into EPI Info version 3.5.4 and exported to STATA version 14 for analysis. Bi-variable and multivariable logistic regression analyses were conducted to assess the association of variables with the current family planning use. Results A total of 518 HIV-positive women were included in the study. Among HIV-positive women, 35.3% had an unmet need for family planning, and 21.4% responded that their pregnancies were unwanted. About two-thirds (68.1%) of women were using a modern family planning method at the time of the study. Among women who were currently using family planning, 88.8% got the service from a family planning clinic in the same facility, and only 1.1% got the service from the HIV care unit. Women who were not knowledgeable on PMTCT (AOR 0.47, 95% CI = 0.24–0.90), divorced or separated women (AOR 0.19, 95% CI = 0.10–0.37) and women in the age group of 25–34 years (AOR 0.42, 95% CI = 0.20–0.88) and 35–49 years (AOR 0.41, 95% CI = 0.17–0.99) were less likely to use modern family planning methods compared with those women who were knowledgeable, married and women in the age group of 15–24 years. Besides, women with higher income (AOR 2.12, 95% CI = 1.26–3.57) were more likely to use modern family planning methods compared with women with lower incomes. Conclusion This study indicated that there is a high unmet need for family planning among HIV-positive women and low family planning services integration in the PMTCT/ART clinics. Efforts should be strengthened to tackle the factors which hinder the use of modern family planning and improve family planning service integration.


Background
Women of childbearing age account for more than half of the world's Human Immunodeficiency Virus (HIV) cases and unintended pregnancy is high among HIV positive women [1]. Globally, nearly 1700 infants become infected with HIV every day and 90% of these new infections are acquired through mother-to-child transmission (MTCT). The uses of family planning methods were among the strategies to prevent HIV positive birth [1]. This indicates that strengthening family planning services to HIV positive women gives an added value to prevent MTCT.
Globally, 222 million women either want to delay or avoid their pregnancy but they are not using modern contraceptive methods. This includes women who are HIV positive and those at risk of HIV [2][3][4]. Added to this, without appropriate prevention of mother to child transmission (PMTCT) interventions, about 50% of those infants born with HIV will die before their second birthdays [5][6][7]. Global commitments to eliminate new pediatric HIV infections recognized that preventing unintended pregnancies in HIV positive women is an essential HIV prevention strategy [8]. Therefore, preventing unintended pregnancies among women living with or at-risk of contracting HIV is a key component of the global HIV prevention strategy [8]. Family planning can also help achieve HIV prevention goals and improve maternal and child health outcomes [2].
Integrating family planning and HIV services is important to get information and services for both family planning and HIV care. Ensuring access to family planning options in PMTCT services saves time, increases uptake, improves the productivity of nurses, and decreases patient waiting times [9]. Additionally, this strategy promotes a one-stop shopping service that is user-friendly that improves the health outcomes of mothers and children [10]. There are different modalities of service integrations in different settings [11,12]. These include the provision of family planning within HIV testing, care, or treatment sites within PMTCT services, or within peer-outreach and community-based and home-based programs.
Ethiopia is among the 21 global priority countries with the highest number of pregnant women living with HIV who need PMTCT services [13]. These 21 countries accounted for 90% of the total number of pregnant women living with HIV that need services to prevent MTCT of HIV. In Ethiopia, there were 29,630 HIV positive mothers needing PMTCT services in 2017 and 8653 were from the Amhara region [14]. The adult HIV prevalence was also estimated to be 1.2% in 2014 [15,16]. The report also showed that the number of pregnancies among HIV positive mothers of the Amhara Region in 2014/2015 was 61.2% [17].
According to the 2013/2014 report of the Ethiopian HIV Prevention and Control Office (HAPCO), 18.8% of pregnant women on ART reported that their pregnancy was unintended [18]. The Federal Ministry of Health of Ethiopia has started integrating family planning with ART unit and HIV testing and counseling (HTC), and PMTCT within maternal, newborn and child health services since 2015. However, the programs to prevent MTCT of HIV continue to be executed as a narrow set of interventions that initiates in antenatal care. Besides, limited studies are observed on family planning integration in Ethiopia as well as the Amhara region. Therefore, this study aimed to examine the status of family planning integration to HIV care from client and facility perspectives and identify factors associated with current family planning use.

Study design and area
A cross-sectional study design was employed to assess the status of family planning integration to HIV care from client and facility perspectives in three referral hospitals (Gondar Referral Hospital, Dessie Referral Hospital, and Debre Birhan Referral Hospital) and three health centers (Gondar Town Health Center, Dessie Health Center and Debre Birhan Health Center) in Amhara region from December 2017 to April 2018. Amhara region is located in the northwestern part of Ethiopia.

Study population and sampling
All HIV-positive women who gave birth during the last 6 weeks to 24 months and who were on PMTCT follow up during the study period were included in the study. Also, facility audits in all selected health facilities were done to assess the availability of family planning services. However, all HIV-positive women who were seriously sick (women who were unable to communicate due to illness), who gave birth within the last 6 weeks, and who were pregnant were excluded from the study.
The sample size was determined using a single population proportion formula and calculated using EPI-info version 7.2.1.0 software. The sample was determined based on prevalence of unmet need for family planning which is 18.8% among women living with HIV [18] which is a proxy indicator to see family planning and HIV integration status, 5% margin of error, 95% confidence interval and design effect of 2, and 10% nonresponse rate. Hence, the final sample size of the study was 517 HIV-positive women.
A multi-stage sampling technique with simple random sampling at each stage was employed. At the first stage, three referral hospitals and three health centers were selected by using a simple random sampling technique. In the second stage, HIV positive women who fulfilled the inclusion criteria were selected using a systematic random sampling technique from the PMTCT unit. The PMTCT registers were the sampling units and HIVpositive women on PMTCT follow up were the study participants. The number of study participants from each selected health facility was determined using proportional to population size calculation.

Data collection procedures
A structured questionnaire was used to collect the data. The structured questionnaire was prepared in English and translated to Amharic and then back to English to keep its consistency. The questionnaire was developed by reviewing journal articles, WHO and MOH PMTCT guidelines, and mother-baby pair cohort registers [19][20][21] (Supplementary file 1). It consisted of the dependent variables: family planning integration status and current use of family planning; and independent variables such as personal factors (socio-demographic factor, maternal education, monthly income), reproductive and related factors (number of pregnancy, and number of ANC visits); knowledge about HIV testing and counseling, MTCT, and PMTCT; institutional factors (privacy of ART room, method mix for family planning); social factors (stigma and discrimination, partner disclosure); and desire to have children, unintended pregnancies, partner desire to have children, previous use of a contraceptive method and unmet need of family planning.
Twelve data collectors and four supervisors were recruited to administer the questionnaire using exit interviews. Exit interviews were conducted with a pre-tested structured questionnaire after taking informed consent from the study participants.

Data processing and analysis
Statistical analysis was undertaken using STATA version 14. Frequencies, proportions, and means were used to describe the data. A bivariate logistic regression analysis was carried out to see the association of socio-demographic factors, maternal and reproductive factors, and knowledge of MTCT of HIV on the current use of family planning. Variables associated with the outcome variable during bivariate logistic regression at p-value ≤0.2 were included in the multiple logistic regression models, using backward fitting. Variables persisted to be associated with the outcome variable at P ≤ 0.05 were considered to be significantly associated with the outcome variable.
The reliability of the tools was measured using Cronbach's alpha value and scales with a value above 0.7 were believed as reliable. Overall model fitness was measured using the log-likelihood ratio test. Based on the statistical significance of the probability of model chi-square less than 0.05 was supported the model to be a good fit. Hosmer and Lemeshow test goodness of fit were also used as a statistical value of more than 0.05 to characterize a logistic regression model as a better fit. A Wald test was used to test the statistical significance of the relationship between current family planning use and individual independent variables in the model.
Family planning integration was defined as the provision of family planning services (short and longacting family planning methods in addition to condom) within HIV testing, care, or treatment sites, and within the PMTCT unit. Unmet need for family planning was also defined as the proportion of women with no desire to become pregnant immediately before the most recent pregnancy but who are not using any method currently.

Ethical considerations
The University of Gondar Ethics Review Board approved the research proposal. A support letter was secured from the Amhara National Regional Health Bureau. Written informed consent was obtained from all research participants after the explanation of study objectives. The aims, benefits and the time it takes to complete the questionnaire were explained to the participants. Besides confidentiality, anonymity and their right to refuse from participation in the study were explained to them.

Socio-demographic characteristics of the study participants
Five hundred eighteen HIV positive women participated in the study with a response rate of 100%. The estimated sample size was 517 but one additional participant was included in the study due to her presence during the study period. Among the 518 HIV positive women interviewed, 389 (75.1%) were orthodox Christians, 410 (79.2%) were married, 113(21.8%) unable to read and write and 253(48.8%) were housewives. The majority (66.4%) of the respondents were in the age group of 25-34 years. The median age was 30 years (IQR: 27-33 years), and the median family monthly income was 1500 Birr. Three hundred eleven (60%) HIV-positive women had one to two pregnancies at the time of study and 71.2% of the respondents' youngest child age was 3-12 months (Table 1).

Fertility desires and family planning history
About 85.9% of HIV-positive women gave birth after knowing their HIV status and 70.8% HIV-positive women had used the family planning method before their last pregnancy. Overall, 33.2% of the respondents who already had children had the desire to have more children. Among HIV-positive women, 49.4% intended to have another child after 2 years. For nearly two-thirds (59.9%) of the study participants, the reason to have more children was to replace themselves. Among HIVpositive women, 35.3% had an unmet need for family planning, 21.4% ever had an unwanted pregnancy and 12.9% ever had induced abortion ( Table 2).
Family planning integration to HIV care and current use of family planning methods From 518 HIV-positive women, the majority (96.5%) discussed family planning with their health care provider in the current visit and 68.1% were currently using a modern family planning method. The most frequent methods of contraception among family planning users were implant (35.9), followed by injectable (32.6%), IUCD (14.2%), condom (8.2%) and 8.0% used Pills. Dual method use (condom and other methods such as pills, injectable, and IUCD) was reported by only 2.8%. Among women who currently used family planning, 41.1% preferred to get the service at ART/PMTCT clinic and 52.1% preferred to get the service in the family planning unit. However, among women who currently used family planning, the majority (88.8%) got the service from the family planning clinic in the same facility and only 1.1% got the service from PMTCT/ART unit (Table 3).

Family planning service audit
In all selected health facilities there were separate service delivery points for family planning, PMTCT, and ART units. Two of the six health facilities had a poster in PMTCT and ART unit advertising family planning services. There was a limited choice of family planning methods available in those ART/PMTCT clinics providing family planning services. The health care workers of two ART clinics were trained on family planning. Among the six facilities, only two health facilities were providing family planning services other than male condoms at the HIV clinic (PMTCT/ART). Only oral contraceptives and condoms were available in those ART/ PMTCT clinics providing family planning services.

Factors associated with current use of modern family planning methods
The current use of modern family planning was significantly associated with maternal age, marital status, family income, and knowledge of MTCT. Women in the age group of 25-34 years were 42% (AOR 0.42, 95% CI = 0.20-0.88) and women in the group of 35-49 years were 41% (AOR 0.41, 95% CI = 0.17-0.99) less likely to use modern family planning methods compared with women in the age group of 15-24 years. Divorced or separated women were 19% (AOR 0.19, 95% CI 0.10-0.37) less likely to use modern family planning methods compared with married women. Women with higher income were 2.12 (AOR 2.12, 95% CI = 1.26-3.57) times more likely to use modern family planning methods compared with women with lower income, and women who were not knowledgeable on PMTCT were 47% (AOR 0.47, 95% CI = 0.24-0.90) less likely to use modern family planning methods than those who were knowledgeable (Table 4).
In this study, the most frequent method of contraception among HIV-positive women was Implant (35.9%), followed by injectable (32.6%). However, only 8.2% of the study participants were using condom. Even though the use of condoms is essential among HIV-positive women, the study revealed that the use of condoms and dual method use among respondents is low compared with similar studies in which show 79.6% male condom use in Ghana [22], and 42.9% in Dire Dawa, Ethiopia [27]. This may be explained by the current study uses only women as study population and women might not directly control condom use. This will be a great concern for the risk of HIV transmission. This study reveals that a high proportion of women use implant among family planning users which is higher compared with the findings of other studies   conducted in Ghana (7.1%), Tanzania (13.3%), and Zambia (8%) [22][23]28]. This may be explained by the availability of service at a lower health facility level (the service is provided by a health extension worker at a health post level in Ethiopia).
The study reveals that, despite being HIV-positive, 33.2% of the respondents who already had children had the desire to have more children which is much higher than the finding of a study in Cambodia (7.3%) [26]. The finding is consistent with the study conducted in Dire Dawa, Ethiopia where 32% of respondents had the desire to have more children [27]. The study also reveals that 60% of HIV-positive women had one to two pregnancies at the time of study and 85.9% gave birth after knowing their HIV status in this study. Low risk of MTCT after ARV may favor this outcome among HIV-positive women.
The integration of family planning and HIV services greatly helps in supporting the implementation of prong two at all levels of program and health service management. Addressing women's reproductive health needs holistically strengthens the impact of both family planning and HIV services [10]. The integration of family planning services to HIV services can increase access and uptake [2,9]. Family planning integration has increased the use of family planning by 12.9% in Kenya [30]. But, in this study, only 1.1% got the service from PMTCT/ART unit. The facility audit also showed that among the six facilities, only two health facilities were provided with family planning services other than male condoms at the HIV clinic (ART/PMTCT unit). There was a limited choice of family planning methods available in those ART/PMTCT clinics providing family planning services. Health workers who were working in only two ART clinics had been trained in family planning. This shows the integration of services was poor. This finding is in line with the findings of a study conducted in five countries of Africa (Ethiopia, Kenya, Rwanda, South Africa, and Uganda) [31] on integration of family planning to HIV care, which shows that most ART clinics had only one or two providers on duty and many of these providers indicated that they did not have family planning training. This study also has a similar finding with a study conducted in Uganda which showed that ART clinic did not have contraceptives onsite [32]. Similar studies conducted in Ethiopia and South Africa showed the presence of weak integration of family planning services to chronic HIV care [27,33]. A study conducted in Kenya showed that 73% of women and 71% of men thought that they or their partner would be more likely to use family planning if the services were offered at the HIV clinic [34]. Besides, a study in Zambia revealed that most respondents said they would access family planning services had it been available within the ART clinic [28].
This study indicates that a high proportion of women with no desire to be pregnant were not using any modern method of contraception and there was no method mix at ART/PMTCT unit in those facilities that integrate the service. This might have been a factor for low uptake of modern family planning and hence strengthening the integration of family planning services in the Adult HIV clinic and PMTCT clinic is important.
The unmet need for family planning among HIVpositive women in this study is higher compared to the unmet need among the general population in Amhara Region, Ethiopia (17%) [35]. This is also supported by a study conducted in Dire Dawa, Ethiopia which shows a high unmet need for family planning (36%) among women living with HIV [27]. The finding is comparatively higher than the findings reported from Kenya (20%) [31], Ghana 27.8% [22], Western Ethiopia (15.4%) [36], and Hawassa city Ethiopia (19.1) [37]. This study also indicates that 21.4% of participants ever had an unwanted pregnancy and 12.9% ever had induced abortion.
In this study maternal age, marital status, family income, and knowledge about MTCT were strongly associated with the current use of contraception. Women in the age group of 25-34 years and women in the group of 35-49 years were less likely to use modern family planning methods compared with women in the age group of 15-24 years. This is consistent with the findings of studies conducted in Malawi [38], and Ethiopia [39]. Divorced or separated women were less likely to use modern family planning methods compared with married women. This is in line with studies done in Kenya [40], Nigeria [41], and Ethiopia [39]. This study reveals that women with higher income were more likely to use modern family planning methods compared with women with lower income and women who were not knowledgeable on MTCT were less likely to use modern family planning methods than those who were knowledgeable. Similar findings were found from studies conducted in Nigeria [41], and Ethiopia [39]. This might Limitations of this study, due to the cross-sectional nature of the data, cause and effect relationship between the dependent and independent factors could be weak; and social desirability bias may not be avoidable even though data collectors were trained. Besides, current contraceptive use was based on self-report by the women who might have reported what was perceived as socially acceptable or correct, which would have overestimated the estimates obtained in this study. Despite these limitations, the data being gathered have a better description of family planning among HIV positive women.

Conclusion
The study shows that there is a high unmet need for family planning among HIV-positive women and low integration of family planning services in PMTCT/ART clinics. Knowledge about MTCT of HIV, family income, marital status, and maternal age are predictors of current contraceptive use. Reducing the unmet need for modern family planning methods by improving the provision of family planning services to HIV-positive women through the integration of family planning to HIV care and increasing awareness of HIV positive women about PMTCT is recommended for prevention of mother to child transmission of HIV.

Additional file 1: English Version Questionnaires
Abbreviations AOR: Adjusted odds ratio; ART: Antiretroviral therapy; CI: Confidence interval; FP: Family planning; HCT: HIV counseling and testing; HIV: Human immunodeficiency virus; MTCT: Mother-to-child transmission; OR: Odds ratio; PMTCT: Prevention of mother-to-child transmission