Discussion

Multiple complex demands are placed on a woman living with HIV in the immediate postnatal period. Continued condom use is recommended to all HIV-seropositive women regardless of the HIV serostatus of their partner. However, the choice of an additional method of contraception depends on the need to continue ART. Traditionally, only Depo-Provera or an intrauterine contraceptive method [either the copper intrauterine device (IUD) or the Mirena^® intrauterine system] have been considered appropriate choices among women who continue antiretroviral treatment after delivery: increased failure rates of oral contraceptives (both the combined and progestogen-only pills) and subdermal progestogen-only implants have been reported when these drugs are prescribed concurrently with ART.4 ,5 However, some preliminary data suggest that newer antiretroviral drugs such as boosted atazanavir and maraviroc may be co-administered with a combined contraceptive pill that contains at least 30 µg ethinylestradiol without significant interaction, increasing the contraceptive choices of HIV-seropositive women.6 ,7

While the time from delivery to the resumption of sexual activity is reported to vary widely,8 the importance of providing women with an early opportunity to establish appropriate contraception should not be overlooked. Indeed, the association of an increased risk of adverse perinatal outcomes with an inter-pregnancy interval of less than 6 months is well documented.9 Women attended for postnatal review by 4 weeks postpartum in 80% of pregnancies but, in this non-breastfeeding population, ovulation may have already occurred in those seen beyond 2 weeks postpartum. Nonetheless, the present results suggest that the uptake of a second contraceptive method in addition to condom use is high, and that prescription of contraception in the context of a specialist HIV service can ensure that drug interactions are minimised to offer all women an individual approach to the most appropriate and effective method.

Yet this study also highlights the vulnerability of the women who did not attend for clinical review and contraceptive advice in the immediate postnatal period. The potential reasons for non-attendance are many, and require further qualitative investigation. Local anecdotal evidence suggests that reasons include logistical difficulties with transport and child care, fear of disclosure to visiting family and friends, and simply being too busy to remember to attend. However, non-attendance may also signal more serious issues such as postnatal depression and difficulty in adjusting to a new HIV diagnosis.10 The present data did not allow the authors to identify factors associated with non-attendance; also the analysis is limited by small sample size and retrospective design.

These data have several other limitations. In spite of prescribers' guidelines and the advice given at the authors' clinic, women' contraceptive choices in the postnatal period will be confounded by their experience of the methods used pre-pregnancy, and previous advice given by alternative health care providers and community members, which it was not possible to address in the present analysis. No assessment was made as to whether women sought postnatal contraceptive advice from an alternative clinic or health care provider such as their general practitioner, which may account for some women's non-attendance. Importantly, in looking at explanatory factors associated with non-attendance, individual unadjusted ORs are presented that do not account for other known and unknown confounding factors. Furthermore, as a retrospective analysis of cohort data, no assumptions can be made about the power of the study to detect such associations, nor about the degree to which these results are transferable to other settings and populations.

However, the authors are not aware of similar studies in HIV-seropositive women living in the UK. The Ukraine Post Natal Cohort Study of HIV-Infection Childbearing Women was established in 2007.11 Data reported in 2010 among the cohort of 371 women estimated that 21% of this group were not using contraception in the postnatal period, which is similar to the present population group. Despite similar levels of postnatal family planning counselling (91%), the reported use of methods other than condoms was significantly lower, with 0.6% of women using an injectable method and 0.9% of women using an IUD. One of the major barriers cited for contraceptive use was affordability, which is obviated by the availability of free contraception in the UK. Differences in the uptake of non-barrier methods may also reflect differences in the experience, beliefs and cultural norms of both women and their health care providers in the two countries.12 The World Health Organization does not currently recommend the use of IUDs among women diagnosed with AIDS due to concerns of increased risk of pelvic infection.13 However, IUDs are commonly inserted for HIV-seropositive women in the UK, and Faculty of Sexual and Reproductive Healthcare guidance states that the benefits of intrauterine methods outweigh these risks, such that there is no restriction associated with a diagnosis of HIV in itself.14