Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic.
OBJECTIVE
To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use.


METHODS
Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically.


RESULTS
64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears.


CONCLUSIONS
Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.
Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
Kathryn
K
Church
Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
Alison
A
Wringe
Family Life Association of Swaziland, Manzini, Swaziland.
Phelele
P
Fakudze
London School of Hygiene & Tropical Medicine, Manzini, Swaziland.
Joshua
J
Kikuvi
Family Life Association of Swaziland, Manzini, Swaziland.
Zelda
Z
Nhlabatsi
UNFPA, Mbabane, Swaziland.
Rachel
R
Masuku
Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK Family Life Association of Swaziland, Manzini, Swaziland London School of Hygiene & Tropical Medicine, Manzini, Swaziland Family Life Association of Swaziland, Manzini, Swaziland UNFPA, Mbabane, Swaziland Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
Susannah H
SH
Mayhew
D000328:Adult; D002755:Choice Behavior; D003267:Contraception / Q000379:methods*; D003268:Contraception Behavior / Q000523:psychology / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D013541:Eswatini / Q000453:epidemiology; D005193:Family Planning Services / Q000379:methods*; D005260:Female; D006679:HIV Seropositivity / Q000453:epidemiology* / Q000523:psychology; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009042:Motivation; D011247:Pregnancy; D012736:Sex Education; D012747:Sexual Partners
AFRICA; CONDOMS; CONTRACEPTION; FAMILY PLANNING; HIV CLINICAL CARE