HIV/HAART and Pregnancy/Contraception in Rakai, Uganda

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DESCRIPTION (provided by applicant): Over 13 million women in sub-Saharan Africa were estimated to be infected with HIV/AIDS by end of 2007. The goal of this study is to assess the interactions between HIV infection, fertility outcomes and contraceptive use in the context ART availability and use among individuals and couples in Rakai, Uganda. Under the proposed RO1, we plan to analyze data collected annually on a sample of the approximately 12,000 Rakai Community Cohort Survey (RCCS) participants surveyed annually since 1994. Our specific aims are to assess: (i) determinants of contraceptive use and impact of fertility desires and intention on contraceptive use and pregnancy rates, (ii) impact of hormonal contraceptives on HIV disease progression as well as the impact of ARTs on fertility outcomes, contraceptive use and high risk behaviors, and (iii) fertility outcomes and contraceptive use among HIV-concordant and serodiscordant couples. Rates of contraceptive use, pregnancy, and pregnancy loss will be assessed through annual surveys and rate ratios estimated using Poisson regression. Log-binomial regression methods will be used to assess determinants of contraceptive use. Survival analyses and Kaplan-Meier survival curves will be used to assess the impact of hormonal contraceptives on HIV progression indicators (time from infection to death, time-to- AIDS, time to CD4 <250/mm3, and CD4 decline, viral set point and clinical symptoms). Proportional rate models will be used to estimate the within woman change in frequency of pregnancy and pregnancy loss before and after ART use. To account for repeat measurements within individuals we will use random-effects models for continuous variables and Markovian and random-effects logistic regression for binary outcomes with GEE estimation of robust variance. The RCCS provides unique longitudinal, community based data on HIV status, sociodemographic, behavioral and health characteristics. There is an urgent need for data on effective, long-term contraceptives for HIV-infected women and impact of HIV treatment on fertility outcomes, contraceptive use and high risk behaviors. It is critical that factors influencing reproductive health outcomes and contraceptive use in the backdrop of HIV infection and ART availability and use are better understood so as to inform policy and programs to guide individuals and couples make safer decisions regarding their sexual health and child bearing. PUBLIC HEALTH RELEVANCE: With a very high total fertility rate (6.7), low levels of contraceptive use (15.6%) and high levels of unmet need (35%) in Uganda, there is a pressing need to understand factors affecting decisions regarding HIV prevention, contraceptive use and pregnancy outcomes and the extent to which these factors are modified by ART availability and use. The RCCS has data to answer these pressing public health questions regarding contraceptive choices and fertility outcomes among HIV+ and HIV- individuals and couples.