HIV-infected adolescent and young adult women experience high rates of unintended pregnancies, sexually transmitted infections (STI), and secondary HIV transmission to uninfected partners[1–3]. Furthermore, unintended pregnancies increase perinatal HIV transmission risk to offspring.[2] The risk of HIV infection among young women is heightened in the Southeastern United States, and specifically Georgia (GA), where the burden of HIV/AIDS falls disproportionately upon African American youth[4, 5]. While teen pregnancy rates are dropping in Georgia, rates remain consistently above the national average[6, 7]. The United States (U.S.) National Strategy for HIV/AIDS[8] and the Healthy People 2020 Objectives[9] aim to reduce both unintended pregnancies and STI/HIV among vulnerable populations; to achieve this goal, it is critical to understand and encourage improvement of reproductive health behaviors, practices and associated outcomes in young HIV-infected women.

Currently, there are limited data on contraceptive practices, sexual behaviors, knowledge, and attitudes regarding pregnancy and STI/HIV prevention among young HIV-infected women. Most research has focused either on younger adults not in the United States[10–15] or on older HIV-infected adults in the United States[16, 17]. However, the challenges, beliefs and practices of younger HIV-infected women likely differ from those in other countries and those of older adult counterparts. Studies of uninfected adolescents and young adults may not be truly representative since reproductive health and STI prevention priorities may change with HIV infection, reinforcing the importance of condom use.[18] Reports on younger HIV-infected individuals often lack documentation of patient beliefs on contraceptive methods and how this may influence choice and use.[17, 19, 20]

HIV-infected women engaging in unprotected sex risk secondary HIV transmission to uninfected partners and acquisition of other STIs or super-infection with drug-resistant HIV.[1, 3, 21, 22] Previous data demonstrate high rates (40–63%) of unprotected sex among young HIV-infected women. [18] Furthermore, qualitative data highlight differing attitudes among horizontally and perinatally infected young women; while some perinatally infected young women insist on consistent condom use, many are challenged with HIV serostatus disclosure and communication about barrier protection, so they defer condom use.[23] Clinical guidelines recommend comprehensive reproductive health counseling to include dual methods of pregnancy prevention by highly effective contraceptive methods, including contraceptive implants and intrauterine devices (IUD), and STI/HIV prevention through consistent use of condoms.[24, 25] While current Centers for Disease Control and Prevention (CDC) medical eligibility guidelines do not restrict contraceptive use based on HIV status alone,[26] many providers may be unaware of these recommendations. Further, may providers worry about drug-drug interactions between hormonal contraceptives and antiretroviral therapy (ART), lack training in contraceptive provision, or believe that effective hormonal contraception will lead to reduced condom use. Thus, it is unclear what information young HIV-infected women are receiving and how these messages inform contraceptive choices and sexual behaviors; it is also unclear how these issues may differ between women who were perinatally versus horizontally HIV infected.

This study aimed to explore current reproductive health knowledge, attitudes and practices among HIV-infected adolescents and young adults receiving medical care at an HIV clinic in Atlanta, GA. Additionally, we explored factors associated with contraception, condom and dual-method use at last coitus within a social ecological framework to determine the possible correlates of less effective contraceptive practices to address in future reproductive health interventions. Expanding our understanding of contributors to sexual behaviors and family planning practices within a social ecological framework can inform future efforts to improve preventive care in this high-risk population.

Of the 103 women who completed the survey, 52.4% were perinatally infected and 28.2% reported no prior sexual intercourse (Table 1). Among the 54 perinatally infected women, 22 reported no prior sexual activity (40.1%). Average age was 22 (range 14–30) years; 89.3% were African American, 41.8% were enrolled in school, 39.8% had at least one prior pregnancy, and 89.3% were taking medication for HIV (combination ART). The majority (63.1%) had an undetectable viral load, and the mean CD4+ T-cell count was 446.0 cells/μl (+/- 289.53), with 43.7% having a CD4+ T-cell count of >500 cells/μl.

Among our cohort of young HIV-infected women in Atlanta, Georgia, ineffective pregnancy prevention and unsafe sexual practices were prevalent, despite participants being actively engaged in comprehensive HIV care. Similar rates of low contraceptive and dual method use have been described in other HIV-infected cohorts[27] and uninfected young African American cohorts.[28] Condoms were the most prevalent form of contraceptive used among women in our cohort, a finding that is reflected in prior studies among HIV-infected women, both domestically and globally.[27, 29] This likely reflects increased concerns regarding HIV-transmission to uninfected partners; however, this approach is suboptimal for prevention of unintended pregnancy. Furthermore, while condom use as a preventive strategy for HIV/STIs is essential, almost 40% of these young, HIV-infected women reported not using a condom at last coitus.

There have been several studies of behavioral interventions involving counseling or education aimed at increasing condom or dual method use uptake and continuation among young women living with HIV [30, 31], however few have demonstrated efficacy. Many of the factors associated with use of condoms, most or moderately effective contraception, and dual methods were at an individual or relationship level, compared to community or societal level. By recognizing that individual-level factors seem to be the strongest influencers of safer sexual practices, efforts towards individually tailored patient-centered prevention counseling may be a particularly important reproductive health intervention.

While partner communication and disclosure are often encouraged as part of counseling for HIV-infected individuals, partner communication factors related to HIV/STI prevention or exclusivity did not appear to influence practices in the cohort. Among sexually active women, those perinatally infected did not behave differently from than their horizontally infected counterparts with regard to pregnancy and HIV/STI prevention. However, those with improved virologic suppression and higher CD4+ T-cell counts were more likely to use contraception. These findings suggest that HIV-infected women who are adherent to antiretrovirals may be more consistent with clinic visits and other medications, including the injectable or oral contraceptive methods. Given that poor virologic control is associated with increased risk of mother-to-child transmission, the need for more effective strategies to address pregnancy prevention is paramount to management in this challenging group. One potential approach is to reduce the user-dependent contraceptives by promoting long-acting reversible contraceptives.

While contraceptive use was higher among women with virologic suppression, condom use did not significantly differ between groups. Although this suggests that knowledge of virologic suppression might not alter condom use, this is a dynamic relationship that will require a longitudinal study design. Similarly concerning is that those with more frequent coitus reported less condom use. This finding has been reported by other investigators with some proposing “condom use fatigue.”[32, 33] Alternatively, factors such as more frequent coitus and older age may reflect a more stable relationship, where condom use may be perceived as less important. While barrier protection is pivotal to STI/HIV prevention, their use remains inadequate, necessitating the investigation of other approaches, including couples counseling and testing, antiretroviral treatment as prevention, pre-exposure prophylaxis of uninfected partners, and utilization of microbicides as they become available within the context of a multi-faceted HIV prevention approach.

One might expect that desire for a child in the next year would be associated with contraceptive use at last coitus. The data did not support this. However, since few women desired children in the next year, the confidence intervals were wide. Contraceptive use is not solely influenced by desire for a child, highlighting the need to recognize the broad cadre of factors that determine usage.[34] Given the high rates of unintended pregnancy, coupled with the risk of mother-to-child transmission, efficacious reproductive health counseling messaging needs to be further developed for HIV-infected young women who do not desire children. It is also important to engage women in fertility discussions within the context of routine HIV care.[35] Safe contraceptive practices should be tailored to an individual’s priorities, which may not be static, especially for younger women. Accordingly, ongoing reproductive health counseling within the context of HIV care is desirable. While we are unaware of proven interventions among HIV-infected young adults in the United States that have increased contraceptive use, research among uninfected women have highlighted that structured counseling, removal of cost and immediate access to highly effective contraception can increase the uptake of highly effective contraceptives and reduce unintended pregnancy[36–39].

This is one of the first studies to examine potential factors that influence contraceptive and condom use practices from a social-ecological framework among a high-risk cohort of young HIV-infected women in the United States. However, there are several limitations for this analysis. While a strength of our study was the broad range of potential influences we evaluated, this can result in a greater chance for at least one Type I error. Further, our small sample size limits our power to detect potential associations that may exist as well as to conduct a multinomial logistic regression to evaluate distinct categorical differences among those who use condoms only, contraceptives only or dual method use. Additionally, as our data are cross-sectional, we cannot comment on causality or temporality of these factors or know if changes in any of these characteristics may result in subsequent changes in practices. We largely relied on self-report, which may increase our chances of recall and social desirability bias. To reduce this risk of social desirability bias, we aimed to ensure confidentiality and utilized ACASI. As we did not assess partner characteristics, such as HIV status, we are limited in our analysis of partner dynamics. Although only 19% of subjects approached declined participation, our results may be biased towards individuals more interested in or knowledgeable about contraception or those with different sexual practices than those who declined participation. Lastly, we focused on a population of young adults in metropolitan Atlanta with HIV, thus generalizability of our findings may be limited to other cohorts of young HIV-infected women.

In conclusion, our results highlight the need to enhance individual-level interventions to improve pregnancy and STI/HIV prevention practices among young HIV-infected women in the United States. While provider-level, societal- and community-level factors may be important to other aspects of an individual’s overall wellbeing, they were not strongly influential on behaviors in our study. Thus, efforts must shift focus to developing and evaluating individual-level interventions, such as patient-tailored education and counseling, to increase the uptake of dual methods with user-independent contraceptives. Furthermore, development of new preventive strategies, such as multipurpose prevention technologies that are effective at preventing pregnancy and STIs and/or HIV, may help to overcome the persistent challenges in consistent condom use.