1. Women living with HIV are still missing highly effective contraception Results from the ANRS-Vespa2 Study, 2011, Lert F, Maraux B, Bajos N, Dray.Spira R, Spire B, Annabel Desgrées du Loû, Hamelin C and the Vespa2 study group

2. Context In Western Europe, increase of life expectancy, normalisation of life expectations including sexual life and parental expectations Renewed needs regarding family planning Among new diagnoses, More than half in women of childbearing age Large proportion in migrant women from Sub Saharan Africa (UNAIDS 2013) Contraception among women living with HIV Still large dominance of condom as contraceptive method (Heard 2004, Massad 2007, Sun 2012) No effect of hormonal contraception on the response to ART (Robinson 2012) Safety of intrauterine device (Curtis 2009) Unmet need for contraception High rates of unintended pregnancies with proportions ranging from 50% to 85% (Loufty 2013) Overall, scarcity of information on the contraceptive profile of women living with HIV (Haberl 2013, Sutton 2014) 2

3. Objectives Describe the pattern of contraceptive use among women living with HIV in France (2011) To estimate the proportion of women of childbearing age concerned with contraception To document contraceptive methods To assess the correlates of highly effective contraceptive methods (HEC) 3

4. Methods The ANRS-VESPA2 study, France, 2011 Cross-sectional national representative survey of HIV-positive hospital outpatients Face-to -face questionnaire using standardized questions on contraception Weighted data to account for sampling and participation bias Study population Women in childbearing age (18-49 years) n=662 women born in sub-Saharan Africa : 56 % Other women 44 % = French native women (38%) and other migrant women (6%) Frequency and characteristics of women concerned by contraception Frequency of methods of contraception Stratified univariate logistic regression to explore the correlates of highly effective methods (HEC) vs Condom. 4

5. Variables of interest Sexually active in the past 12months Able to conceive (not sterile, not menopausal) Neither pregnant nor seeking to be pregnant at time of data collection Women concerned by contraception Highly effective contraception (HEC) Pill, Intra Uterine Device, Implant, Medical sterilization Condoms None or traditional methods (withdrawal, periodic abstinence) Methods of contraception 5

6. Distribution of women of childbearing age according to the need of contraception 6

7. Characteristics of women concerned by contraception according to country of birth Migrant women from sub-Saharan Africa N=174 Other women (French native and other migrants) N=153 p. Social and reproductive factors Age (median) 32 years42 years 0.001 With children 69 %29 %0.001 Time since diagnosis 6 years17 years0.001 Current stable partner 86 %81%0.27 Currently employed 48 %56%0.27 Severe material deprivation 43 %26%0.001 Access to HEC factors Full health insurance coverage 51 %80%0.001 Visit to a gynaecologist<12months 77 %81%0.52 Medical factors On ART 86 %91%0.22 Cardiovascular risk 16%8%0.06 7

8. Methods of contraception 8

9. Correlates of highly effective methods vs. condoms among women on contraception Migrant women from SSA N=146 Other women (French natives and other migrants) N=120 Crude OR95% ICp.Crude OR95% ICp. Age (years) 18-29 30-39 40-49 5.9 2.6 1 1.5-22.6 0.8-7.7 0.03 0.6 1.9 1 0.9-3.2 0.7-5.5 0.31 At least one childrenYes vs No3.71.7-8.0 0.001 1.60.9-3.0 0.10 Current stable partnerYes vs No1 1,0-1.0 0.20 4.5 1.2-17.2 0.02 Current employmentYes vs No2.4 1-5.61 0.05 0.9 0.4-2.5 0.91 Severe material deprivation Yes vs No1.40.5-4.0 0.50 3.3 1.4-9.8 0.001 9 No statistical association with health insurance, visit to a gynaecologist, cardiovascular risk.

10. Discussion (1/3) Contraceptive patterns of women living with HIV One in five women is not using any modern contraceptive method : much higher than in the general population (9%, Bajos, 2012) Among women on contraception, condom has remained the most used contraceptive method (# 75%) No significant difference between migrant women from sub-Saharan Africa and other women regarding the use of contraceptive method 10

11. Discussion (2/3) Correlates of highly effective contraception methods Difference in correlates of highly effective contraception methods between Sub-Saharan women and other women (French native and other migrants) – Among migrant women from sub-Saharan africa Children : After delivery, heath professionals might offer a broader range of contraceptive methods in maternity hospitals Employment : a possible acculturation pathway – Among French and other migrant women Casual partnership associated with more condom : low sexual activity (29% with sexual intercourse in the last 4 weeks) Low use of highly effective method : not an accessibility issue – No association with health insurance, 80% of women with a gynecologist visit in the 12 month period – Physicians’ attitudes ? Do they provide women living with HIV with the full range of contraceptive options ? 11

12. Discussion (3/3) Strengths and limitations of the Vespa2 study 12 Strengths Vespa2 study : a nationwide representative survey of women living with HIV in France Contraceptive patterns were documented with a standardized questionnaire Limitations Vespa2 questionnaire did not documented unintented pregancies and history of abortions. Not enough statistical power to perform a stratified multivariate logistic regression of correlates of contraception methods.

13. Conclusion 13 In the future, preventive effect of ART in HIV transmission might further decrease the level of condom use WHO recommendations, 2012 “Women living with HIV can safely use hormonal contraceptives” Need to promote the concept of DUAL PROTECTION To provide women living with HIV with the full range of contraceptive options, communication is urgently needed towards HIV care specialists, gynaecologists, GPs and towards women as well.

14. Acknowledgements The VESPA2 survey was sponsored and funded by the French National Agency for Research on Aids and Viral Hepatitis (ANRS). We thank all PLWHIV who agreed to participate in the ANRS VESPA2 survey, all medical staff members in the participating hospitals, as well as the community-based organisations AIDES and Act-Up Paris who supported the survey. The ANRS VESPA2 Study Group: France Lert and Bruno Spire (scientific coordinators), Patrizia Carrieri, Rosemary Dray-Spira, Christine Hamelin, Nicolas Lorente, Marie Préau and Marie Suzan-Monti, with the collaboration of Marion Mora. Methodological and ground support: Yann Le Strat (InVS, Saint-Maurice), Lise Cuzin (Hôpital Purpan, Toulouse), Laurence Meyer (Cesp, Inserm, Le Kremlin Bicêtre), Daniela Rojas-Castro (Aides, Pantin) and Hugues Fischer (Act-Up Paris). Data collection: The ClinSearch firm and the social research institute Ipsos. Participating hospitals and investigators 14

15. Highly effective contraception vs. Condom among women using modern contraception p= NS HEC Condom