Regarding "knowledge, attitudes, and use of emergency contraception among rural Western North Carolina Women".

To the Editor: We read the article by Fagan et al (1) and the subsequent editorial on emergency contraception (EC) (2) with interest and agree wholeheartedly with the authors. In recent years, the Medical Center of Louisiana HIV Outpatient Program (HOP) clinic has become increasingly proactive in offering EC as a choice to women with HIV (to be used in conjunction with condoms). This is particularly true for women prescribed medications that are contraindicated in pregnancy if the patient can not or will not commit to a highly effective contraceptive method in addition to condoms.

To better define the HOP population that would be eligible for EC, a survey was conducted in the HOP clinic during July 2005. Nonsterilized, heterosexually active women with HIV between the ages of 18 and 42 years using only condoms for contraception were invited to participate. Women were informed about EC and then were offered a prescription. Subjects who elected to receive a prescription for EC were required to perform a urine pregnancy test.

The majority of the study population (n = 34) were African-American (97%). Seventy-nine percent classified themselves as single, while others were either married (17.6%) or separated (2.9%). The most common reasons for not currently using a contraception method in addition to condoms were 1) feeling that condoms would protect them well enough (53%), 2) not wanting to have any possible side effects (38%), 3) not wanting to take any more medications (23%), and 4) concern about birth control methods adversely affecting their HIV treatments (12%). These were also the most frequent reasons for opting to not use EC.

Eighty-eight percent claimed to have had a pregnancy. Thirty-two percent became pregnant "by accident" and 23.5% had had an elective pregnancy termination. Fifteen percent stated that they had been sexually assaulted in the past, and 27% admitted to having sex while intoxicated or on drugs.

Within the last year, 91% of the subjects claimed to have had at least one male sexual partner. The last time they had vaginal sex with men, 82% claimed that their partner used a condom. Within the last six months, 12% claimed that they had vaginal sex with a man and did not use a condom, while 24% claimed that they had a condom accident (slippage or breakage) during this same time period.

Eighteen (53%) wanted a prescription for EC. Thirty-five percent did not want a prescription, and 12% were not sure. Two of the study subjects wanting prescriptions for emergency contraception were found to be pregnant at baseline screening.

Although the study sample was small, the survey does highlight some common perceptions or attitudes among women with HIV who are candidates for EC. Condom failure or nonuse was common, and even though several women had previously been in situations that would dramatically increase their chances for condom failure or nonuse (intimate partner violence or substance use), a relatively high proportion felt secure using only barrier methods for contraception. The desire to avoid side effects and not take additional medications was prevalent. This was the reason stated by several women for declining EC, but ironically, these sentiments should have motivated this population to opt for EC over other highly effective methods. Cryptic pregnancies in high-risk populations are not uncommon, underscoring the importance of baseline pregnancy screening for women prescribed EC.

Further education on EC to women with HIV and their providers is warranted. Additional research to investigate tolerability and EC use patterns is also needed in this unique population.

Acknowledgment

This project was supported in part by Grant #U 19 AI061972-01 (Gulf South STI TM CRC).

Rebecca A. Clark, MD, PhD

Max Madhere, BS

Heather Serice, MPH

HIV Outpatient Program

Medical Center of Louisiana at New Orleans 

New Orleans, LA

References

1. Fagan EB, Boussios HE, Moore R, et al. Knowledge, attitudes, and use of emergency contraception among rural Western North Carolina Women. South Med J 2006;99:806-810.

2. Humphrey DA. Emergency contraception: a call to education. South Med J 2006;99:795.