Determination of multipurpose prevention technology choice for contraception and HIV/STI prevention: A survey of sexually active women in Nigeria

INTRODUCTION

Interest in contraception and human immunodeficiency virus (HIV) prophylaxis in the context of multiple sexual and reproductive health risks women face suggests a place for multipurpose prevention techniques (MPTs). The MPTs are designed to protect patients from unintended pregnancy, HIV, and other sexually transmitted infections (STIs) by combining contraception and pre-exposure prophylaxis (PrEP) into one unified delivery method.^[1-4] Male and female condoms are currently the most basic and readily available forms of MPTs.^[5,6] Nigeria’s 2 million plus people living with HIV/acquired immunodeficiency syndrome (AIDS) ranks her the second largest country with an HIV epidemic in the world including one of the highest transmission rates in the world with UNAIDS estimating that it accounted for over two-thirds of new infections in the West and Central Africa regions.^[7,8] About 80% of this infected population reportedly contracted HIV after unprotected heterosexual contact with women being disproportionately affected. Risks of exposure for women include their anatomy as well as a multifactorial disadvantage when negotiating for safe sexual practices.^[8] The previous studies have shown that various factors affect women’s acceptance and adherence to contraception including MPTs. Therefore, it is crucial that as the development of MPTs continues, we compare it with other modern contraceptives being used voluntarily and persistently. In evaluating contraception choices, the essential characteristics of women include effectiveness, safety, affordability, long-lasting effects, and whether the method was “forgettable.”^[9] The MPT development is centered around discrete female products, thus ensuring that vaginally delivered products such as gels, rings, and inserts are more favorable due to the availability and the ability of women to use them without partner knowledge.^[10,11] Another concern that beguiles women is the availability of MPT products that lack hormonal activity, as it will present a safer option for most women, who inadvertently react to hormonal contraceptives. To date, only condoms serve this purpose, and their use is largely dependent on the male partner’s consent, hence taking the decision out of the hands of the female. This issue serves to indicate that more novel MPTs are required and an assessment of women’s reactions to their use is an unexplored parameter. Despite conjecture regarding factors related to the acceptance of MPTs, there has been no specific research on the level of interest in MPTs and factors that would increase their acceptance among women in Nigeria. This study aims to determine the sexual characteristics of women in Nigeria and assess product factors associated with MPT acceptance among the identified interested individuals.

MATERIALS AND METHODS

This study is a cross-sectional survey exploring the interest in MPTs among heterosexual women (aged 18–59 years) living in Nigeria. The survey is a representative sampling from all geo-political zones since cultural norms and demographic factors vary across the six zones. To estimate sample size, authors assumed a 95% level of confidence, a 5% margin of error, and estimated incidence of MPTs at 50%;^[12,13] this yielded a sample size estimate of 384 respondents.^[12]

A pretested data collection tool was utilized for this study. This tool was previously validated by Hynes et al.^[13]The data collection tool (questionnaire) was developed using Google Forms^®, an online mobile tool for creating customized surveys.

It consisted of two parts:

• Part 1: Questions exploring the respondent’s sociodemographic data and

• Part 2: Questions exploring respondents’ sexual behavior and concerns, contraceptive use history, and factors that will promote their acceptance of MPTs. These questions were developed following a review of the literature.

The survey was delivered to respondents electronically (Google^® Forms), and all volunteers received links through WhatsApp. Reminders were sent through WhatsApp, text, and email reminders where feasible. The tool was set to keep all respondents anonymous, ensuring there was no collection of identifying information. The survey was published in the English language and was open to respondents from December 11, 2020, to January 11, 2021.

The researchers shared the web link to the survey through various WhatsApp groups in the six geo-political zones of Nigeria. These groups existed before the study and were formed for community enlightenment purposes.

The authors ensured representation across geo-political zones by monitoring responses and actively inviting women from communities that were underrepresented in the survey. Weekly reminders were sent to the platforms to get as many respondents as possible within the survey period. Eligible participants were heterosexual women (aged 18–59 years) living in Nigeria who had been sexually active in the past three months.

RESULTS

The survey was opened between December 11, 2020, and January 11, 2021, during which time 393 respondents participated, the mean age among the respondents was 35.51 years (Standard Deviation ± 8.96). The highest percentage of respondents came from the Southwest (39.1%) while the lowest participation was recorded from Northwest Nigeria. About one-half of the respondents were married or in a relationship; approximately 77% had earned a bachelor’s degree or higher and over three quarters (86%) were currently employed. Moreover, about 46% of the women had been pregnant [Table 1].

Contraceptive use history

About two-thirds of the respondents were not hoping to get pregnant at the time of the study (67%). About 60% of the respondents never use any form of birth control during sexual intercourse, and only 16% indicated that they use it all time. Most of the respondents that do not use any method of contraception indicated that they do not think that they need to use any method (15%), about 8% think that the methods are not safe and are designed to make women sterile (8%) while 7% do not know that they need to use any method, the husband does not believe in them and do not believe they work. For their last sexual encounter, only about 24% used a condom [Table 3].

Table 3: Contraceptive use history of respondents.

Variable	Option	Frequency (%)
Are you currently hoping/planning to get pregnant?	Rather not say	19 (4.8)
	No	262 (66.7)
	Yes	112 (28.5)
In the past 3 months, how often did you use any form of birth control during sexual intercourse?	Never	235 (59.8)
	Rarely	56 (14.2)
	Some of the time	25 (6.4)
	Most of the time	13 (3.3)
	All the time	64 (16.3)
Select your reasons for not using any form of birth control during sexual intercourse. (if not all the time)	I don’t believe they work	28 (7.1)
	My husband does not believe in them	29 (7.4)
	Our religion does not accept them	23 (5.9)
	Our culture does not support their use	25 (6.4)
	The methods are not safe	30 (7.6)
	The methods are designed to make women sterile	30 (7.6)
	They are too expensive	26 (6.6)
	I do not know if I need to use any method	28 (7.1)
	I do not think I need to use any method	58 (14.8)
	We are currently trying to have a child	52 (13.2)
	Nonresponse	64 (16.3)
Did you (or your partner) use a condom the last time you had sexual intercourse?	Rather not say	0 (0.0)
	No	300 (76.3)
	Yes	93 (23.7)

The chosen contraception from the respondents is depicted in Figure 1. Condoms were the most favorite whether mostly used (34%), used in the past three months (27%) or the week before the survey (22%). Condoms were followed by birth control pills for mostly used (17%) and use in the past three months (11%), but for use in the week before the survey, the withdrawal method came in second at 14%. The most used form of contraception was shown to be no method used at (15%), withdrawal method (11%), and intrauterine device (7%).

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Figure 1:

Forms of contraception used by the respondent by categories.

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Model validation

Model assessment and goodness-of-fit were performed using the Hosmer-Lemeshow test and Nagelkerke R squared. The Nagelkerke R squared= 0.798 (i.e., the model explained 79.8% of the variance of interest) in MPTs, which suggests a good prediction power. The Hosmer-Lemeshow test at Chi-square value = 8.339 (P < 0.05) for this model showed good agreement between the predicted and observed values with 95% of the imputed datasets and, therefore, supports the model’s adequacy for fitting the data. It had adequate prediction power, supported by the overall percentage prediction of 91.3, which indicated that about 91.3% of the cases were correctly classified or predicted by the model at a 0.50 (50.0%) cutoff value [Figure 2]. That is, the model is correct at Chi-square value = 357.623 (P < 0.05), about 9 out of 10 times in predicting interest in MPTs. The performance of the model was assessed using the receiver operating characteristic curve (ROC) based on the saved predicted probabilities. The ROC = 0.780 (95% CI 0.735–0.824) [Table 7], hence, was able to discriminate between women who are interested and those who are not interested in MPTs. The ROC curve is a visual index of the accuracy of interest in MPTs. The further the curve lies above the reference line, the more accurate the test, which can be easily observed from the ROC curve. The model was correctly specified and had an adequate ability to distinguish between individuals who are interested in MPTs and those who are not.

Table 7: Area under the ROC curve based on the saved predicted probabilities.

Test result variable (s): Predicted probability
Area	Std. Errora	P-valueb	95% CI
			Lower Bound	Upper Bound
0.780	0.025	0.001	0.735	0.824

The test result variable (s): Predicted probability has at least one tie between the positive actual state group and the negative actual state group. ^aUnder the nonparametric assumption. ^bNull hypothesis: true area=0.5. ROC: Receiver operating characteristic, CI: Confidence interval

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Figure 2:

Receiver operating characteristic curve (ROC) based on the saved predicted probabilities.

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DISCUSSION

Very few women are practicing informed safer sex and HIV self-testing consistently with their partners in Nigeria compared to the intended targets (95-95-95 target for treatment: 95% of people living with HIV know their HIV status; 95% of people know their status on treatment; and 95% of people on treatment with suppressed viral loads) for stopping HIV transmission.^[13-15] Although this has been incorporated into the national HIV and AIDS strategic framework, many women are unaware of their partner’s HIV status and may not know to protect themselves adequately or know they should use contraceptives consistently.^[16-18] Although HIV self-testing is easy to use, discrete, available, and promotes partner cotesting, benefits to the general population may be limited by lack of adoption. Health infrastructure deficits, multidimensional poverty, and multifactorial inhibitors are barriers that continue to reduce the impact of these interventions.^[19].

Many women in this study may have overestimated their own health safety. For example, more women reported condomless sex than those who reported being worried (at least “often”) about contracting HIV, STIs or becoming pregnant. This consideration is consistent with the low STI testing reported by respondents. Sexually active women aged 30–50 years, who had formal education, did not have a discordant partner and had a high self-perceived risk of unintended pregnancy are more likely to have an interest in MPTs. In a previous study, Hynes et al. found no association between age, self-perceived HIV risk factors, and interest in MPTs among sexually active women in the US.^[13] There is still a high preponderance of condomless sexual contact exposing many females to sexual and reproductive health risks. This risk exacerbates the already higher biological risk for HIV transmission that women suffer.^[14,15] In many African countries, sociocultural norms, values, the power imbalance between men and women, and practices that promote gender inequality may contribute to the continued high prevalence of risky sex practices. These barriers and challenges also contribute to the generally poor uptake of modern contraceptives among women, adherence, and consistency.

There is a high unmet need for contraceptives among sexually active women (respondents) in this study (26.5%). Women are said to have an unmet contraceptive need if they say, they would prefer to avoid a pregnancy but are not using a contraceptive.^[20] This is higher than the reported 16% of the NDHS, a more representative survey.^[21] Condoms were the most used form of contraception reported by respondents in all-time considerations, similar to NDHS survey reports in 2008 and 2013.^[21] This may be related to the multiple benefits associated with its use (e.g., STI protection and pregnancy prevention). Condoms can be used discreetly, are effective when used appropriately, are widely available without medical consultation, and have a lower cost for acquisition and lower medical risk for adverse effects. It should also be noted that in recent studies with sexually active youth in Nigeria, the continued high prevalence of this method was attributed by youth to sociocultural bias, discrimination, and the unwillingness of providers (including gatekeepers) to provide long-acting reversible contraception services to youth.^[22] Barriers to the adoption of modern contraceptives reported in this study align with those reported by Durowade et al. and Asekun-Olarinmoye et al.^[23,24] They include religious bias, partner resistance, sociocultural issues, gaps in knowledge of contraceptives, and costs. Several interventions have been implemented by the government and partners to address these barriers- from behavioral change communication to providing free contraceptives in public health facilities. However, for various reasons including poor health infrastructure, poor funding, and lack of political will, the effect of the interventions has been limited.

In our study, 86% of respondents reported an interest in using MPTs when they become available. The enthusiasm is similar to the 83% reported by Hynes et al. among sexually active women in the US.^[13] This number is, however, lower than the 96% reported by Minnis et al.^[25] Participants in the study by Minnis et al. reported that the simplicity, ease of use, stress, and protection against unforeseen events (e.g., rape, partner infidelity, and condom failure) of MPTs make them desirable.^[25] This desirability, as in this study, was moderated by concerns for safety, sociocultural norms, and biases. Respondents in this study reported safety as the most important consideration for adopting an MPT. This is aligned with the global properties Brady and Tolley posit that may improve the desirability for MPTs over other methods.^[26] Safety and other considerations identified are similar to the elicited barriers to the adoption of modern contraceptives reported by respondents. It is, therefore, important to recognize that developing MPTs without addressing the existing barriers may only result in product substitution and not improve adoption overall.

Respondents also appeared to have rated desirability for prevention of STIs, cost, and duration of action (probably for discreteness of method) over the prevention of pregnancy. Moreover, of interest is that this study found the influence of partners’ opinions and consent to a low influence. This is interesting since, in Nigerian families, sociocultural norms and practices keep women in a lower power dynamic than their partners.^[22] What this signifies is that with increasing privacy, women may indeed be able to disregard their partner’s disapproval and adopt discrete, long-lasting MPTs. Respondents reported interest in using MPTs with daily pills ranking the highest among these products. The preference for everyday pills could stem from the awareness, widespread use of oral contraceptive pills, perceived safety profile of the method, and the perceived ease for the female to maintain control of the choice of MPT without the male partner’s permission pills.^[27-29] This buttresses research supporting the inclusion of PrEP with oral contraceptives for dual protection against both HIV and unplanned pregnancies.^[30,31] Vaginal rings and inserts had lower ratings, and self-administered injections had the lowest rating of interest when compared with pills. However, these findings are inconsistent with the report by Hynes et al. where the most preferred formulations for delivery of PrEP and MPT among women in the US were long-acting injections.^[32]

On-demand protection from HIV, STIs, and unplanned pregnancies was preferred over constant use of MPT. A wide range of research has developed these on-demand products ranging from vaginal rings, freeze-dried inserts, microspheres, gels, etc.^[5,33,34] The limitations arising from coital dependency and user dependency of some of the methods were seen to affect the choice of on-demand MPTs. In evaluating product factors associated with future acceptance, the mean response ratings for safety, effectiveness, privacy, and affordability were very high. The respondents were, however, more concerned with efficacy than side effects arising from MPT use. The affordability of MPTs is critical to the uptake of the product by consumers. It is estimated that 150 million Nigerians live on less than $2 per day, according to the African Development Bank in its Nigerian economic outlook.^[35] Hence, the affordability of an MPT product is critical to its uptake. The Nigerian Federal Ministry of Health, working with the Society for Family Health, provides heavily subsidized birth control medications comprising long-acting injections, IUDs, etc. The HIV treatments, PEP and PrEP are also offered to clients at no cost.^[35] Hence, when MPTs become available, it will be necessary to integrate their use within the current framework utilized to encourage women to adopt them at no more than the current costs of between $0.5 and $20/month.^[36] The overall study population was able to relate to an MPT that mimicked their preferred contraceptive dosage form; hence, the daily pill as an MPT could be deemed the most preferred option in the population studied.

CONCLUSION

The factors that support the future use of MPTs among women in Nigeria include product safety, long-lasting effectiveness at preventing STIs and pregnancy, affordability, and the possibility of privacy. Most of the respondents will prefer MPTs formulated as pills compared to gels, inserts, or injections. The model implies that a unit increase in women aged (30–39) years and (40–49) years, married women, formally educated women, women who are housewives, women who have not had any kind of sexual intercourse with an HIV-positive male partner, and women who have had an unintended pregnancy will have increase interest in MPTs by the respective estimated coefficients. A future direction for the study would be to identify and develop products based on the suggestions from the respondents working towards either ensuring product costs are affordable or developing policies alongside to improve access.