Broadening the discussion: Addressing contraception and safer conception with female sex workers in Tanzania

1 June 2018


“When I was diagnosed in 1994, we were told not to have any relationships or to think of having a child. Now there are more options so women and service providers need to be updated.”


As this person living with HIV advocate from Tanzania correctly observes, during the last three decades of the HIV epidemic, there has been a dramatic evolution in the way providers and programs can address family planning and reproductive health for women living with HIV. What started as a blanket admonition to abstain from sex has evolved into a growing need for a broader discussion about women’s fertility desires in light of new biomedical and behavioral strategies for minimizing the risk of transmission to the HIV-negative partner and to the baby.


Family planning counseling for women living with HIV must not only meet their need for contraception, but address their desire to have children safely, either now or someday.


Little is known, however, about women’s and providers’ awareness of biomedical and behavioral advances and the fertility intentions of different populations of HIV-positive women of reproductive age, such as sex workers.


Project SOAR is conducting implementation science research in Dar es Salaam, Tanzania, to help meet these knowledge gaps. Specifically, SOAR aims to better understand the holistic family planning needs of HIV-positive female sex workers, ages 18–49, and to examine how well community-based reproductive health services help these women avoid pregnancy or conceive safely.


In Tanzania, national guidelines recommend providing family planning and “safer pregnancy” counseling services for women living with HIV, as well as integrated reproductive health services for women who sell sex.


“We are interested in finding out whether and how HIV services address and support these women’s need to prevent unwanted pregnancy, as well as to plan for a safer pregnancy if desired” explained Eileen Yam of the Population Council, the study’s principal investigator. “Now that effective treatment is available for women living with HIV, there is growing recognition that the scope of family planning counseling needs to go beyond contraception; at some point, most of these women want to have children.”


To gain a preliminary picture of the situation, Dr. Yam first conducted a secondary analysis of data on contraceptive need and fertility intentions among a sample of more than 600 FSWs living with HIV in Njombe and Mbeya provinces, participants in a separate ongoing study. The analysis confirmed that women living with HIV who sell sex have both a need for contraception and a desire to have (more) children now or in the future.


About half of the sample (52 percent) already had two or more children. More than two-thirds of respondents (72 percent) did not want to get pregnant in the next two years. Yet, 30 percent had an unmet need for contraception—they were neither consistent condom users nor users of an effective non-barrier method. At the same time 21 percent were trying to get pregnant and another 20 percent wanted to have a/nother child someday. Yet few women knew about strategies to get pregnant more safely such as use of ART by the HIV-positive partner and self- insemination with sperm from an HIV-negative male partner.


“Our study in Dar es Salaam is helping us go deeper in understanding the realities and experiences of HIV-positive female sex workers and of the health workers who provide integrated family planning and HIV services to them,” noted Catherine Kahabuka of CSK Research, a study co-investigator.


In addition to Drs. Yam and Kahabuka, the research team includes representatives from Sauti—the implementing organization—and the Reproductive and Child Health Section of the Ministry of Health.


“What has impressed me about this SOAR study are its efforts to bridge the gap between research, programming, and policy through early and meaningful involvement of Sauti and the Ministry of Health,” explained Dr. Kahabuka. “These efforts have included consultations around study design and visits to the study sites.”


The Dar es Salaam study consists of client exit interviews with 300 female sex workers, observations of provider/client consultations, and qualitative interviews with providers and female sex workers who wish to become pregnant.


Initial findings from Sauti health providers reveal that they are very conversant in and comfortable with providing contraceptive counseling. In addition, they are generally supportive of women’s desire to have children, although they have gaps in their understanding of safer conception strategies, highlighting the need for further training.


“You cannot tell one not to have a child just because she has contracted HIV at an early age.”


“Some providers tend to avoid such questions due to lack of knowledge. If service providers are not trained on how to talk to them, they will not find it important to talk about fertility desires.”


These and other findings are helping to inform Sauti’s integrated HIV/FP services, while providing evidence in support of the growing body of global and regional guidance on sexual and reproductive health and rights for women living with HIV.


Further analysis of the data is continuing and additional results are expected in mid-2018.


Related resources:
Female sex workers living with HIV in Tanzania have both a need for contraception and a desire to have children in the future

Are services meeting the holistic family planning needs of female sex workers living with HIV in Tanzania?


Photo courtesy of CSK Research Solutions