Evaluating the competing risks of HIV acquisition and maternal mortality in Africa: a decision analysis.

OBJECTIVE: To model the risk of HIV acquisition and maternal mortality for women in four African countries in the light of previous data on risk of HIV acquisition and hormonal contraceptive use.
DESIGN: Decision analysis.
SETTING: Chad, Kenya, South Africa and Uganda. POPULATION: Women of reproductive age, at risk of HIV, who do not desire pregnancy.
METHODS: A decision analysis model was built to compare the consequences of removing progestin injectables from use, assuming an increased risk of HIV acquisition. Three scenarios were considered in four African countries: replacement of progestin injectables with no method, with combined oral contraceptives (COC) or with an intrauterine device (IUD). Health outcomes measured include: life-years, maternal mortality, HIV acquisition and unsafe abortion. Sensitivity analysis, including Monte Carlo simulation, was performed around all variables. MAIN OUTCOME MEASURES: HIV acquisition, maternal mortality and life-years.
RESULTS: If progestin injectables are removed from use, without a minimum of 70-100% of women switching to an IUD or COCs, up to nine additional maternal deaths will occur for every case of HIV averted. Sensitivity analysis demonstrated that this finding persisted across a broad range of variables.
CONCLUSIONS: Contraception is critical to preserving life for women in Africa. In the absence of clear evidence regarding hormonal contraception and HIV acquisition, policy decisions must not overlook the very real risk of maternal mortality.