Female sterilization has become the focus of reproductive rights debate in the past few decades due to an observed increasing trend in its use followed by a decrease after the passing of Law 9263, also known as the Family Planning Law. Both the law and the regulations for its implementation, issued respectively in 1997 and 1999 by the Federal Government , legalized the practice of sterilization and established explicit guidelines for its use
From 1996 to 2006, female sterilization fell among married and cohabiting women between 15–44 years of age from 38.5% in 1996, to 25.9% in 2006 and vasectomies increased from 2.8 to 5.1% [2-4]. However, despite the legal impediments established by the law, female sterilization is still carried out in conjunction with cesarean section and this procedure also have remained the most prevalent way to give birth (5). The prevalence of hormonal oral contraceptive experienced a small increase, from 23.1% to 27.4%, and the use of condoms increased dramatically during the period, from 4.6 in 1996 to 13% in 2006 [3-4].
In fact, during this period Brazil experienced a change in the patterns of contraceptive use due to a number of factors , apart from the Family Planning Law, which are not the focus of this paper, except one: the AIDS epidemic. The rapid increase in the AIDS cases since the 1980s, in Brazil and elsewhere fostered a huge change in sexual practices and brought the use of condoms to the center of the debate on STI prevention . The AIDS epidemic also affected reproductive and sexual practices and choices, especially for women living with HIV.
Brazil has approximately 280,000 officially documented cases of AIDS among women, the vast majority of whom are of reproductive age. Antiretroviral therapy is widely available, and new cases of AIDS are decreasing rapidly among children under one as a result of the prevention of mother-to-child transmission (PMTCT) .
Studies carried out mostly before the implementation of the ACTG 076 protocol , showed divergent findings regarding reproductive outcomes among WLHIV. Higher rates of abortion, a decline in fertility rates, and an increase in voluntary sterilization rates were observed by some of them. However, either no differences or smaller rates in the same outcomes were pointed out by others.
In Brazil, few studies have suggested higher rates of sterilization among HIV-positive women compared to their HIV negative or not HIV tested counterparts [11-14]. Among the general population, female sterilization in Brazil is more prevalent among women in older cohorts, with higher parity, less schooling and among black women. It is easier to have the procedure carried out in combination with a cesarean section and at private hospitals [3-4]. However little is known among specific groups, such as WLHIV, particularly after law regulation.
This study estimates the risk of getting sterilized after HIV diagnosis compared to those not living with HIV. In this sense, it adds further aspects to the current literature about women’s reproductive health, and particularly those living with HIV. To our knowledge, this is the first comparative study to explore the probability of obtaining female sterilization among WLHIV and WNLHIV using a longitudinal analysis
Materials and methods
Data used for this analysis come from GENIH study, which aimed to investigate aspects of sexual and reproductive health of WLHIV and compare them with those of women not living with HIV – WNLHIV (women with HIV seronegative results or unknown status). A cross-sectional quantitative study was conducted between February 2013 and April 2014 in the city of São Paulo, comparing two probabilistic samples of 975 WLHIV and 1,003 WNLHIV users of public health services aged 18 to 49 years.
Given the objectives of this paper, analysis was restricted to women with parity one and more, since sterilization among nulliparous women is extremely rare. WLHIV who were sterilized before diagnosis (n=61) and those who were infected with HIV through vertical transmission (n=20) were also excluded. The final sample analysis included 683 WNLHIV and 690 WLHIV.
Information on female sterilization is used as the dependent variable, considering the age at sterilization. The independent variables used to analyze the risk of obtaining a female sterilization, based on previous studies are: HIV diagnosis, its presence or absence (key variable), schooling at the time of the interview (incomplete elementary and lower, complete elementary and higher), race/color (brown “parda”, black “preta”, white “branca”), and parity at last delivery (1-2, 3+).
The occurrence of female sterilization, was analyzed as follows. Firstly, we calculated the frequency of female sterilization by parity, educational attainment, race/ethnicity and type of procedure for each group (WLHIV and WNLHIV). Secondly, the probability of being sterilized once HIV diagnosed as compared to those not diagnosed was estimated by using hazard models. For this analysis, we fitted multivariable-adjusted Cox models to calculate hazard ratios for obtaining the procedure and respective 95% confidence intervals. The interval width (in years) was calculated from age 15, when almost all of them have no children, until the time of the interview (censored data) or female sterilization (event). In cases where no sexual intercourse was reported in the 12 months preceding the interview, women were censured at the time of the last sexual intercourse. The analysis consisted of two models that took into account the parity of women.
All statistics were estimated taking into account the sample design of the study and analysis were conducted using SPSS 20.0 and STATA 14.0. The project was approved by Institutional Review Boards of all institutions participating in the study, and an informed consent form was signed by all women.
Results and discussion
Among women with at least one child, 19.6% of WLHIV had ended their reproductive trajectory through sterilization after HIV diagnosis, compared to 16% of WNLHIV. For the majority, sterilization was performed in conjunction with cesarean sections in both groups, but its proportion is higher among WLHIV (78.3% versus 58.7% among WNLHIV).
Table 1 Hazard ratios for female sterilizations by HIV status, education and color/race, and stratified by parity. São Paulo, 2013-14.
0.88 (0.54 - 1.43)
0.94 (0.69 - 1.29)
Incomplete elementary and lower
1.66 (1.05 - 2.64)*
1.01 (0.68 - 1.48)
Complete elementary and higher (ref)
1.51 (0.93 - 2.45)
0.86 (0.60 - 1.25)
2.86 (1.49 - 5.46)**
0.95 (0.57 - 1.58)
White (“branca”) (ref)
* p<0.05; ** p<0.005; p<0.0001
The hazard model indicates no statistical difference in the risk of female sterilization between WLHIV and WNLHIV in both parity-related groups (Table 1).
Women with less them elementary school were two times more likely (p=0.038) to have female sterilization among those with lower parity. Black women were almost three times more likely (p=0.013) to have the procedure among those with the same parity.
The cumulative probability of having an sterilization is much higher among women with three or more children with no difference between WLHIV and WNLHIV (Fig 1).
Fig 1 Cumulative probability of sterilization from models in Table 1 for women living and not living with HIV. São Paulo, 2013-14
One previous study comparing female sterilization between WLHIV and WNLHIV in Brazil identified higher prevalence of the procedure among women living with HIV compared to those not living with HIV . However, this study did not consider information such as age, education or parity, and whether sterilization was carried out before or after HIV diagnosis, which makes comparison with our results very difficult.
A possible explanation for the differences between our results and previous findings would have been a decrease in the prevalence of sterilization among women living with HIV, similar to what has happened among the general female population in Brazil . Several studies have argued as to whether part of this decline is due to a decrease in demand for sterilization, or the difficulties introduced by the Family Planning Law in the process of having such a procedure [2-3]. In the case of WLHIV, it is also possible to assume that this decrease contains an additional element: it may be related to the advent of antiretroviral therapy and the success of the most effective antiretroviral regimens for prophylactic prevention of mother-to-child transmission .
The advent of antiretroviral therapy has turned AIDS into a chronic disease, and has offered the possibility of longer and healthier lives for women living with HIV. Advances in HIV treatment and prevention technologies have changed the context within which women decide whether or not to have children, and has thus expanded the realm of options for HIV-positive individuals, and in doing so, may have contributed to the decrease in the use of irreversible methods such as tubal ligation. In Brazil, reliable and widened access to HIV treatment and prevention  concurred with the implementation of the Family Planning Law from 1996 to 2000 .
Finally, the much higher proportion of sterilization performed in conjunction with cesarean sections observed among WLHIV deserves further analysis. For instance, modeling postpartum sterilizations separately from interval procedures, would give us a much more complex scenario regarding the association between HIV infection and female sterilization.
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