OBJECTIVES. This study examined hormonal contraceptive use and pregnancy in urban Rwandan women, following human immunodeficiency virus (HIV) antibody testing and counseling. METHODS. A sample of 1458 childbearing urban Rwandan women aged 18 to 35 years was tested and followed for 2 years. RESULTS. At enrollment, 17% of 998 HIV-negative women and 11% of 460 HIV-positive women were pregnant, and 17% vs 23%, respectively, were using hormonal contraceptives. One year later, half of the HIV-positive and one third of the HIV-negative hormonal-contraceptive users had discontinued use. The 2-year incidence of pregnancy was 43% in HIV-positive and 58% in HIV-negative women. HIV-positive women with fewer than four children were more likely to become pregnant than those with four or more; this association persisted in multivariate analyses but was not noted among HIV-negative women. At the end of the study, over 40% of non-users said that they would use hormonal contraception if it was provided at the study clinic, but 40% of HIV-positive women desired more children. CONCLUSIONS. Research is needed to identify the practical and psychosocial obstacles to effective long-term contraception among HIV-positive women. HIV counseling programs must specifically address the issue of childbearing.