Number of pregnancies, outcome expectancies, and social norms among HIV-infected young women

The Experience of Pregnancy in Women Living With HIV: A Meta-Synthesis of Qualitative Evidence

The lived experience of pregnancy from the perspectives of women living with HIV (WLWH) is not well understood. We aimed to understand the meaning of pregnancy for WLWH. A meta-synthesis was conducted to review and integrate qualitative studies about the phenomena; 12 databases were used to perform the search in English, Spanish, and Portuguese. Articles using qualitative methods published in peer-reviewed journals were included. Data were analyzed using the meta-synthesis method. We found that, for pregnant WLWH, pregnancy evolved as a mediated experience of commitment and dedication. The vital life experience of pregnancy was defined as an interplay of emotions, coping strategies, and feelings of satisfaction. Pregnancy in WLWH was experienced and impacted by societal beliefs, as the women focused all their efforts to take care of themselves and their babies.

African American Women and AIDS: Factors Influencing Risk and Reaction to HIV Disease

African American women represent the fastest growing group of individuals infected with HIV in the United States. Social and contextual influences on HIV risk vulnerability in this group are discussed, with particular emphasis on risk behaviors related to heterosexual contact and injection drug use. Social factors associated with the sex-ratio imbalance and low rates of condom use in the African American community are addressed, as are contextual influences related to environmental stress and psychosocial issues. We describe interventions that directly address both social and contextual influences on African American women’s risk behaviors. Finally, mental health and psychological concerns are presented as a framework for better understanding women’s reactions to HIV/AIDS and for developing comprehensive programs and services that better meet their needs.

Reasons and Justifications for Considering Pregnancy Among Women Living With Hiv/Aids

Despite the risks associated with pregnancy, available data suggest that HIV-infected women are no less likely to become pregnant than uninfected women. To understand HIV-infected women's reasons for wanting to have a child, focused interviews were conducted with a predominantly minority sample of 51 HIV-infected women in New York City. They were noted to actively weigh both the potential risks and benefits of their pregnancy decisions. Women reported three major reasons for wanting a child: (1) her husband/boyfriend really wants children, (2) having missed out on raising her other children, and (3) believing that a child would make her feel complete, fulfilled, and happy. Women also reported several justifications that they believed offset the risks of pregnancy, including: (1) other HIV-infected women were having healthy babies, (2) feeling optimistic about having a healthy baby due to the prophylactic effects of AZT (zidovudine), (3) having faith that God will protect the child, (4) being young and “healthy” will prevent transmission, and (5) feeling that she is better able to raise a child now. These findings suggest that to make fully informed pregnancy decisions, women should be encouraged to explore their reasons for wanting pregnancy, as well as discuss the potential risks.

Behavioral interventions to promote condom use among women living with HIV

BACKGROUND

High rates of HIV infection among women of reproductive age have dramatic consequences for personal and public health. Prophylaxis during sexual intercourse in the form of condoms has been the most effective way to prevent both STI and HIV transmission among people living with HIV.

OBJECTIVES

To investigate the effectiveness of behavioral interventions in promoting condom use among women living with HIV.

SEARCH STRATEGY

We conducted a comprehensive literature search in several scientific databases, clinical trials databases, conference proceedings, and conference websites to identify studies produced between 1980 and May 2010 that met our selection criteria.

SELECTION CRITERIA

Studies were included in the analysis if they conducted a randomized controlled trial that examined the effects of behavioral interventions on condom use among HIV-positive women; considered at least one HIV-related behavioral outcome (e.g., reported protected anal, vaginal, or oral sex) or biological outcome (e.g., acquisition of STIs); and one follow-up assessment three months or more after the intervention. Studies were assessed irregardless of langauge or publication status.

DATA COLLECTION AND ANALYSIS

We used random effects models to summarize odds ratios (ORs) that compared intervention and control groups with respect to a dichotomous outcome (consistent versus inconsistent condom use). We used funnel plots to examine publication bias and a χ(2) statistic to test for heterogeneity. The methodological and evidence quality was evaluated through risk of bias criteria and the GRADE system, respectively.

MAIN RESULTS

Five primary studies that collectively researched a total of 725 women living with HIV were analysed. When compared to standard care or minimal HIV support intervention, meta-analysis showed that behavioral interventions had no effect on increasing condom use among HIV-positive women. This finding was consistent at various follow-up meetings (3, 6, and 12-months) as well as over the entire 12-month follow-up period (OR= 0.82; 95% CI 0.65-1.04; p=0.11). Only one study presented adequate data to analyze the relationship between behavioral interventions and STI incidence. Studies included in this analysis demonstrated low risk of bias based on the risk of bias criteria. However, sample size was considered inadequate across all studies.

AUTHORS' CONCLUSIONS

Meta-analysis shows that behavioral interventions have little effect on increasing condom use among HIV-positive women. However, these findings should be used with caution since results were based on a few small trials that were targeted specifically towards HIV-positive women. To decrease sexual transmission of HIV among this population, we recommend interventions that combine condom promotion, family planning provision and counselling, and efforts to reduce viral loads among HIV-positive women and their partners (e.g., HAART treatment provision). New research is needed to address the needs of HIV-positive women, including an assessment of the impact of interventions that combine safer sexual behavior and harm reduction approaches.

Reproductive decisions for women with HIV: motherhood's role in envisioning a future

Cultural influences might exert more influence on HIV-positive women's reproductive choices than HIV-related conditions. In this article we report on grounded theory research on how women with HIV made reproductive decisions during a time of transition from HIV as potentially fatal to mothers and newborns to its current status as an often controllable chronic illness. Eighty HIV-positive women of childbearing age in three United States cities were interviewed, and the interviews were analyzed using grounded theory techniques. The core concept of the findings was that women's decisions were based on their judgment of the relative weight of positive aspects of motherhood versus the often negative pressures of social and public opinion. These findings have relevance for future research as well as for program development and policy.

Pregnancy decisions among women with HIV

Nearly 80% of women currently infected with HIV are of childbearing age. As women of childbearing age continue to be at risk of contracting HIV, there will be an increased need for choices about whether or not to have biological children. The purpose of this exploratory study was to investigate the influence of partners, physicians, and family members on pregnancy decisions, as well as the impact of HIV stigma on these decisions. Results indicated that most women chose not to become pregnant since learning their HIV diagnosis and the woman's age at the time of diagnosis is significantly associated with this decision. Additional factors included fear of transmitting HIV to their child, personal health-related concerns, and desire to have children. Women with a procreative inclination were more likely to choose to become pregnant which outweighed social support and personal health concerns. Implications and suggestions for future research are noted.

Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection

The objective of the study was to characterize human immunodeficiency virus (HIV)-seropositive pregnant adolescents according to maternal reproductive, behavioral, and psychosocial characteristics. Data were derived from the national HIV/AIDS Reporting System (HARS, 2001-2004) and the Perinatal Guidelines Evaluation Project (PGEP, 1997-1999). Births to HIV-seropositive 13- to 21-year-olds reported to HARS via pediatric case report forms, and HIV-seropositive pregnant adolescents (aged 13- 21 years) who participated in PGEP were identified and characterized. In the 28 states with confidential, name-based perinatal HIV exposure reporting, 1183 live births occurred to 1090 seropositive adolescents. Fifteen births were to perinatally HIV-infected adolescents. HIV serostatus was known before the index pregnancy in half the cases (52.6% and 49.2% in HARS and PGEP, respectively). Of seropositive PGEP adolescents, 67% were previously pregnant; most pregnancies (83.3%) were unplanned. Many HIV-seropositive pregnant adolescents were aware of their serostatus when they became pregnant. Pregnancy and transmission risk reduction interventions targeting young seropositive females are needed.

Aspectos psicológicos da gestação e da maternidade no contexto da infecção pelo HIV/Aids

A epidemia de HIV/aids tem atingido cada vez mais mulheres em idade reprodutiva, sendo que muitas já são mães ou se tornam mães quando descobrem a infecção. Os estudos revisados indicam que a infecção pelo HIV/Aids pode alterar de muitas formas a experiência da gestação e da maternidade, gerando uma sobrecarga psicológica relacionada ao estigma e ao risco de transmissão para a criança. Apesar disso, pesquisas sugerem que muitas mulheres portadoras do HIV/Aids buscam transmitir uma identidade materna positiva para os filhos e se preocupam intensamente com o futuro deles. Foram encontrados poucos estudos brasileiros sobre aspectos psicológicos da maternidade nesse contexto, em especial a respeito do impacto da profilaxia para prevenção da transmissão vertical sobre a experiência da gestação, do parto e do puerpério. As dificuldades em aderir ao tratamento e a práticas sexuais seguras denotam a falta de atenção às demandas específicas dessas mães, sendo que o foco das políticas de saúde permanece sobretudo dirigido para a criança.

"He won't use condoms": HIV-infected women's struggles in primary relationships with serodiscordant partners

We investigated the sexual behaviors of 55 HIV-infected women in Wisconsin who narrated their lives in 10 interviews over 2 years during 2000 to 2003. We sought to examine the interpersonal situations in which sexual risk occurred. During the prospective period, 58% (32) were abstinent and 24% (13) practiced safe sex exclusively. The remaining 18% (10) engaged in unprotected sexual intercourse, but only in primary partnerships, almost all of which were with serodiscordant partners. We focused on experiential detail and narrative depth of 10 women who had sex without condoms. These narratives demonstrate how the women attempted to initiate condom use but engaged in unprotected sexual intercourse regularly at the insistence of their partners. Consequently, these women lived in trepidation of causing their partners' sickness and death.

Caring for adolescents with HIV

Adolescents comprise a growing proportion of people diagnosed with HIV or AIDS. Navigating adolescence while infected with HIV presents specific challenges not only to the youth but to their families and caregivers. As children enter their teen years, they have medical, physiologic, and psychosocial issues that differ greatly from both younger children and young adults. These issues include the limited number of medications available, mental illness (especially depression), and psychosocial issues such as distorted body image, sexual awareness, and problems with family and peer relations. Many of these issues are heightened in this population and can be important factors that can influence adherence. Awareness of these issues is important for health care providers, for if they understand not just the illness itself, but the psychosocial issues of the patient they are treating, the clinician can optimize treatments and adherence, and help these young persons successfully transition into adulthood.

Limitations in knowledge of HIV transmission among HIV-positive patients accessing case management services in a resource-poor setting

HIV has increasingly become an infection of poverty. Adequate HIV transmission knowledge among HIV-positive patients is necessary to reduce the risk of secondary infection and protect those who are uninfected from transmission. This study was conducted among individuals enrolled in a program that serves impoverished HIV patients in the Boston area. Although the mean HIV transmission knowledge score was 80% for this group, a significant proportion of patients demonstrated limitations in knowledge of HIV transmission. Highly vulnerable patients, such as those who reported not accessing HIV medications, a history of sexual abuse, or problems getting clothing, had lower levels of HIV knowledge. This paper hopes to alert providers that their most vulnerable patients may be at an increased risk of re-infection or transmission due to limited HIV knowledge. Programs that serve HIV-positive patients coping with poverty and other serious problems need to ensure adequate knowledge of HIV transmission to reduce the overall burden of HIV in resource-poor settings.

Newly homeless youth STD testing patterns over time

PURPOSE

To use the Behavioral Model for Vulnerable Populations to examine the predisposing and need characteristics of newly homeless youth that are associated with sexually transmitted disease (STD) testing over time.

METHODS

A longitudinal cohort of newly homeless youth from Los Angeles County (n = 261; ages 12-20 years) were followed for 24 months. Youth were interviewed at baseline, 3, 6, 12, 18, and 24 months, and asked about their background, housing situation, emotional distress (using the Brief-Symptom Inventory), substance use, sexual risk behaviors, and their STD testing rates. We modeled our longitudinal data using logistic random effects models.

RESULTS

Characteristics of homeless youth that were associated with STD testing in our multivariate model included time in study (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1-1.6), age at baseline (OR 1.2, 95% CI 1.1-1.4), being African-American (OR 2.7, 95% CI 1.4-5.3), being from a mixed race/ethnic group (OR 2.8, 95% CI 1.3-5.8), self-identifying as a gay/bisexual male (OR 2.9, 95% CI 1.2-6.9), self-identifying as a heterosexual female (OR 2.2, 95% CI 1.3-3.7), using amphetamines (OR 1.7, 95% CI 1.1-2.6), and history of having gotten someone/becoming pregnant (OR 2.3, 95% CI 1.4-3.9). Youth who lived in an apartment were less likely to have received an STD test than youth who lived in other types of housing (OR .4, 95% CI .2-.9). Sexual risk behaviors such as inconsistent condom use (OR 1.0, 95% CI .6-1.4) and number of sexual partners over past 3 months (OR 1.1, 95% CI 1.0-1.1) were not predictive of STD testing over time.

CONCLUSIONS

A need exists for interventions to target young newly homeless youth who engage in high-risk sexual behaviors to increase their STD testing rates and thereby decrease their risk for HIV infection.

Predictors of sexually transmitted infection testing among sexually active homeless youth

We examined the association between sexual risk behaviors and sexually transmitted infection (STI) testing in a sample of homeless youth. Of 261 youth interviewed, 50% had been sexually active in the past 3 months. Gender variation in sexual behaviors and risk were found. Boys were more likely than girls to engage in anal sex (46% vs. 15%), to have 3 or more sexual partners (46% vs. 17%) and to engage in anonymous sex (38% vs. 21%). Girls were less likely to use condoms consistently and more likely to engage in sex with a partner suspected of having an STI (20% vs. 4%). In the past 3 months, the STI testing rates were similar for boys and girls (46%). However, girls were more likely to have positive STI results (46% vs. 9%). In a multivariate logistic regression analysis, the only variable that was an independent predictor of STI testing was having either gotten someone or having become pregnant in the past 3 months. High-risk sexual behaviors did not predict STI testing in our sample. Outreach programs are needed that target sexually active homeless youth for early STI testing and treatment.

To reproduce or not: HIV-concordant couples make a critical decision during pregnancy

Making decisions about whether to keep or terminate a pregnancy is an emotionally laden process for any woman. The purpose of this study was to explore gender-based power relationships and cultural influences on reproductive decision making during pregnancy among 4 HIV-concordant couples in Taiwan. Feminist ethnography was used to explore how reproductive decisions were made during pregnancy. The study findings showed that the process of a couple's decision making about their desired outcome of pregnancy can be categorized as occurring in 3 stages: shaping the meaning of the pregnancy, encountering medical systems, and structuring decisions. These Taiwanese couples interpreted the meaning of their pregnancy as a "kindly" reminder from God, to make them aware of the HIV status, and having a child as a way for them to demonstrate filial piety. A couple's perception of substantial support from senior family members and from health care providers was crucial to the decision to continue the pregnancy to term. The Confucian value of filial piety drove the couples' reproductive decisions during pregnancy.

Longitudinal study of mental health and psychosocial predictors of medical treatment adherence in mothers living with HIV disease

Cross-sectional studies to date that examine psychosocial correlates of antiretroviral adherence have insufficiently addressed the challenges of long-term adherence. This longitudinal study examined mental health, substance abuse, and psychosocial predictors of long-term adherence to antiretroviral medications and medical appointments among HIV-seropositive mothers recruited from an infectious disease clinic of a large urban medical center. Individual interviews were conducted at baseline and two follow-up points, 8 to 18 months after enrollment. Based on a model of health behavior, we examined psychiatric and psychosocial predictors of adherence to antiretroviral medications and medical appointments over time. Presence of a psychiatric disorder, negative stressful life events, more household members, and parenting stress were significantly associated with both missed pills and missed medical appointments at follow-up. Baseline substance abuse was associated with missed pills at follow-up and lack of disclosure to family members at baseline was associated with missed medical appointments at follow-up. These findings suggest that interventions that integrate mental health, substance abuse and medical care may be important to improving the medical adherence and health of HIV-seropositive women, particularly in multistressed populations with substantial caregiving and other life demands.

Factors affecting reproductive decisions of African American women living with HIV

PURPOSE

This exploratory study used focus groups to examine attitudes and beliefs of HIV-infected African American women of child-bearing age about pregnancy and antiretroviral therapy.

METHODS

A convenience sample of thirty-three African American women of child-bearing age participated in five focus groups. Attitudes and beliefs about pregnancy decisions and the use of antiretroviral therapy during pregnancy were examined.

RESULTS

Many of the women in this study living with HIV remained committed to having children and expressed confusion about their chances of transmitting the virus to their children.

CONCLUSIONS

Health care providers must be aware of these concerns and convey clear and accurate information through the most readily accepted channels. Participants suggested that messages about these issues be conveyed by other women living with HIV who have faced these same decisions.

HIV infection and pregnancy status among adults attending voluntary counseling and testing in 2 developing countries

OBJECTIVES

This study investigated the impact of HIV voluntary counseling and testing (VCT) on reproduction planning among 1634 adults in 2 sub-Saharan countries.

METHODS

Data were obtained from a multisite randomized controlled trial.

RESULTS

At 6 months post-VCT, the women more likely to be pregnant were younger (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.0, 6.5), not using contraceptives (OR = 0.1; 95% CI = 0.1, 0.3), and HIV infected (OR = 3.0; 95% CI = 1.3, 7.0). An interaction emerged linking pregnancy intention at baseline and HIV serostatus with pregnancy at follow-up (OR = 0.1; 95% CI =.0, 0.4) Partner pregnancy rates did not differ by HIV serostatus among men.

CONCLUSIONS

HIV diagnosis may influence reproduction planning for women but not for men.

Factors influencing intent to get pregnant in HIV-infected women living in the southern USA

This descriptive study sought to identify factors that influence HIV-infected women's intent to get pregnant. Interviews were conducted with a convenience sample of n = 322 HIV-infected women at risk for pregnancy. Participants were predominantly African-American (84.4%), single (57.9%), and ranged in age from 17 to 48 years. Forty per cent (n = 128) of the women had been pregnant since becoming HIV-positive. Potential factors influencing intent to get pregnant that were examined included demographic characteristics, HIV-related factors and personal beliefs and attitudes. In simple logistic regression models, younger age, increased motivation for child bearing, decreased perceived threat of HIV, decreased HIV symptomatology, higher traditional gender role orientation, and greater avoidance coping were all associated with greater intent to get pregnant. Following a model selection procedure, motivation for child bearing (OR = 16.05, 95% CI 7.95, 30.41) and traditional sex roles (OR = 4.49, 95% CI 1.44, 13.55) were significantly associated with greater intent to get pregnant. Traditional gender role orientation and motivation for childbearing are significant factors in predicting intent to get pregnant among HIV-infected women. These factors, as well as other non HIV-related factors, need to be routinely assessed by health care providers in developing plans of care for HIV-infected women.

Incident pregnancy rates in HIV infected and HIV uninfected at-risk adolescents

PURPOSE

To compare pregnancy incidence between HIV infected and HIV uninfected adolescents over a 3-year period and to characterize factors that differentiate pregnant from nonpregnant HIV infected females.

METHODS

Female adolescents enrolled in Reaching for Excellence in Adolescent Care and Health (REACH), a national cohort study, and nonpregnant at baseline comprised the sample (n = 345). Subject information on pregnancy, risk behavior, and psychosocial characteristics was obtained through interview, chart review, physical examination and laboratory data collected every 3 months. Incident pregnancy rate was analyzed using Cox proportional hazards modeling; the predictors of incident pregnancy were evaluated using repeated measures analysis.

RESULTS

Ninety-four pregnancies were identified over 3 years. No significant difference in pregnancy incidence was detected between HIV infected and uninfected females (20.6 and 28.4 per 100 person-years, respectively, p = .16). However, for adolescents with living children at entry, HIV infected females were significantly less likely to become pregnant than HIV uninfected (HR = .45; p = .03). Among HIV infected adolescents, significant predictors of incident pregnancy were older age (p = .01) and not using hormonal contraception (p = .00), whereas increased spiritual hope and passive problem-solving capacity were protective against pregnancy (p = .02, and.05, respectively). Multivariate analysis revealed pregnancy prior to study entry to be predictive for (OR = 3.0; 95% CI: 1.2-7.7), and increased spiritual hope to be protective (OR = .4; 95% CI: .2-.9) against incident pregnancy in HIV infected females without the hormonal contraceptive variable in the model.

CONCLUSIONS

The pregnancy rate is high in this study population. Further research is needed into its determinants and attenuating factors, particularly the role of spiritual elements, to design better contraceptive services and reproduction-related education targeting high-risk youth.