Factors that predict fertility desires for people living with HIV infection at a support and treatment centre in Kabale, Uganda

Fertility Desire and Associations with Condomless Sex, Antiretroviral Adherence, and Transmission Potential in a Cohort of Kenyan Women Living with HIV in Sero-discordant Relationships: A Mixed Methods Study

For women living with HIV (WLH) in serodiscordant partnerships, decisions about childbearing can challenge condom use and antiretroviral adherence. In a prospective cohort of 148 WLH in serodiscordant partnerships, 58 (39%) wanted more children in the future but were not currently trying to conceive (fertility desire), and 32 (22%) were currently trying to become pregnant (fertility intent). Detection of prostate specific antigen (PSA) in vaginal secretions, a marker for recent condomless sex, was lowest in women with fertility desire and highest in women with fertility intent. Detectable viral load followed a similar pattern. Risk of HIV transmission, when condomless sex and PSA detection occurred concurrently, was three to fourfold higher at visits with fertility intent compared to visits with fertility desire. Qualitative interviews underscored the importance women place on childbearing and suggested that they had limited information about the role of antiretroviral therapy in reducing sexual HIV transmission.

Fertility desire of HIV-positive men and women in public health hospitals

Objective:

Despite the increased emphasis on antiretroviral therapy and other healthcare services for HIV-infected individuals, issues of fertility desire have received relatively little attention. In particular, little is known about actual fertility desire and determinants of fertility desires among HIV-infected women and men receiving antiretroviral therapy.

Methods:

A cross-sectional study was conducted among HIV-positive individuals in public health hospitals of Addis Ababa City from 1 October to 30 November 2021. A pretested structured questionnaire was used to collect the data with a consecutive sampling technique. EpiData 4.6.2 and SPSS 25 were used for data entry and analysis. Bivariate and multivariable logistic regression analyses were done to identify factors associated with fertility desire. An adjusted odds ratio with a 95% confidence interval was computed for data interpretation. A p value of ⩽0.05 was considered to be statistically significant.

Result:

Among 400 participants, 55% (95% confidence interval = 50%, 60%) have future fertility desire. Factors like age less than 35 years (adjusted odds ratio = 24.03, 95% confidence interval = 9.99, 57.83), a secondary education level (adjusted odds ratio = 2.78, 95% confidence interval = 1.21, 6.40), being married (adjusted odds ratio = 2.89, 95% confidence interval = 1.39, 5.99), being employed (adjusted odds ratio = 3.12, 95% confidence interval = 1.56, 6.24), being diagnosed with HIV in the past 1 year (adjusted odds ratio = 4.02, 95% confidence interval 2.07, 7.80) or past 2–4 years (adjusted odds ratio = 9.80, 95% confidence interval = 3.89, 26.02) have a significant association with future fertility desire. Respondents using contraceptives were 90.9% less likely to have future fertility desire (adjusted odds ratio = 0.09, 95% confidence interval = 0.05, 0.18).

Conclusion:

The magnitude of future fertility desire was founded high. Further research on this topic should include qualitative studies to provide a deeper understanding of people living with HIV fertility desires.

"Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches

Background

Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC.

Methods

In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy.

Results

The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2.

Conclusions

More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach.

Trial registration

Clinicaltrials.gov, NCT03167879; date registered May 23, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01109-z.

Prevalence and factors associated with fertility desire among people living with HIV: A systematic review and meta-analysis

BACKGROUND

The fertility desire of people living with HIV (PLHIV) has been rising in the past decade. However, there are many studies among which the association remains controversial between the fertility desire of HIV-infected persons and antiretroviral therapy (ART), sex, marital status, and educational level.

METHODS

We performed a literature search of these meta-analyses in PubMed, the Cochrane Library, Web of Science and ScienceDirect in November 2019. We also reviewed references of eligible studies to complement the search. We used pooled odds ratios (ORs) and 95% confidence intervals (CIs) with a random-effects model and a fixed-effects model to estimate the association between fertility desire among PLHIV and ART, sex, age, marital status, educational level, and number of children. Subgroups with I square values (I2) and sensitivity analyses were performed to assess the heterogeneity and the stability of the overall ORs, respectively. We evaluated publication bias using Egger's test and a visual inspection of the symmetry in funnel plots.

RESULTS

In these meta-analyses 50 articles were included with 22,367 subjects. The pooled prevalence of fertility desire among PLHIV was estimated to be 42.04%. The pooled analyses showed that the fertility desire of PLHIV is associated with ART (OR = 1.11, 95% CI:1.00-1.23, P = 0.043), sex (OR = 1.51, 95% CI:1.10-2.09), age (OR = 2.65, 95% CI:2.24-3.14), marital status (OR = 1.34, 95% CI:1.08-1.66), educational level (OR = 0.85, 95% CI:0.73-1.00, P = 0.047) and the number of children (OR = 3.99, 95% CI:3.06-5.20). PLHIV who are on ART, are male, are younger than 30, are married/cohabiting, have received a secondary education or above, and are childless have a higher prevalence of fertility desire. The two factors of age and the number of children, in particular demonstrated a strong significant association with fertility desire. We found moderate heterogeneity in the meta-analyses of age and educational level and high heterogeneity in the meta-analyses of sex, marital status and number of children. Publication bias was detected in the meta-analyses of the association of fertility with sex and educational level.

CONCLUSION

This study demonstrates that the prevalence of fertility desire among HIV-infected people is 42.04%, and the fertility desire among PLHIV is associated with ART experience, sex, age, marital status, the number of children, and educational level. Since a majority of PLHIV are of reproductive age, it is necessary to support PLHIV in terms of their needs regarding reproductive decision-making. Through counseling and reproductive health care, further measures to prevent the horizontal and vertical transmission of HIV should be taken.

Reproductive intentions and corresponding use of safer conception methods and contraception among Ugandan HIV clients in serodiscordant relationships

Context

Among people living with HIV in Uganda, desires to have a child and unplanned pregnancies are both common, while utilization of safer conception methods (SCM) and modern contraceptives are low.

Methods

Three hundred eighty-nine HIV clients who reported considering childbearing with their uninfected partner enrolled in a safer conception counseling intervention trial in Uganda. Multiple regression analysis and baseline data were used to examine correlates of reproductive intentions and behaviors, including use of safer conception methods and contraception.

Results

Most (n = 313; 80.5%) reported that both they and their partner wanted to have a child now, which was associated with being married, in a longer relationship, not having a child with partner, greater SCM knowledge, lower internalized childbearing stigma, and higher perceived community stigma of childbearing. However, just 117 reported trying to conceive in the prior 6 months, which was associated with being female, not having a child with their partner, less decision-making control within the relationship, and greater perceived cultural acceptability of SCM. Among those who had tried to conceive in the past 6 months, 14 (11.9%) used SCM, which was associated with greater control in decision making. Of the 268 who were not trying to conceive, 69 (25.7%) were using a modern contraceptive, which was associated with being in a shorter relationship, less control over decision-making, more positive attitudes towards contraception and lower depression.

Conclusion

Methods to promote reproductive goals are underused by HIV serodiscordant couples, and relationships characteristics and childbearing-related stigma appear to be most influential and thus targets for intervention.

Trial registration

Clinicaltrials.gov, NCT03167879; date registered May 23, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10163-7.

Childbearing desire and reproductive behaviors among women living with HIV: A cross-sectional study in Abidjan, Côte d'Ivoire

Introduction

Evidence on childbearing desire and reproductive behaviors in women living with HIV on antiretroviral therapy (ART) is scarce, particularly in West Africa. We investigated the prevalence and associated factors of childbearing desire in HIV-infected women in care in Abidjan, Côte d’Ivoire and explored whether such desires were translated into behaviors related to contraceptive use and communication with health personnel.

Methods

A cross-sectional survey was conducted in two HIV-care facilities in Abidjan, Côte d’Ivoire in 2015. Eligible women were non-pregnant, non-menopausal, aged 18–49 years and diagnosed as HIV-infected. The outcomes were childbearing desire, prevalence of modern contraceptive use, unmet needs for family planning and intention of the last pregnancy since HIV diagnosis. Women wishing to conceive immediately were asked whether they had discussed their desire with HIV healthcare workers. Logistic regression models were used to assess the associations between the outcomes and women’s characteristics.

Results

Of 1,631 women, 80% declared having childbearing desire. No association was found between women’s childbearing desire and ART status or its duration. In multivariate models, younger age, being in a stable relationship and having no or only one child were significantly associated with increased childbearing desire. Of the women wishing to conceive immediately (n = 713), only 43% reported having had fertility-related dialogue with healthcare provider. Among sexually active women wanting to avoid or delay pregnancy (n = 650), unmet needs for family planning was 40%. Regarding the last pregnancy since HIV diagnosis, one in three women reported not having wanted a baby at that time.

Conclusions

Pregnancy desire in women living with HIV in Abidjan was extremely high. Integration of safe conception strategies as well as improvement of contraceptive uptake among women in need of family planning are of utmost importance to ensure optimal conception and to avoid transmission of HIV to the male partner or to the forthcoming child.

Determinants of Fertility Desire among Women Living with HIV in the Childbearing Age Attending Antiretroviral Therapy Clinic at Jimma University Medical Center, Southwest Ethiopia: A Facility-Based Case-Control Study

Background

High fertility and aspiration to have more children are a normal phenomenon in many developing countries including Ethiopia. The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Despite the growing number of women living with HIV/AIDS, the issues of fertility and childbearing intention have not been widely studied in Ethiopia.

Objective

To identify determinants of fertility desire among women living with HIV in the childbearing age attending antiretroviral therapy clinic at Jimma University Medical Center, Southwest Ethiopia.

Methods

A facility-based case-control study was conducted in March 2019. Cases were women living with HIV who had fertility desire, and controls were those who had not. Data was collected using a face-to-face interview using a pretested questionnaire. The data was entered into EpiData 3.1 and exported to SPSS Version 24 for analysis. Bivariate and multivariable logistic regression analyses were used to identify candidate and independent determinants of fertility desire, respectively. Independent determinants associated with fertility desire were assessed using AORs with their corresponding 95% CIs at P value < 0.05 cutoff point. Results. Three hundred forty-four (115 cases and 229 controls) were included into the study with a 100% response rate. Age categories 15-24 (AOR: 4.1; 95% CI: 2.0, 8.4) and 25-34 (AOR: 2.3; 95% CI: 1.3, 4.2) years, not using family planning (AOR: 2.3; 95% CI: 1.4, 4.0), and having a sexual partner (AOR: 1.9; 95% CI: 1.1, 3.2) were independent predictors of fertility desire.

Conclusions

Age of women, family planning, and sexual partner were found to be the independent predictors of fertility desire among women living with HIV/AIDS. Policymakers and health care providers who are working on an ART clinic should try to consider the effects of these factors for women living with HIV while developing HIV/AIDS interventions and discussing on sexual and reproductive health issues with their clients, respectively.

Fertility Desire and Its Determinants Among People Living with HIV in Antiretroviral Therapy Clinic of Teku Hospital, Nepal

Background

Pregnancy in people Living with HIV/AIDS (PLHIV) involves significant public health risks, including the risk of HIV transmission to uninfected partners and the fetus. Despite the growing importance of fertility issues for HIV-infected people, little is known about their fertility desires in Nepal. This study, therefore, aimed to determine the magnitude of and factors associated with the fertility desire of PLHIV.

Patients and Methods

A cross-sectional study was conducted among 280 PLHIV attending the antiretroviral therapy (ART) clinic in Teku Hospital, Nepal. A standard semi-structured questionnaire was administered to participants using systematic random sampling. Data were entered using Epi-data 3.1 and analyzed using SPSS software version 20.

Results

Out of the total participants, 12.1% desired to have a child. Among those having this desire, 44.1% had not decided when to have a child. Reasons for desiring a child were having no children (44.1%), wanting to have a child of different sex than the previous one (29.4%), followed by wanting to have another child (26.5%). Factors such as being male (COR: 3.1, 95% CI: 1.3-7.0), being ≤40 years of age (COR: 3.8, 95% CI: 1.5-9.4), higher age at marriage (COR: 7.7, 95% CI: 1.5-39.6), middle socio-economic status (COR: 3.5, 95% CI: 1.7-7.3), having no children (COR: 22.9, 95% CI: 8.6-60.8) or fewer children (COR: 74.8, 95% CI: 9.7-575.1), greater CD4 count (COR: 2.8, 95% CI: 1.3-5.9) and having moderate knowledge of prevention of mother-to-child transmission (COR: 5.4, 95% CI: 2.3-12.7) had higher odds of having fertility desire.

Conclusion

Around one in every ten participants had a desire for fertility despite their HIV status. This calls for special attention in promoting integrated services for HIV and reproductive health. It will be important to include counseling and other services for those with fertility desire alongside providing ART.

Pregnancy Incidence and Fertility Desires Among Couples by HIV Status in Rakai, Uganda

BACKGROUND

The desire for more children and pregnancy rates are influenced by many relationship dynamics and HIV serostatus of couples.

SETTING

Rakai Community Cohort Study in Uganda.

METHODS

Couple data were retrospectively linked from survey rounds between 2007 and 2015 to assess drivers of fertility desire and pregnancy incidence by HIV status (M-F-; M+F+; M-F+; and M+F-). Multivariable modified Poisson regression was used to estimate prevalence ratios of fertility desire, whereas multivariable Poisson regression was used to estimate incidence rate ratios of pregnancy associated with couple characteristics.

RESULTS

Six thousand six hundred forty-seven couples contributed to 7656 person-years. Approximately 40% of couples (where at least 1 HIV+) desired more children. Unmet need for family planning was evident; couples of medium or low Socioeconomic status and with coresident children had lower fertility desires but higher pregnancy rates. Older age, being in a polygamous union, and having a HIV+ spouse in care were associated with lower fertility desire while having an older male partner was associated with higher fertility desire. Pregnancy incidence was lower with older age, among women using hormonal contraception and condoms, HIV+ concordant couples and couples where the HIV+ spouse was in care while pregnancy incidence were higher among women who desired more children, and serodiscordant couples (M-F+).

CONCLUSIONS

There are many drivers of fertility desires and pregnancy rates, and HIV does not diminish the desire for more children. Unmet need for family planning was evident and highlighted the need to understand and meet the contraceptive needs of couples.

Knowledge and correlates of use of safer conception methods among HIV-infected women attending HIV care in Uganda

BACKGROUND

Many people living with HIV would like to have children but family planning (FP) services often focus on only contraception. Availability of safer conception services is still very low in most low income countries. In this study we assessed the knowledge and use of safer conception methods (SCM) among HIV infected women in HIV care in Uganda to inform integration of safer conception in existing FP services.

METHODS

Data were accrued from a nationally representative cross-sectional survey of 5198 HIV+ women aged 15-49 years from 245 HIV clinics in Uganda. Knowledge and use of safer conception methods and associated factors were determined. The measure of association was prevalence ratio (PR) with corresponding 95% confidence intervals, obtained using a modified Poisson regression via generalized linear models. All the analyses were conducted using STATA version 12.0.

RESULTS

Overall knowledge of any safer conception method was 74.1% (3852/5198). However only 13.2% knew 3 to 4 methods, 18.9% knew only 2 methods and 42% knew only one method. Knowledge of specific SCM was highest for timed unprotected intercourse (TUI) at 39% (n = 2027) followed by manual self-insemination (MSI) at 34.8% (n = 1809), and pre-exposure prophylaxis (PrEP) at 24.8% (n = 1289). Knowledge of SCM was higher in the Eastern region (84.8%, P < 0.001), among women in HIV-discordant relationships (76.7%, p < 0.017), and those on ART (74.5%, p < 0.034). Overall, 1796 (34.6%) women were pregnant or reported a birth in the past 2 years-overall use of SCM in this group was 11.6% (209/1796). The odds of use of SCM were significantly lower in Kampala [adj. PR = 0.489(0.314, 0.764)] or Eastern region [adj.PR = 0.244; (0.147, 0.405)] compared to Northern region. Higher odds of SCM use were associated with HIV status disclosure to partner [adj.PR = 2.613(1.308, 5.221)] and sero-discordant compared to HIV+ concordant relationship [adj.PR = 1.637(1.236, 2.168)]. Pre-existing knowledge of any one SCM did not influence SCM use.

CONCLUSIONS

Knowledge and use of SCM among HIV+ women in care is low. Efforts to improve HIV status disclosure, integration of safer conception into FP and HIV services and regional efforts to promote sensitization and access to safer conception can help to increase uptake of safer conception methods.

Study protocol of "Our Choice": a randomized controlled trial of the integration of safer conception counseling to transform HIV family planning services in Uganda

BACKGROUND

About 40% of HIV-positive women in sub-Saharan Africa become pregnant post-diagnosis. Despite about half of their pregnancies being planned, safer conception methods (SCM) are underutilized among serodiscordant couples, partially due to the fact that safer conception counseling (SCC) has not been integrated into routine HIV family planning (FP) services.

METHODS

Our Choice is a comprehensive FP intervention that promotes unbiased childbearing consultations to ensure clients receive SCC or contraception services to achieve their desired reproductive goals. The intervention is theoretically grounded and has demonstrated preliminarily feasibility and acceptance through pilot testing. This three-arm cluster randomized controlled trial compares two implementation strategies for integrating Our Choice into routine FP services vs. usual care. Six sites in Uganda will be randomized to receive either (1) Our Choice intervention with enhanced training and supervision provided by study staff (SCC1), (2) Our Choice intervention implemented by the Ministry of Health's standard approach to disseminating new services (SCC2), or (3) existing FP services (usual care). Our Choice and usual care FP services will be implemented simultaneously over a 30-month period. Sixty clients in serodiscordant relationships who express childbearing desires will be enrolled by a study coordinator at each site (n = 360) and followed for 12 months or post-pregnancy (once, if applicable). Analysis will compare intervention arms (SCC1 and SCC2) to usual care and then to each other (SCC1 vs. SCC2) on the primary outcome of correct use of either SCM (if trying to conceive) or dual contraception (if pregnancy is not desired). Secondary outcomes (i.e., pregnancy, use of prevention of mother-to-child transmission services, condom use, and partner seroconversion) and cost-effectiveness will also be examined.

DISCUSSION

Findings will provide critical information about the success of implementation models of varying intensity for integrating SCC into FP, thereby informing policy and resource allocation within and beyond Uganda.

TRIAL REGISTRATION

NCT03167879 ClinicalTrials.gov, Registered 30 May, 2017.

Factors associated with adherence to antiretroviral therapy among HIV infected children in Kabale district, Uganda: a cross sectional study

Objectives

This study was set out to assess the level of adherence to antiretroviral therapy (ART) and its determinants among children receiving HIV treatment in Kabale district, south western Uganda, in order to inform interventions for improving pediatric ART adherence.

Results

Overall, 79% (121/153) of the children did not miss ART doses over the 7 days. Caregiver forgetfulness was the major reason for missing ART doses, 37% (13/35). Other reasons included transportation costs to the health facilities, 17%, (6/35) and children sitting for examinations in schools. Older children (11–14 years) were more likely to adhere to ART than the younger ones (0–10 years) (AOR = 6.41, 95% CI 1.31–31.42). Caregivers, who knew their HIV status, had their children more adherent to ART than the caregivers of unknown HIV status (AOR = 21.64: 95% CI 1.09–428.28). A significant proportion of children in two facilities 21.5% (32/153) missed ART doses within the previous week. Support for providers to identify clues or reminders to take drugs, extending HIV testing to caregivers and innovative models of ART delivery that alleviate transport costs to caregivers and allow sufficient drugs for children in school could enhance drug adherence among children.

Stigma gets in my way: Factors affecting client-provider communication regarding childbearing among people living with HIV in Uganda

INTRODUCTION

Many HIV-affected couples living in sub-Saharan Africa desire to have children, but few quantitative studies have examined support for their childbearing needs. Our study explored client-provider communication about childbearing and safer conception among HIV clients in Uganda.

METHODS

400 Ugandan HIV clients in committed relationships and with intentions to conceive were surveyed. Knowledge, attitudes and practices related to childbearing, and use of safer conception methods were assessed, including communication with providers about childbearing needs, the correlates of which were examined with bivariate statistics and logistic multivariate analysis.

RESULTS

75% of the sample was female; 61% were on antiretroviral therapy; and 61% had HIV-negative or unknown status partners. Nearly all (98%) reported the desire to discuss childbearing intentions with their HIV provider; however, only 44% reported such discussions, the minority (28%) of which was initiated by the provider. Issues discussed with HIV providers included: HIV transmission risk to partner (30%), HIV transmission risk to child (30%), and how to prevent transmission to the child (27%); only 8% discussed safer conception methods. Regression analysis showed that those who had communicated with providers about childbearing were more likely to have been diagnosed with HIV for a longer period [OR (95% CI) = 1.09 (1.03, 1.15)], while greater internalized childbearing stigma was associated with lower odds of this communication [OR (95% CI) = 0.70 (0.49, 0.99)], after controlling for all bivariate correlates and basic demographics.

CONCLUSIONS

Communication between HIV clients and providers about childbearing needs is poor and associated with stigma. Innovations to mitigate stigma among clients as well as training to improve health worker communication and skills related to safer conception counseling is needed.

Reproductive desire among women living with HIV/AIDS in Central Brazil: Prevalence and associated factors

Background

The purpose of this study was to estimate the prevalence and examine the factors associated with reproductive desire among women living with HIV/AIDS (WLWHA) in Central Brazil.

Methods

A cross-sectional study involving 274 WLWHA, aged 18 to 49 years, was conducted with the support of treatment services and non-governmental organizations that assist people living with HIV/AIDS. Data regarding sociodemographic characteristics, substance use, sexual behavior, and reproductive variables were collected through interviews. Poisson regression with robust variance was used to analyze the factors associated with reproductive desire.

Results

The prevalence of reproductive desire was 25.9% (95.0% confidence interval [CI]: 21.1–31.4%). This outcome was associated with age < 30 years (adjusted prevalence ratio [APR]: 2.93; p < 0.001), black skin color or race (APR: 2.28; p = 0.017), partner's reproductive desire (APR: 7.55; p < 0.001), absence of children (APR: 2.13; p = 0.003), history of abortion (APR: 1.65; p = 0.045) and undetectable viral load at the time of data collection (APR: 1.92; p = 0.043).

Conclusion

The prevalence of reproductive desire among WLWHA was relatively high. It is necessary to include fertility issues as part of assistance and counseling for women in referral services to support them with their feelings, goals, and needs regarding reproductive choices.

HIV status and treatment influence on fertility desires among women newly becoming eligible for antiretroviral therapy in western Kenya: insights from a qualitative study

BACKGROUND

Factors influencing fertility desires among HIV-infected individuals remain poorly understood. With new recommendations for universal HIV treatment and increasing antiretroviral therapy (ART) access, we sought to evaluate how access to early ART influences fertility desires among HIV-infected ART-naïve women.

METHODS

Semi-structured in-depth interviews were conducted with a select subgroup of 20 HIV-infected ART-naïve women attending one of 13 HIV facilities in western Kenya between July and August 2014 who would soon newly become eligible to initiate ART based on the latest national policy recommendations. The interviews covered four major themes: 1) definitions of family and children's role in community; 2) personal, interpersonal, institutional, and societal factors influencing fertility desires; 3) influence of HIV-positive status on fertility desires; and 4) influence of future ART initiation on fertility desires. An iterative process of reading transcripts, applying inductive codes, and comparing and contrasting codes was used to identify convergent and divergent themes.

RESULTS

The women indicated their HIV-positive status did influence-largely negatively-their fertility desires. Furthermore, initiating ART and anticipating improved health status did not necessarily translate to increased fertility desires. Instead, individual factors, such as age, parity, current health status, financial resources and number of surviving or HIV-infected children, played a crucial role in decisions about future fertility. In addition, societal influences, such as community norms and health providers' expectations of their fertility desires, played an equally important role in determining fertility desires.

CONCLUSIONS

Initiating ART may not be the leading factor influencing fertility desires among previously ART-naïve HIV-infected women. Instead, individual and societal factors appear to be the major determinants of fertility desires among these women.

Safer Conception for Couples Affected by HIV: Structural and Cultural Considerations in the Delivery of Safer Conception Care in Uganda

In countries with high HIV prevalence and high fertility desires, the rights of HIV-affected couples to have children are a pressing issue. Conception among people living with HIV carries risks for both horizontal and vertical HIV transmission. In Uganda ~100,000 HIV-infected women become pregnant annually. Providers face a number of challenges to preventing HIV transmission, reducing unplanned pregnancies, and ensuring safer conception. We report findings from interviews with 27 HIV-affected couples (54 individuals) in Uganda. We explored key cultural and structural factors shaping couples' childbearing decisions. Our data reveal a complex intersection of gender norms, familial expectations, relationship dynamics, and HIV stigma influencing their decisions. Participants provided insights regarding provider bias, stigma, and the gendering of reproductive healthcare. To reduce horizontal transmission HIV and family planning clinics must address men's and women's concerns regarding childbearing with specific attention to cultural and structural challenges.

Prevalence and Correlates of Use of Safer Conception Methods in a Prospective Cohort of Ugandan HIV-Affected Couples with Fertility Intentions

We examined the prevalence and correlates of safer conception methods (SCM) use in HIV-affected couples with fertility intentions. A prospective cohort of 400 HIV clients in Uganda who had fertility intentions with their partner was surveyed every 6 months for 24 months. Logistic regression analysis was used to determine individual, relationship and provider level predictors of SCM use. Over one-third (35%) reported any use of timed unprotected intercourse (TUI) during the study; use of other SCM was rare. Baseline predictors of any TUI use included lower social support, greater perceived provider stigma of childbearing, greater SCM awareness, greater control over sexual decision making in the relationship, inconsistent condom use, and the belief that a desire for childbearing impedes condom use. These findings highlight the need for policy and provider training regarding integration of safer conception counselling into family planning and reproductive health services for people living with HIV.

An Approach to Developing a Prediction Model of Fertility Intent Among HIV-Positive Women and Men in Cape Town, South Africa: A Case Study

As a 'case-study' to demonstrate an approach to establishing a fertility-intent prediction model, we used data collected from recently diagnosed HIV-positive women (N = 69) and men (N = 55) who reported inconsistent condom use and were enrolled in a sexual and reproductive health intervention in public sector HIV care clinics in Cape Town, South Africa. Three theoretically-driven prediction models showed reasonable sensitivity (0.70-1.00), specificity (0.66-0.94), and area under the receiver operating characteristic curve (0.79-0.89) for predicting fertility intent at the 6-month visit. A k-fold cross-validation approach was employed to reduce bias due to over-fitting of data in estimating sensitivity, specificity, and area under the curve. We discuss how the methods presented might be used in future studies to develop a clinical screening tool to identify HIV-positive individuals likely to have future fertility intent and who could therefore benefit from sexual and reproductive health counseling around fertility options.

Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania

AIM

To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa.

DESIGN

Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression.

RESULTS

Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use.

CONCLUSIONS

There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.

Fertility Desires and Intentions among People Living with HIV/AIDS (PLWHA) in Southern India

INTRODUCTION

The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Combination Antiretroviral Therapy (cART) has increased the life expectancy of PLWHA as a result of which they may consider child bearing. There are hardly any studies from India addressing the fertility desires among PLWHA.

AIM

This study was done to assess the fertility desires of PLWHA in Southern India.

MATERIALS AND METHODS

It was a cross-sectional study conducted among 230 HIV-positive men and women who presented to Kasturba Medical College (KMC), Mangalore, India. Study was conducted between October 2012 and October 2014. Statistical analysis was performed using SPSS software version 11.5. Chi-square test, Fisher's exact test and student t-test was used to find out the association of various factors affecting fertility desire. A p-value of less than 0.05 was considered statistically significant.

RESULTS

The mean age of our study population was 36.3±5.5 years. The mean age of males was 37.3±6 years and for female 34.9±5 years. In our study 132 (57.4%) were males. Majority were literate 229 (99%). Majority of patients were employed 166 (72%). In our study 195 (84.7%) were on cART. Out of 230 PLWHA 39 (16.95%) were unmarried and 151(65.5%) married PLHIV were living with partners at the time of study. In our study 77 (33.5%) patients had fertility desire. Age, gender, marital status, number of children, partner's fertility desire and HIV status of partner had an association with fertility desire.

CONCLUSION

Providing universal access to cART is the main aim of national programs. It is high time that these programs focus on fertility issues of PLWHA. Reproductive rights of PLWHA need to be respected. Physicians and HIV counselors should proactively discuss and address reproductive issues of PLWHA.

Safer Conception Methods and Counseling: Psychometric Evaluation of New Measures of Attitudes and Beliefs Among HIV Clients and Providers

With data from 400 HIV clients with fertility intentions and 57 HIV providers in Uganda, we evaluated the psychometrics of new client and provider scales measuring constructs related to safer conception methods (SCM) and safer conception counselling (SCC). Several forms of validity (i.e., content, face, and construct validity) were examined using standard methods including exploratory and confirmatory factor analysis. Internal consistency was established using Cronbach's alpha correlation coefficient. The final scales consisted of measures of attitudes towards use of SCM and delivery of SCC, including measures of self-efficacy and motivation to use SCM, and perceived community stigma towards childbearing. Most client and all provider measures had moderate to high internal consistency (alphas 0.60-0.94), most had convergent validity (associations with other SCM or SCC-related measures), and client measures had divergent validity (poor associations with depression). These findings establish preliminary psychometric properties of these scales and should facilitate future studies of SCM and SCC.

Determinants of Desire for Children among HIV-Positive Women in the Afar Region, Ethiopia: Case Control Study

INTRODUCTION

The desire for a child in Ethiopian society is normal. Among HIV positive women, due to the risk of MTCT, it is imperative to understand factors influencing women's desire for children. This study aimed at assessing factors associated with desire for children among HIV-positive women in two selected hospitals of Afar Regional State, Ethiopia.

METHODS

A facility based case-control study was conducted among 157 cases (with a desire) and 157 controls of HIV positive individuals registered in the selected health facilities. The participants were selected by random sampling technique. Data were collected using face-to-face interview and was analyzed using logistic regression.

RESULT

Factors found to be independently associated with desire for children were age categories of 20-24 years (OR = 6.22, 1.29-10.87) and 25-29 years (OR = 14.6, 3.05-21.60), being married (OR = 5.51, 2.19-13.54), Afar ethnicity (OR 6.93, 1.19-12.14), having HIV-positive children (OR 0.23, 0.09-0.63), duration on ART more than one year (3.51, 1.68-9.05), CD4 count greater than 350 (OR 4.83, 1.51-7.27) and discussion of reproductive health issues with health providers (OR 0.31, 0.12-0.51).

CONCLUSION

Women who were young, married, Afar, those who received ART more than one year, and had CD4 count >350 were more likely to have a desire for children.

RECOMMENDATION

Health care workers at ART clinic should openly discuss about the reproductive options for the women living with HIV/AIDS.

Effect of subsequent pregnancies on HIV disease progression among women in the Mulago Hospital MTCT-Plus program in Uganda

OBJECTIVE

To investigate the effect of subsequent pregnancies on HIV disease progression among HIV-infected women at Mulago Hospital, Uganda.

METHODS

In a retrospective cohort study, data were analyzed from women enrolled in the Mother-To-Child Transmission Plus program from March 2003 to December 2011. The CD4 cell count, the development of new AIDS-defining opportunistic infections, and the AIDS-related mortality were compared between women with and without subsequent pregnancies.

RESULTS

Overall, 409 women were enrolled and 195 (47.7%) had subsequent pregnancies. Antiretroviral therapy (ART) was initiated in 143 (73.3%) women with and 155 (72.4%) women without subsequent pregnancies. Kaplan-Meier analysis for women receiving ART showed no differences between women with and without subsequent pregnancies in the median times to clinical failure (62.7 vs 64.7 months; P=0.31), immunological failure (68.8 vs 75.5 months; P=0.10), and death (68.8 vs 75.5 months; P=0.53). In a Cox regression analysis, subsequent pregnancies were not associated with immunological failure during follow-up (adjusted hazard ratio 1.13, 95% confidence interval 0.06-2.09).

CONCLUSION

Subsequent pregnancies could have no detrimental effect on HIV disease progression among HIV-infected women whose treatment is well managed.

Multi-level Correlates of Safer Conception Methods Awareness and Attitudes Among Ugandan HIV Clients with Fertility Intentions

Many people living with HIV desire childbearing, but low cost safer conception methods (SCM) such as timed unprotected intercourse (TUI) and manual self-insemination (MSI) are rarely used. We examined awareness and attitudes towards SCM, and the correlates of these constructs among 400 HIV clients with fertility intentions in Uganda. Measures included awareness, self-efficacy, and motivation regarding SCM, as well as demographics, health management, partner and provider characteristics. Just over half knew that MSI (53%) and TUI (51%) reduced transmission risk during conception, and 15% knew of sperm washing and pre-exposure prophylaxis. In separate regression models for SCM awareness, motivation, and self-efficacy, nearly all independent correlates were related to the partner, including perceived willingness to use SCM, knowledge of respondent's HIV status, HIV-seropositivity, marriage and equality in decision making within the relationship. These findings suggest the importance of partners in promoting SCM use and partner inclusion in safer conception counselling.

Attitudes, Knowledge, and Correlates of Self-Efficacy for the Provision of Safer Conception Counseling Among Ugandan HIV Providers

High rates of childbearing desires (59%) and serodiscordant partnerships (50%) among people living with HIV (PHLA) in Uganda highlight the need for safer conception counseling (SCC). Provider attitudes about counseling PLHA on the use of safer conception methods (SCM) have been explored in qualitative studies, but published quantitative investigations are scarce. Data from 57 Ugandan providers were collected to examine providers' attitudes about childbearing among PLHA and engagement in discussions about childbearing, as well as their knowledge, interest, self-efficacy, and intentions to provide SCC. Correlates of self-efficacy for the provision of SCC were explored to inform the development of training programs. Providers reported a general awareness of most SCM, especially timed unprotected intercourse (TUI); but just over half felt they knew enough to counsel clients in the future and all wanted more training. Childbearing was discussed with less than a third of reproductive aged patients and was mostly initiated by patients. Most providers saw value in providing SCC and believed that most aspects of SCM would be acceptable to their clients, but numerous barriers were endorsed. Self-efficacy was greatest among providers who had had more childbearing conversations, greater SCM awareness, perceived fewer barriers and greater intentions to counsel on TUI. Providers evidence fewer stigmatizing attitudes than in the past. However, those who endorsed more stigmatizing attitudes evidenced a trend for reporting lower self-efficacy for providing SCC. Training will need to simultaneously focus on increasing providers' SCC knowledge and skills while instilling a more realistic appraisal of the risks of assisting couples to employ SCM versus doing nothing.

Correlates of Use of Timed Unprotected Intercourse to Reduce Horizontal Transmission Among Ugandan HIV Clients with Fertility Intentions

We examined the correlates of use of safer conception methods (SCM) in a sample of 400 Ugandan HIV clients (75 % female; 61 % on antiretroviral therapy; 61 % with HIV-negative or unknown status partners) in heterosexual relationships with fertility intentions. SCM assessed included timed unprotected intercourse, manual self-insemination, sperm washing, and pre-exposure prophylaxis (PrEP). In the 6 months prior to baseline, 47 (12 %) reported using timed unprotected intercourse to reduce risk of HIV infection (or re-infection), none had used manual self-insemination or sperm washing, and two had used PrEP. In multiple regression analysis, correlates of use of timed unprotected intercourse included greater perceptions of partner's willingness to use SCM and providers' stigma of childbearing among people living with HIV, higher SCM knowledge, and desire for a child within the next 6 months. These findings highlight the need for policy and provider training regarding integration of couples' safer conception counselling into HIV care.

Messages on pregnancy and family planning that providers give women living with HIV in the context of a Positive Health, Dignity, and Prevention intervention in Mozambique

Background

Family planning is an important HIV prevention tool for women living with HIV (WLHIV). In Mozambique, the prevalence of HIV among women of reproductive age is 13.1% and the average fertility rate is high. However, family planning and reproductive health for WLHIV are under-addressed in Mozambique. This study explores provider descriptions of reproductive health messages in order to identify possible barriers and facilitators to successfully addressing family planning and pregnancy concerns of WLHIV.

Methods

In 2006, a Positive Health, Dignity, and Prevention program was introduced in Mozambique focused on training health care providers to work with patients to reduce their transmission risks. Providers received training on multiple components, including family planning and prevention of mother-to-child transmission (PMTCT). In-depth interviews were conducted with 31 providers who participated in the training in five rural clinics in three provinces. Data were analyzed using qualitative content analysis.

Results

Analysis showed that providers’ clinical messages on family planning, pregnancy, and PMTCT for WLHIV could be arranged along a continuum. Provider statements ranged from saying that WLHIV should not become pregnant and condoms are the only valid form of family planning for WLHIV, to suggesting that WLHIV can have safe pregnancies.

Conclusion

These data indicate that many providers continue to believe that WLHIV should not have children and this represents a challenge for integrating family planning into the care of WLHIV. Also, not offering WLHIV a full selection of family planning methods severely limits their ability to protect themselves from unintended pregnancies and to fully exercise their reproductive rights. Responding to the reproductive health needs of WLHIV is a critical component in HIV prevention and could increase the success of PMTCT programs.

Increasing incidence of pregnancy among women receiving HIV care and treatment at a large urban facility in western Uganda

Background

Antiretroviral treatment restores physical functioning and may have an impact on fertility desires. Counseling is given to HIV positive women to create awareness and to provide information on pregnancy and delivery. The purpose of this study was to determine the incidence of pregnancy and factors that predict pregnancy among women of reproductive age receiving HIV care and treatment at a large urban center in western Uganda.

Methods

We conducted a retrospective cohort study using routinely collected data at the Immune Suppression (ISS) Clinic of Mbarara Regional Referral Hospital located in Mbarara District, western Uganda collected between January 2006 and June 2010. Women aged 15 to 50 years were eligible for analysis. The primary outcome was incidence of pregnancy calculated as number of pregnancies per 1000 person years (PY). Data was analyzed by calendar year and year of enrolment and used survival analysis to determine the predictors of pregnancy.

Results

A total of 3144 women were included with a median follow up of 12.5 months. The overall incidence rate was 90.7 pregnancies per 1000 person years. Incidence increased from 29.8 pregnancies per 1000 PY in 2006 to 122 pregnancies per 1000 PY in 2010 (p < 0.001). Significant predictors for pregnancy were younger age (HR 10.96 95% CI 3.22-37.2), married (HR 2.09 95% CI 1.69-2.64) and single (HR 1.95 95% CI 1.34-2.84) compared to widowed or separated, primary education (HR 1.65 95% CI 1.02-2.66), not knowing the HIV status of the spouse (HR 1.46, 95%CI 1.13-1.93) compared to knowing. The use of family planning (HR 0.23 95% CI 0.18- 0.30) and an increase in CD4 count between baseline and most recent count were protective against pregnancy. ART use was not a significant predictor.

Conclusion

Incidence of pregnancy among women receiving routine HIV care and treatment has increased and is almost comparable to that in the general population. Thus routine HIV care should integrate reproductive health needs for these women.

Electronic supplementary material

The online version of this article (doi:10.1186/1742-4755-11-81) contains supplementary material, which is available to authorized users.

Fertility desire and associated factors among people living with HIV attending antiretroviral therapy clinic in Ethiopia

Background

The reproductive decisions made by PLHIV and their partners have a long-term consequences for the survival and wellbeing of their families and a society at large. Evidence relating to fertility and reproductive intentions among PLHIV is rare, despite the fact that more than 80% of PLHIV are of reproductive age. The aim of the study was to determine fertility desire and associated factors among PLHIV attending ART clinic in Fitche Hospital.

Methods

A facility based cross-sectional study design with both quantitative and qualitative data collection methods was employed from February21-April 20th, 2013. The study participants were selected by using simple random sampling technique. A pre- tested structured questionnaire was used to collect data. Both bivariate and multivariate logistic regressions were used to identify associated factors.

Result

The prevalence of fertility desire of PLHIV in Fitche Hospital was 133(39.1%) with 95% CI of (34.3% -44.3%). This study identified that factors found to be associated with fertility desire were: − Age from 18-29y [AOR = 3.95, 95% CI: 1.69 - 9.22) and 30-39y (AOR = 3.91, 95% CI: 1.90 -8.19)], marital length ≤4y [AOR = 5.49, 95% CI: 2.08-14.51), within 5-9y (AOR = 4.80, 95% CI: 2.14-10.78) and 10-14y (AOR = 2.82, 95% CI: 1.19 -6.63], had not biological living children [AOR = 11.42, 95% CI: 3.27-39.90) and had more than one child (AOR = 3.67, 95% CI: 1.27-10.62)], community pressure [AOR = 3.67, 95% CI: 1.54-8.70], partner fertility [AOR = 7.18, 95% CI: 3.39-15.22)], duration HIV diagnosis≤1y[AOR = 4.99, 95% CI: 1.91-13.09], disclosed HIV serostatus [AOR = 3.9, 95% CI: 1.37-11.10] and partner sero-difference [AOR = 2.05, 95% CI: 1.01- 4.15] were some of the factors significantly associated with fertility desire.

Conclusion

The prevalence of fertility desire of PLHIV in the study area was 39.1%. In this study:- age, marital length, biological child, partner, community pressure, duration of HIV-diagnosis, discordant HIV-test and disclosure of HIV-serostatus to partner were demonstrated to have more associations with fertility desire among PLHIV, therefore, these factors should be emphatically considered during PLHIV’s reproductive health program development.

Fertility desire among HIV-positive women in Tigray region, Ethiopia: implications for the provision of reproductive health and prevention of mother-to-child HIV transmission services

Background

There is growing recognition of the difficult reproductive decisions faced by HIV-positive women. Studies in both resource-constrained and developed countries have suggested that many HIV-positive women continue to desire children in spite of their understanding of the possible risks that HIV poses. This study investigates the factors associated with fertility desire among HIV-positive women in Tigray region, Ethiopia.

Methods

A cross-sectional survey was conducted among 964 HIV-positive women receiving HIV care in 12 health centers of Tigray region. In each health center, the number of study participants was allocated proportionally to the load of HIV-positive women in the chronic care clinics. A descriptive summary of the data and a logistic regression model were used to identify factors associated with fertility desire using odds ratios with a 95% confidence interval and P-value of 0.05.

Results

Four hundred and thirty nine (45.5%) of the participants reported a desire to have children in the future. Eighty six percent of the women had given birth to at least one live baby at the time of study, with the median number of live births being 2 (Inter quartile range = 1,3). Women in the age group of 15–24 years [AOR = 2.64(95% CI: 1.44, 4.83)] and 25–34 years [AOR = 2.37 (95% CI: 1.60, 2.4 3.50)] had higher fertility desire as compared to women in the age group of 35–49 years. Having no children [AOR = 25.76 (95% CI: 13.66, 48.56)], having one to two children [AOR = 5.14 (95% CI: 3.37, 7.84)] and disclosing HIV status to husband/sexual partner [AOR = 1.74 (95% CI: 1.11, 2.72)] were all independently associated with fertility desire.

Conclusions

Age, HIV disclosure status to husband/sexual partner, and relatively few live children were all found to influence HIV-positive women’s fertility desire. Programmers and policy makers should consider the effects of these factors for HIV-positive women as they develop HIV/AIDS interventions.

Contraceptive use and unmet need for family planning among HIV positive women on antiretroviral therapy in Kumasi, Ghana

BACKGROUND

A key strategy for minimizing HIV infection rates especially via reduction of Mother- to-Child transmission is by reducing the unmet need for family planning. In Ghana, the integration of family planning services into Antiretroviral Therapy services for persons living with HIV/AIDS has largely been ignored. We set out to measure the prevalence of modern methods of contraception, the unmet need for family planning and to identify factors associated with the use of modern methods of contraception among HIV positive women on anti retroviral therapy.

METHODS

This was a descriptive cross sectional study of HIV positive women in their reproductive ages accessing care at an adult Antiretroviral Therapy Clinic in Kumasi, Ghana. Data was collected using a structured questionnaire. Data analysis was conducted using Epi Info version 7.1.2.0.

RESULTS

A total of 230 women were included in the study. Fifty six percent were in the 30-39 year age group. The mean age (SD) was 36.3 (5.4) years. While 53.5% of respondents desired to have children, partner desire for children was reported by 54.6% of respondents with partners. About 74% had received information on contraception from their provider. 42.6% of participants and/or their partners were using a contraception method at the time of study; the male condom (79.6%) being the most commonly used method. The estimated unmet need for contraception was 27.8%. Contraceptive use was strongly associated with partner knowledge of HIV status (AOR = 3.64; 95% CI 1.36-9.72; p = 0.01) and use of a contraceptive method prior to diagnosis of HIV (AOR = 6.1; 2.65-14.23; p < 0.001).

CONCLUSION

Contraceptive Prevalence is high among HIV positive women in Kumasi compared with the general Ghanaian population. Despite this, there still is a high unmet need for family planning in this population. We recommend continuous education on contraceptives use to HIV patients accessing HAART services to further increase contraceptive uptake.

Antiretroviral Therapy Helps HIV-Positive Women Navigate Social Expectations for and Clinical Recommendations against Childbearing in Uganda

Understanding factors that influence pregnancy decision-making and experiences among HIV-positive women is important for developing integrated reproductive health and HIV services. Few studies have examined HIV-positive women's navigation through the social and clinical factors that shape experiences of pregnancy in the context of access to antiretroviral therapy (ART). We conducted 25 semistructured interviews with HIV-positive, pregnant women receiving ART in Mbarara, Uganda in 2011 to explore how access to ART shapes pregnancy experiences. Main themes included: (1) clinical counselling about pregnancy is often dissuasive but focuses on the importance of ART adherence once pregnant; (2) accordingly, women demonstrate knowledge about the role of ART adherence in maintaining maternal health and reducing risks of perinatal HIV transmission; (3) this knowledge contributes to personal optimism about pregnancy and childbearing in the context of HIV; and (4) knowledge about and adherence to ART creates opportunities for HIV-positive women to manage normative community and social expectations of childbearing. Access to ART and knowledge of the accompanying lowered risks of mortality, morbidity, and HIV transmission improved experiences of pregnancy and empowered HIV-positive women to discretely manage conflicting social expectations and clinical recommendations regarding childbearing.

Fertility desires among men and women living with HIV/AIDS in Nairobi slums: a mixed methods study

Objectives

Fertility desires require new understanding in a context of expanding access to antiretroviral therapy for people living with HIV/AIDS in Sub-Saharan Africa. This paper studies the fertility desires and their rationales, of slum-dwelling Kenyan men and women living with HIV/AIDS who know their serostatus, but have different antiretroviral therapy treatment statuses. It addresses two research questions: How do people living with HIV/AIDS consider their future fertility? What factors contribute to an explanation of fertility desires among people living with HIV/AIDS.

Methods

A mixed methods study (survey [n = 513] and in-depth interviews [n = 41]) with adults living with HIV/AIDS living in Nairobi slums was conducted in 2010. Regression analyses assess independent relationships between fertility desires and socio-demographic factors. Analyses of in-depth interviews are used to interpret the statistical analyses of fertility desires.

Results

Our analyses show that fertility desires are complex and ambivalent, reflecting tensions between familial and societal pressures to have children versus pressures for HIV (re-)infection prevention. More than a third (34%) of men and women living with HIV expressed future fertility desires; however, this is significantly lower than in the general population. Factors independently associated with desiring a child among people living with HIV/AIDS were age, sex, number of surviving children, social support and household wealth of the respondent.

Discussion

Increasing access to ART is changing the context of future childbearing for people living with HIV/AIDS. Prevailing values mean that, for many people living with HIV/AIDS, having children is seen as necessary for a “normal” and healthy adult life. However, the social rewards of childbearing conflict with moral imperatives of HIV prevention, presenting dilemmas about the “proper” reproductive behaviour of people living with HIV/AIDS. The health policy and service delivery implications of these findings are explored.

"Our hands are tied up": current state of safer conception services suggests the need for an integrated care model

We conducted in-depth interviews with a variety of health care providers (n = 33) in Uganda to identify current services that could support and act as barriers to the provision of safer conception counseling (SCC). Consistent with their training and expertise, providers of all types reported provision of services for people living with a diagnosis of HIV or AIDS who desire a child. Important barriers, including a lack of service integration, poor communication between stakeholders, and the absence of policy guidelines, were identified. Drawing on these data, we propose a model of integrated care that includes both SCC services and prevention of unplanned pregnancies.

"I may not say we really have a method, it is gambling work": knowledge and acceptability of safer conception methods among providers and HIV clients in Uganda

In this qualitative study, researchers assessed knowledge, acceptability, and feasibility of safer conception methods (SCM; timed unprotected intercourse [TUI], manual self-insemination, and sperm washing) among various health care providers (n = 33) and 48 HIV clients with recent or current childbearing intentions in Uganda. While several clients and providers had heard of SCM (especially TUI), few fully understood how to use the methods. All provider types expressed a desire to incorporate SCM into their practice; however, this will require training and counseling protocols, sensitization to overcome cultural norms that pose obstacles to these methods, and partner engagement (particularly by men) in safer conception counseling.

Pregnancy incidence and outcomes among women receiving preexposure prophylaxis for HIV prevention: a randomized clinical trial

IMPORTANCE

Antiretroviral preexposure prophylaxis (PrEP), using tenofovir disoproxil fumarate (TDF) and combination emtricitabine/tenofovir disoproxil fumarate (FTC+TDF), is efficacious for prevention of human immunodeficiency virus (HIV) acquisition. PrEP could reduce periconception HIV risk, but the effect on pregnancy outcomes is not well defined.

OBJECTIVE

To assess pregnancy incidence and outcomes among women using PrEP during the periconception period.

DESIGN, SETTING, AND PARTICIPANTS

Randomized trial among 1785 HIV-serodiscordant heterosexual couples (the Partners PrEP Study) in which the female partner was HIV uninfected that demonstrated that PrEP was efficacious for HIV prevention, conducted between July 2008 and June 2013 at 9 sites in Kenya and Uganda.

INTERVENTIONS

Daily oral TDF (n = 598), combination FTC+TDF (n = 566), or placebo (n = 621) through July 2011, when PrEP demonstrated efficacy for HIV prevention. Thereafter, participants continued receiving active PrEP without placebo. Pregnancy testing occurred monthly and study medication was discontinued when pregnancy was detected.

MAIN OUTCOMES AND MEASURES

Pregnancy incidence, birth outcomes (live births, pregnancy loss, preterm birth, congenital anomalies), and infant growth.

RESULTS

A total of 431 pregnancies occurred. Pregnancy incidence was 10.0 per 100 person-years among women assigned placebo, 11.9 among those assigned TDF (incidence difference, 1.9; 95% CI, -1.1 to 4.9 [P = .22 vs placebo]), and 8.8 among those assigned FTC+TDF (incidence difference, -1.3; 95% CI, -4.1 to 1.5 [P = .39 vs placebo]). Before discontinuation of the placebo treatment group in July 2011, the occurrence of pregnancy loss (96 of 288 pregnancies) was 42.5% for women receiving FTC+TDF compared with 32.3% for those receiving placebo (difference for FTC+TDF vs placebo, 10.2%; 95% CI, -5.3% to 25.7%; P = .16) and was 27.7% for those receiving TDF alone (difference vs placebo, -4.6%; 95% CI, -18.1% to 8.9%; P = .46). After July 2011, the frequency of pregnancy loss (52 of 143 pregnancies) was 37.5% for FTC+TDF and 36.7% for TDF alone (difference, 0.8%; 95% CI, -16.8% to 18.5%; P = .92). Occurrence of preterm birth, congenital anomalies, and growth throughout the first year of life did not differ significantly for infants born to women who received PrEP vs placebo.

CONCLUSIONS AND RELEVANCE

Among HIV-serodiscordant heterosexual African couples, differences in pregnancy incidence, birth outcomes, and infant growth were not statistically different for women receiving PrEP with TDF alone or combination FTC+TDF compared with placebo at conception. Given that PrEP was discontinued when pregnancy was detected and that CIs for the birth outcomes were wide, definitive statements about the safety of PrEP in the periconception period cannot be made. These results should be discussed with HIV-uninfected women receiving PrEP who are considering becoming pregnant.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00557245.

Fertility intentions among HIV positive women aged 18-49 years in Addis Ababa Ethiopia: a cross sectional study

Background

Given the degree of HIV epidemic among women and the current antiretroviral therapy (ART) scale up in Ethiopia; considering the issue of fertility is vital to ensure the delivery of integrated reproductive health along with prevention services provided to positive women. This study was aimed to assess fertility intentions of women living with HIV attending public health institutions (hospitals & health centers) in Addis Ababa, Ethiopia.

Methods

Institution based cross sectional survey was conducted, among 1855 HIV positive, women aged 18–49 years selected from different public health facilities in Addis Ababa; from June to October 2012. Information was gathered by using interviewer administered questionnaires. Data were double entered in EPI Info version 3.5.2 software, cleaned finally exported to IBM SPSS statistics version 20 for analysis. Logistic regression models were used to predict the association of study variables and adjusted for possible confounders.

Result

Overall, 44% of women reported fertility intention. ART users had higher fertility intention (AOR; 1.26, 95%CI; 1.01 to 1.60) than ART naïve. In addition to this, having partner being on sexual relationship, young age, being single and having fewer or no children were found to be predictors of fertility intentions. The presence of ART, improvement of health condition and the influence of husband were the main reasons for childbearing intentions of women in the study area.

Conclusion

A considerable proportion of women reported fertility intention. There was an association between fertility intentions and ART use. It is important for health care providers and policy makers to strengthen the fertility need of HIV positive women along with HIV care so that women may decide freely and responsibly on their fertility issues.

Disclosure of HIV serostatus to male partner and use of modern contraceptives among women receiving HIV care services in Kampala, Uganda

OBJECTIVE

To investigate whether disclosure of HIV status is associated with use of modern contraceptives (MCs) among women attending HIV care services at an AIDS Information Center (AIC) in an urban setting in Uganda.

METHODS

In a cross-sectional study between March and April 2010, HIV-positive married women aged 15-49years who had received their HIV-positive serostatus results at least 4weeks previously were interviewed at the AIC, Kampala, Uganda. Female use of MCs was compared by HIV disclosure to male marital partners. Log-binomial regression models were used to obtain crude and adjusted prevalence risk ratios (PRRs) and corresponding 95% confidence intervals (CIs).

RESULTS

Nearly three-quarters (72.6%) of the women had disclosed their HIV-positive status to their partner. Overall, use of MCs was reported by 41.0% of the participants. Use of only 1 MC method was similar between those disclosing (81.1%) and those not disclosing (84.3%), but use of dual methods tended to be higher among disclosers (14.4%) than among non-disclosers (10.8%). In adjusted analyses, MC use was 41.0% lower among disclosers than among non-disclosers (adjusted PRR, 0.59; 95% CI, 0.46-0.77).

CONCLUSION

HIV serostatus disclosure was associated with lower use of MCs among HIV-positive women in Kampala, Uganda.

Meta-analyses of fertility desires of people living with HIV

Background

Literature review has shown that some years back the fertility desires of people living with HIV was low but in the recent years, it was reported as increasing. However, little is known about the strength of association of fertility desire of HIV positive people with antiretroviral therapy (ART) experience, age, sex, education level, and number of children.

Methods

In these meta-analyses, twenty studies from different parts of the world were included. The odds ratios of fertility desires were determined using the random-effects model. Heterogeneity among the studies was assessed by computing values for Tau², Chi-square (Q), I² and P-value. Sensitivity analysis and funnel plot were done to assess the stability of pooled values to outliers and publication bias, respectively.

Results

The pooled analysis demonstrated that fertility desires of study participants had no association with ART. Similarly, the overall odds ratio did not show statistically significant association of fertility desires with sex and educational attainment of study participants although forest plots of some studies fall on increased and some others on decreased sides of fertility desires. The two variables that demonstrated a strong association with fertility desires were age less than 30 years and being childless. The lowest heterogeneity was found in a meta-analysis comparing ART experienced and ART naïve HIV positive people. In all meta-analyses, the sensitivity analyses showed the stability of the pooled odds ratios; and the funnel plots did not show publication or disclosure bias.

Conclusion

Although the fertility desires among childless and younger age group was very strong, we realized that quite a significant segment of HIV-infected people have desire for fertility. Therefore, including fertility issue as integral part of HIV patient care may help several of them in their reproductive decision making (letting them know the risks and methods of prevention while anticipating pregnancy).

A conceptual framework for understanding HIV risk behavior in the context of supporting fertility goals among HIV-serodiscordant couples

Integrated reproductive health services for people living with HIV must address their fertility intentions. For HIV-serodiscordant couples who want to conceive, attempted conception confers a substantial risk of HIV transmission to the uninfected partner. Behavioral and pharmacologic strategies may reduce HIV transmission risk among HIV-serodiscordant couples who seek to conceive. In order to develop effective pharmaco-behavioral programs, it is important to understand and address the contexts surrounding reproductive decision-making; perceived periconception HIV transmission risk; and periconception risk behaviors. We present a conceptual framework to describe the dynamics involved in periconception HIV risk behaviors in a South African setting. We adapt the Information-Motivation-Behavioral Skill Model of HIV Preventative Behavior to address the structural, individual and couple-level determinants of safer conception behavior. The framework is intended to identify factors that influence periconception HIV risk behavior among serodiscordant couples, and therefore to guide design and implementation of integrated and effective HIV, reproductive health and family planning services that support reproductive decision-making.

Contraceptive use and associated factors among women enrolling into HIV care in southwestern Uganda

BACKGROUND

Preventing unintended pregnancies among women living with HIV is an important component of prevention of mother-to-child HIV transmission (PMTCT), yet few data exist on contraceptive use among women entering HIV care.

METHODS

This was a retrospective study of electronic medical records from the initial HIV clinic visits of 826 sexually active, nonpregnant, 18-49-year old women in southwestern Uganda in 2009. We examined whether contraceptive use was associated with HIV status disclosure to one's spouse.

RESULTS

The proportion reporting use of contraception was 27.8%. The most common method used was injectable hormones (51.7%), followed by condoms (29.6%), and oral contraceptives (8.7%). In multivariable analysis, the odds of contraceptive use were significantly higher among women reporting secondary education, higher income, three or more children, and younger age. There were no significant independent associations between contraceptive use and HIV status disclosure to spouse.

DISCUSSION

Contraceptive use among HIV-positive females enrolling into HIV care in southwestern Uganda was low. Our results suggest that increased emphasis should be given to increase the contraception uptake for all women especially those with lower education and income. HIV clinics may be prime sites for contraception education and service delivery integration.

Depression in the pathway of HIV antiretroviral effects on sexual risk behavior among patients in Uganda

HIV antiretroviral therapy (ART) can increase safe sex or lead to disinhibition and less condom use. We conducted one of the first controlled studies of ART effects on sexual risk behavior in sub-Saharan Africa, and the potential explanatory roles of physical and mental health. Participants (302 non-ART, 300 ART) were followed for the first 12 months of HIV care in Uganda. Multivariate intention-to-treat regression analysis showed that frequency of sex increased significantly in both groups, but more among ART patients; when added to the model in separate analyses, changes in physical health functioning and depression were both significant predictors, as was time in HIV care, but there was no longer an ART effect. Both ART and non-ART groups had similar dramatic increases in consistent condom use over time; however, change in depression, unlike physical health functioning, was a significant predictor of consistent condom use when added to this model, and there remained a similar level of increased condom use among ART and non-ART patients. HIV care and ART increase sexual activity and condom use, but depression undercuts the prevention benefits of ART, highlighting the need to integrate mental health services into HIV care.

Changes in sexual desires and behaviours of people living with HIV after initiation of ART: implications for HIV prevention and health promotion

BACKGROUND

As immune compromised HIV sero-positive people regain health after initiating antiretroviral treatment (ART), they may seek a return to an active 'normal' life, including sexual activity. The aim of the paper is to explore the changing sexual desires and behaviour of people on ART in Uganda over a 30 month period.

METHODS

This study employed longitudinal qualitative interviews with forty people starting ART. The participants received their ART, adherence education and counselling support from The AIDS Support Organisation (TASO). The participants were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment, 3, 6, 18 and 30 months of their ART use.

RESULTS

Sexual desire changed over time with many reporting diminished desire at 3 and 6 months on ART compared to 18 and 30 months of use. The reasons for remaining abstinent included fear of superinfection or infecting others, fear that engaging in sex would awaken the virus and weaken them and a desire to adhere to the counsellors' health advice to remain abstinent. The motivations for resumption of sexual activity were: for companionship, to obtain material support, social norms around marriage, desire to bear children as well as to satisfy sexual desires. The challenges for most of the participants were using condoms consistently and finding a suitable sexual partner (preferably someone with a similar HIV serostatus) who could agree to have a sexual relationship with them and provide for their material needs.

CONCLUSIONS

These findings point to the importance of tailoring counselling messages to the changing realities of the ART users' cultural expectations around child bearing, marriage and sexual desire. People taking ART require support so they feel comfortable to disclose their HIV status to sexual partners.