Pregnancy decisions among women with HIV

Reproductive health perspectives of young women with perinatally and behaviourally acquired HIV: A qualitative study

Introduction

The aim of this study was to describe the sexual and reproductive goals of female adolescents with human immunodeficiency virus (HIV) in an urban cohort and decipher if they vary depending on the mode of HIV acquisition.

Methods

We conducted in-depth qualitative interviews with 25 Black and/or Hispanic/Latinx female adolescents living with HIV (14 perinatally, 11 behaviourally acquired) aged 17-25 years who have access to care and antiretroviral therapy at an urban public hospitals (NYC, NY). Interviews were transcribed, coded and analysed using thematic analysis.

Results

Interviews demonstrated that access to antiretroviral therapy and HIV disclosure to a sexual partner were critical aspects of sexual health for the majority of participants. Persons with perinatal HIV defined motherhood as a source of self-validation and were confident that antiretroviral therapy prevents HIV transmission. Persons with behaviourally acquired HIV viewed their status as an insurmountable barrier that will prevent them from attaining sexual intimacy with a partner and expressed persistent concerns about HIV transmission during pregnancy despite reassurance from medical providers.

Conclusion

Sexual and reproductive perspectives of adolescents/young women living with HIV are multifactorial, highly stigmatized, and likely influenced by the mode of HIV acquisition. This population may benefit from patient-centred care models, including sexual health counselling that addresses sexual agency, intimacy, parenting and transmission risk reduction.

Reproductive decision-making of Black women living with HIV: A systematic review

BACKGROUND

Black women living with HIV account for a higher proportion of new HIV diagnoses than other groups. These women experience restricted access to reproductive services and inadequate support from healthcare providers because their position in society is based on their sexual health and social identity in the context of this stigmatizing chronic disease. By recognizing the analytical relevance of intersectionality, the reproductive decision-making of Black women can be explored as a social phenomenon of society with varied positionality.

OBJECTIVE

The purpose of this review was to synthesize the evidence about the reproductive decision-making of Black women living with HIV in high-income countries from the beginning of the HIV epidemic to the present.

METHODS

This systematic review was guided by the JBI evidence synthesis recommendations. Searches were completed in seven databases from 1985 to 2021, and the review protocol was registered with PROSPERO (CRD420180919).

RESULTS

Of 3503 records, 22 studies were chosen for synthesis, including 19 observational and three qualitative designs. Nearly, all studies originated from the United States; the earliest was reported in 1995. Few studies provided detailed sociodemographic data or subgroup analysis focused on race or ethnicity. Influencing factors for reproductive decision-making were organized into the following seven categories: ethnicity, race, and pregnancy; religion and spirituality; attitudes and beliefs about antiretroviral therapy; supportive people; motherhood and fulfillment; reproductive planning; and health and wellness.

CONCLUSION

No major differences were identified in the reproductive decision-making of Black women living with HIV. Even though Black women were the largest group of women living with HIV, no studies reported a subgroup analysis, and few studies detailed sociodemographic information specific to Black women. In the future, institutional review boards should require a subgroup analysis for Black women when they are included as participants in larger studies of women living with HIV.

The role of unintended pregnancy in internalized stigma among women living with HIV in Kenya

BACKGROUND

Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV.

METHODS

Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored.

RESULTS

About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination.

CONCLUSIONS

Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.

Experiences of patients with primary HIV diagnosis in Kermanshah-Iran regarding the nature of HIV/AIDS: A qualitative study

Background

A diagnosis of HIV (human immunodeficiency virus) infection causes a wide range of mental challenges regarding the meaning and understanding of such a diagnosis because of the specific nature of HIV and its social consequences. AIDS patients perceived their disease as multidimensional Stigma and rejection and even discrimination and insult in receiving health services. Therefore, a deep awareness and understanding of an individual's meaning and interpretation of a HIV-positive diagnosis and their relevant experiences are essential for providing better care.

Objective

This study aimed to examine the attitude, understanding, and interpretation of a positive diagnosis of HIV.

Methods

The present qualitative study was based on the descriptive phenomenological method. Participants included 13 HIV-positive patients who had been referred to the Kermanshah Counseling Center for Behavioral Diseases in Iran and diagnosed at most 6 months before being interviewed. The data were collected via semi-structured in-depth interviews.

Results

The continuous analyses of the data and the interview notes resulted in the identification of five main themes: contagious disease with two subthemes Illness and Harm to others, new self with a Crisis of identity subtheme, disappointment with the life ending and impending death subtheme, unmentionable disease with two subthemes secretive and horrifying diseases, and loss with Frustration subtheme.

Conclusion

Because the attitudes and behaviors of other people, such as relatives and people in society had a negative impact on the participants' mental status, as well as on their perceptions and understanding about the positive diagnosis, the focus of care for people with HIV/AIDS should shift from therapeutic issues to socio-cultural ones. These issues play a major role in forming an individual's understanding of HIV and can be a vital factor in improving their activities and adaptations to a positive diagnosis.

Prevalence and factors associated with fertility desires/intentions among individuals in HIV-serodiscordant relationships: a systematic review of empirical studies

INTRODUCTION

Better knowledge about fertility desires/intentions among HIV-serodiscordant partners who face unique challenges when considering childbearing may be helpful in the development of targeted reproductive interventions. The aim of this systematic review was to synthesize the published literature regarding the prevalence of fertility desires/intentions and its associated factors among individuals in HIV-serodiscordant relationships while distinguishing low- and middle-income countries (LMIC) from high-income countries (HIC).

METHODS

A systematic search of all papers published prior to February 2017 was conducted in four electronic databases (PubMed/MEDLINE, PsycINFO, Web of Science and Cochrane Library). Empirical studies published in peer-reviewed journals with individuals in HIV-serodiscordant relationships assessing the prevalence of fertility desires/intentions and/or the associated factors were included in this systematic review. This review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS AND DISCUSSION

After screening 1852 references, 29 studies were included, of which 21 were conducted in LMIC and eight in HIC. A great variability in the prevalence of fertility desires/intentions was observed in LMIC (8% to 84% (one member of the dyad included)). In HIC, the results showed a smaller discrepancy between in the prevalence (32% to 58% (one member of the dyad included)); the prevalence was higher when the couple was the unit of analysis (64% to 73%), which may be related to the fact that all these studies were conducted in the context of assisted reproduction. Few studies examined the factors associated with fertility desires/intentions, and all except one were conducted in LMIC. Individuals (e.g. number of children), couple-level (e.g. belief that the partner wanted children) and structural factors (e.g. discussions with health workers) were found to be associated.

CONCLUSIONS

The results of this systematic review suggest that many individuals in HIV-serodiscordant relationships have fertility desires/intentions, although the prevalence is particularly heterogeneous in LMIC in comparison to HIC. Well-known factors such as younger age and a fewer number of living children were consistently associated with increased fertility desires/intentions. Different couple-level factors emerged, reflecting the importance of considering both the individual and the couple. However, further studies that specifically focus on the dyad as the unit of analysis are warranted.

Fertility desire and associated factors among women on the reproductive age group of Antiretroviral treatment users in Jimma Town, South West Ethiopia

OBJECTIVES

HIV remained the major cause of death in women of reproductive age worldwide. There is limited evidence regarding the fertility desire of HIV positive women receiving HIV care in the study area. Therefore, facility based cross-sectional study was conducted from March to April 2017 to assess fertility desire of HIV positive women and associated factors among mothers in receiving HIV care Jimma town, Southwest Ethiopia. Simple random sampling technique was taken to draw the sample after stratification. Data were analyzed using SPSS version 21 and statistical significance was declared at P value less than 0.05.

RESULTS

This finding showed that, 175 (46.8%) of the Antiretroviral therapy users had fertility desire with those significantly associated factors; women in the age 18-29 years [AOR = 4.05, 95% CI 1.24-13.33], being married [AOR = 0.32, 95% CI (0.13-0.78)], having diploma educational level [AOR = 5.34, 95% CI 1.10, 15.60], having only boys or girls children [AOR = 2.79, 95% CI (1.24-6.25)], having 18-36$ monthly income [AOR = 1.27, 95% CI (1.56-10.67)], Partner's HIV status [AOR = 3.56, 95% CI (3.02-9.33)] and non use of contraceptives [AOR = 2.57, 95% CI (1.08-6.13)]. Fertility desire in the study area was high. Strengthening PMTCT service should consider fertility desire of mothers living with HIV.

Sexuality and childbearing as it is experienced by women living with HIV in Sweden: a lifeworld phenomenological study

The effectiveness of antiretroviral treatment has reduced sexual HIV transmission and mother-to-child-transmission. To optimally support women living with HIV, health care providers need deepened knowledge about HIV, sexuality and childbearing. The aim of this study was to describe the phenomenon sexuality and childbearing as experienced by women living with HIV in Sweden. Data were collected by phenomenon-oriented interviews with 18 HIV-positive women. A reflective lifeworld analysis based on phenomenological philosophy was conducted, describing the meaning structure of the phenomenon. The essence of the phenomenon is that perceptions about HIV and its contagiousness profoundly influence sexual habits and considerations in relation to pregnancy and childbearing. These perceptions are formed in combination with knowledge and interpretations about HIV by the women themselves and by their environments. The essence is further described by its constituents: Risk of transmission imposes demands on responsibility; The contagiousness of HIV limits sexuality and childbearing; Knowledge about HIV transmission provides confident choices and decisions; and To re-create sexuality and childbearing. Although HIV has a low risk of transmission if being well treated, our study shows that HIV-positive women feel more or less contagious, which influences sexuality and decision-making in relation to become pregnant and give birth.

Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique - a qualitative study

Background

In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province.

Methods

In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu’s practice theory.

Results

The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors.

Conclusion

Women’s experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women’s perceptions and the cultural context of maternity when providing information about sexual and reproductive health.

Realizing Women Living with HIV's Reproductive Rights in the Era of ART: The Negative Impact of Non-consensual HIV Disclosure on Pregnancy Decisions Amongst Women Living with HIV in a Canadian Setting

To better understand the structural drivers of women living with HIV's (WLWH's) reproductive rights and choices, this study examined the structural correlates, including non-consensual HIV disclosure, on WLWH's pregnancy decisions and describes access to preconception care. Analyses drew on data (2014-present) from SHAWNA, a longitudinal community-based cohort with WLWH across Metro-Vancouver, Canada. Multivariable logistic regression was used to model the effect of non-consensual HIV disclosure on WLWH's pregnancy decisions. Of the 218 WLWH included in our analysis, 24.8% had ever felt discouraged from becoming pregnant and 11.5% reported accessing preconception counseling. In multivariable analyses, non-consensual HIV disclosure was positively associated with feeling discouraged from wanting to become pregnant (AOR 3.76; 95% CI 1.82-7.80). Non-consensual HIV disclosure adversely affects WLWH's pregnancy decisions. Supporting the reproductive rights of WLWH will require further training among general practitioners on the reproductive health of WLWH and improved access to women-centred, trauma-informed care, including non-judgmental preconception counseling.

Stigma and Spiritual Well-being among People Living with HIV/AIDS in Southern Appalachia

The Appalachian South is disproportionately affected by HIV/AIDS. Partly due to the negative connotation that this disease carries in religiously conservative areas, HIV-related stigma remains a critical barrier to HIV care in the South. However, spirituality is a well-documented, effective coping mechanism among persons living with HIV/AIDS (PLWH). The purpose of this study was to examine the relationship between HIV-related stigma and spiritual well-being among a sample of PLWH (n = 216) in Appalachian counties of Tennessee and Alabama using the HIV Stigma Scale and the Spiritual Well-being Scale. Overall, disclosure of HIV status was the most highly reported stigma concern. Women reported higher levels of stigma and religious well-being than men. While existential well-being was negatively correlated with stigma, no significant overall correlation was found between religious well-being and stigma. Our findings reveal the importance of defining theology and differentiating between cultural religious conditioning and internalized beliefs.

Cross-sectional study on the prevalence and predictors of pregnancy among women living in HIV discordant relationships in a rural Rakai cohort, Uganda

OBJECTIVES

This study examines the prevalence of pregnancy in serodiscordant couples and identifies predictors associated with pregnancy in rural Rakai, Uganda.

STUDY DESIGN

A population-based cross-sectional study that used data from the Rakai Community Cohort Study (RCCS).

SETTING AND PARTICIPANTS

We used data from the RCCS survey round 17 (2015-2016), which included 488 women in serodiscordant relationships. This study was conducted in Rakai district, located in south-western Uganda.

PRIMARY OUTCOMES

Pregnancy status.

STATISTICAL ANALYSIS

Multivariable modified Poisson regression using stepwise selection was used to determine characteristics and behaviours associated with pregnancy status.

RESULTS

The prevalence of pregnancy was 12% in women among serodiscordant couples. HIV-negative women in serodiscordant couples had a slightly higher pregnancy prevalence rate (13.6%) compared with HIV-positive women in serodiscordant couples (11%). Factors significantly associated with higher prevalence of pregnancy were; younger age 15-24 years (prevalence risk ratio (PRR)=4.04; 95% CI 1.72 to 9.50), middle age 25-34 years (PRR=2.49; 95% CI 1.05 to 5.89), Christian religion (PRR=2.26; 95% CI 1.41 to 3.63) and inconsistent condom use in the last 12 months (PRR=4.38, 95% CI 1.09 to 17.53). Neither HIV status nor HIV status disclosure was significantly associated with risk of getting pregnant.

CONCLUSION

Nearly 12% of women in serodiscordant relationships were pregnant, highlighting the need for integrated services to prevent unintended pregnancies and reduce conceptional related risks for those choosing to conceive. Association with younger age and inconsistent condom use suggests a role for early and continued couple-based conception counselling.

High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa

BACKGROUND

Integration of family planning services into HIV care was implemented in South Africa as a core strategy aimed at reducing unintended pregnancies among childbearing women living with HIV. However, it is unclear whether this strategy has made any significant impact at the population level. This paper describes the prevalence and correlates of self-reported unplanned pregnancy among HIV-infected parturient women attending three large maternity centres in the Eastern Cape, South Africa. We also compare unplanned pregnancy rates between HIV-infected parturient women already in care (who have benefitted from services' integration) and newly diagnosed parturient women (who have not benefitted from services' integration).

METHODS

Drawing from the baseline data of the East London Prospective Cohort Study (ELPCS), data of 594 parturient women living with HIV in the Eastern Cape were included. Chi-square statistics and binary logistics regression were employed to determine the correlates of unplanned pregnancy among the cohort.

RESULTS

The prevalence of unplanned pregnancy was 71% (n = 422) with a higher rate among parturient women newly diagnosed during the index pregnancy (87%). Unplanned pregnancy was significantly associated with younger age, single status, HIV diagnosis at booking, high parity and previous abortion. Women who reported unplanned pregnancy were more likely to book late and have lower CD4 counts. After adjusting for confounding variables, having one child and five to seven children (AOR = 2.2; CI = 1.3-3.1), age less than 21 years (AOR = 3.3; CI = 1.1-9.8), late booking after 27 weeks (AOR = 2.7; CI = 1.5-5.0), not married (AOR = 4.3; CI = 2.7-6.8) and HIV diagnosis at booking (AOR = 3.0; CI = 1.6-5.8) were the significant correlates of unplanned pregnancy in the cohort.

CONCLUSION

Unplanned pregnancy remains high overall among parturient women living with HIV in the region, however, with significant reduction among those who were exposed to integrated services. The study confirms that integration of HIV care and family planning services is an important strategy to reduce unplanned pregnancy among women living with HIV. The study's findings have significant implications for the elimination of mother-to-child transmission of HIV in South Africa. Innovative interventions are needed to further consolidate and maximise the benefit of the integration of family planning services with HIV care.

The experience and management of HIV stigma among HIV-negative adults in heterosexual serodiscordant relationships in New York City

Despite treatment advances that have improved the health and life expectancy of HIV-positive people and contribute to the prevention of HIV transmission, HIV stigma is still frequently experienced by HIV-infected individuals and those close to them. This study investigated the types of HIV-related stigma experienced by HIV-negative adults in serodiscordant heterosexual relationships when their partner's HIV-positive status was revealed to family and friends and their strategies to manage such stigma. In-depth interviews were conducted in New York City with 56 men and 44 women who were HIV negative and had been in a relationship for at least six months with an HIV-positive partner of the opposite sex. Those who had disclosed the HIV status of their partner to family or friends experienced four main types of stigmatizing behaviours: distancing (avoidance of the participant or his/her partner for fear of infection), depreciation of the partner (being told their partner is not worthy of them), violation of privacy (people spreading the information that the partner is HIV positive), or accusations (being told that it was wrong to be in a relationship with HIV-positive people or to try to conceive with them). Participants described four main ways of managing actual or anticipated stigma: secrecy (not disclosing the HIV status of their partner to anyone), avoidance (breaking ties with people who held stigmatizing views), seeking support from their partner or the HIV-positive community (e.g., HIV-related organizations or their partner's family or friends), or education (informing family or friends about HIV treatment and prevention). Findings show that HIV-related "courtesy" stigma is frequently experienced by HIV-negative people in serodiscordant relationships but often can be managed. Offering support to individuals in serodiscordant relationships can improve the quality of life of HIV-positive people and their HIV-negative partners and potentially reduce HIV stigma.

Role of HIV in the desire of procreation and motherhood in women living with HIV in Spain: a qualitative approach

Background

Improved antiretroviral treatments and decrease in vertical transmission of HIV have led to a higher number of women living with HIV to consider childbearing. However, stigma and social rejection result in specific challenges that HIV positive women with procreation intentions have to face with. Our objective was to in depth analyse elements shaping their desire for procreation and specifically investigate the impact of HIV.

Methods

A qualitative study was conducted through open interviews with 20 women living with HIV between 18 and 45 years of age, from the Spanish AIDS Research Network Cohort (CoRIS). Interviews were audio-recorded and transcribed. A content analysis was performed.

Results

HIV diagnosis is a turning point in women’s sexual and emotional life that is experienced traumatically. HIV diagnosis is usually associated with the fear of an immediate death and the idea of social isolation. At this moment, women temporarily reject future motherhood or having a sexual life. HIV status is only disclosed to the closed social circle and partner support is essential in HIV diagnosis assimilation process. Health professionals provide information on assisted reproductive technology and on how to minimize risk of partner HIV transmission. Most of barriers for procreation acknowledged by women are not related to HIV. However, women fear vertical transmission and experience other barriers derived from HIV infection. In this context, pregnancy makes women feel themselves as “normal women” despite HIV. Motherhood is considered an element of compensation that helps them to cope with HIV diagnosis. All these elements make health professionals key actors: they provide information and support after HIV diagnosis.

Conclusions

Barriers and drivers for procreation are similar among HIV positive women and general population. However, stigma and discrimination linked with HIV weigh in HIV positive women decision of motherhood. In this context, it is necessary to provide these women with the necessary counselling, guidance and resources to take decisions about procreation properly informed.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0483-y) contains supplementary material, which is available to authorized users.

Reproductive decision-making in women living with human immunodeficiency virus: A systematic review

OBJECTIVES

Analyze and synthesize the research evidence to understand the reproductive decisions made by women living with HIV from the beginning of the epidemic to the present. Evaluate the barriers and the facilitators for reproductive decision-making. Identify areas of strength, improvement, and those requiring further research.

DESIGN AND DATA SOURCES

Systematic review following the PRISMA guideline. PubMed, CINAHL, PsycINFO, Cochrane Library, SocINDEX, Embase, and Scopus databases were searched from 1985 to 2016 using the following Keywords: HIV, AIDS, pregnancy, reproduction, and decision-making.

STUDY SELECTION

A total of 42 research papers were included in this review. Initially, 1563 papers were identified for the review by database (n=1544) and hand (n=19) searches. With three review levels, 1521 papers were excluded (title review, n=1272; abstract review, n=136; and full paper review, n=113). Studies published in English in peer-reviewed journals using both quantitative and qualitative methods and addressing reproductive decisions in women living with HIV were included. Thirdly, inclusion eligibility was assessed by title, abstract, and full text.

REVIEW METHODS

Random allocation conducted by the primary researcher assigned an equal number of papers to each researcher for review, including detailed instructions with an abstraction form. Discrepancies were resolved by two researchers. Research quality was assessed using the NCHBL Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, the Critical Appraisal Skills Programme for the qualitative studies and its version for systematic reviews RESULTS: The review included 42 papers, both quantitative (n=24) and qualitative methods (n=14). Most studies were completed by physicians (n=16) or nurses (n=15). More than two-thirds of the studies were performed in urban settings with predominantly African-American women (n=27). Eight factors were identified as influencing the reproductive decision-making process in women living with HIV: 'Socio-demographic, Health status and Pregnancy', 'Religion and spirituality', 'Beliefs and Attitudes about Antiretroviral Therapy', 'Healthcare providers', 'Significant others', 'Motherhood and fulfillment', 'Fear of perinatal infection and infection of partner(s)', 'Birth control and pregnancy management'.

CONCLUSIONS

Health care providers are not providing patient-centered care by applying scientific evidence to their practice when advising women with HIV in making reproductive decisions. Despite the strong evidence indicating pregnancy for women with HIV results in a safe birthing trajectory, one not likely to jeopardize the health of the either the mother or fetus, providers continue to recommend the women with HIV avoid pregnancy and neglect to invite partners to participate in the discussion.

Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda

OBJECTIVES

To compare risky sexual behaviours between HIV-positive persons initiated on antiretroviral therapy (ART) (ART-experienced) and persons waiting to start on ART (ART-naive) and assess predictors of risky sexual behaviours among HIV-infected patients in rural Rakai district, Uganda.

STUDY DESIGN

This is a cross-sectional study that used data from the Rakai Community Cohort Study (RCCS) database between 2013 and 2014. A structured questionnaire was used for data collection. We used stepwise logistic regression as an index to estimate the adjusted ORs for the association between risky sexual behaviours and ART treatment status.

STUDY SETTING

This study was conducted in Rakai district, located in south-western Uganda. The data for this study were extracted from the RCCS. RCCS is an open prospective cohort of approximately 15 000 consenting participants aged 15-49 years.

PARTICIPANTS

HIV-positive participants aged 18-49 years who had sex at least once a month with any partner prior to the start of the study.

MAIN OUTCOME MEASURES

Inconsistent/no condom use in the last 12 months, alcohol use at last sexual encounter, and two or more sexual partners.

RESULTS

ART-naive participants were more likely to report inconsistent condom use (OR=1.74, 95% CI 1.11 to 2.73) and more likely to drink alcohol at last sexual encounter (OR=1.65, 95% CI 1.11 to 2.46), compared with ART-experienced patients. ART treatment status (p<0.001) was a significant predictor of risky sexual behaviours. Both marital status (p=0.016) and occupation level (p=0.009) were positively associated with inconsistent condom use, while sex (p<0.001) correlated with alcohol use at last sexual encounter.

CONCLUSION

ART-naive participants were more likely to exhibit risky sexual behaviours than the ART-experienced participants. The intensity of risk reduction counselling should be increased for HIV-positive persons waiting to start ART but already in HIV care.

Reticence in disclosure of HIV infection and reasons for bereavement: impact on perinatally infected adolescents' mental health and understanding of HIV treatment and prevention in Johannesburg, South Africa

Survival rates of perinatally infected HIV-positive adolescents (PIA) are increasing in sub-Saharan Africa. There is a gap in understanding how disclosure and bereavement have an impact on PIA beliefs and understanding of their HIV infection and its management. In-depth interviews were conducted with 25 purposively selected adolescents aged 13-19 years from 5 public health clinics in Johannesburg, South Africa. Data were analysed using NVivo 10 using a thematic approach. PIA experience incomplete disclosure both of their HIV status and reasons for their bereavements, which limits their understanding of how they became infected, vertical transmission and prevention options like prevention of mother-to-child transmission (PMTCT). Most participants were orphaned and were experiencing complicated grieving (i.e., engaged in unresolved tasks of grieving) which had a negative impact on their mental health, and ability to accept their HIV status and adhere to treatment. PIA need improved communication regarding vertical transmission and how they became HIV-positive, as well as reasons for death of their loved ones to properly understand their HIV status and engage effectively in management. Honest communication about how relatives died and truthful engagement in the process of disclosure of HIV status is necessary to reduce stigma and complicated grieving, and improve mental health in this population.

The social stigma of HIV-AIDS: society's role

AIDS is a devastating and deadly disease that affects people worldwide and, like all infections, it comes without warning. Specifically, childbearing women with AIDS face constant psychological difficulties during their gestation period, even though the pregnancy itself may be normal and healthy. These women have to deal with the uncertainties and the stress that usually accompany a pregnancy, and they have to live with the reality of having a life-threatening disease; in addition to that, they also have to deal with discriminating and stigmatizing behaviors from their environment. It is well known that a balanced mental state is a major determining factor to having a normal pregnancy and constitutes the starting point for having a good quality of life. Even though the progress in both technology and medicine is rapid, infected pregnant women seem to be missing this basic requirement. Communities seem unprepared and uneducated to smoothly integrate these people in their societies, letting the ignorance marginalize and isolate these patients. For all the aforementioned reasons, it is imperative that society and medical professionals respond and provide all the necessary support and advice to HIV-positive child bearers, in an attempt to allay their fears and relieve their distress. The purpose of this paper is to summarize the difficulties patients with HIV infection have to deal with, in order to survive and merge into society, identify the main reasons for the low public awareness, discuss the current situation, and provide potential solutions to reducing the stigma among HIV patients.

Factors associated with post-diagnosis pregnancies in women living with HIV in the south of Brazil

Objectives

To analyze the factors associated with the occurrence of pregnancies after the diagnosis of infection by HIV.

Methods

Cross-sectional study with women of a reproductive age living with HIV/AIDS cared for in the public services of the city of Porto Alegre, in southern Brazil. The data was analyzed from a comparison between two groups: women with and women without pregnancies after the diagnosis of HIV. Poisson regression models were used to estimate the reasons of prevalence (RP).

Results

The occurrence of pregnancies after the diagnosis of HIV is associated with a lower level of education (RP adjusted = 1.31; IC95%: 1.03–1.66), non-use of condoms in the first sexual intercourse (RP = 1.32; IC95%: 1.02–1.70), being 20 years old or less when diagnosed with HIV (RP = 3.48; IC95%: 2.02–6.01), and experience of violence related to the diagnosis of HIV (RP = 1.28; IC95%: 1.06–1.56).

Conclusions

The occurrence of pregnancies after the diagnosis of infection by HIV does not indicate the exercise of the reproductive rights of the women living with HIV/AIDS because these pregnancies occurred in contexts of great vulnerability.

Reproductive history before and after HIV diagnosis: A cross-sectional study in HIV-positive women in Spain

The aim of this study is to examine the reproductive history of human immunodeficiency virus (HIV)-positive women, before and after HIV diagnosis, to describe the characteristics of women with pregnancies after HIV diagnosis, and to assess the prevalence of mother-to-child transmission.A cross-sectional study was performed among women within reproductive ages (18-49) selected from the cohort in the Spanish AIDS Research Network (CoRIS). A descriptive analysis of the pregnancy outcomes was made according to women's serostatus at the moment of pregnancy and association of women's characteristics with having pregnancy after HIV diagnosis was evaluated using logistic regression models.Overall, 161 women were interviewed; of them, 86% had been pregnant at least once and 39% after HIV diagnosis. There were 347 pregnancies, 29% of them occurred after HIV diagnosis and in these, 20% were miscarriages and 29% were voluntary termination of pregnancy. There were 3 cases of mother-to-child transmission among the 56 children born from HIV-positive mothers; in these cases, women were diagnosed during delivery. Having a pregnancy after HIV diagnosis was more likely when the younger women were at the time of diagnosis: odds ratio (OR) = 1.29 (95% confidence interval 0.40-4.17) for 25 to 29 years old, OR = 0.59 (0.15-2.29) for 30 to 34 years old, OR = 0.14 (0.03-0.74) for ≥35 years old, compared with those <25 years at diagnosis, who were diagnosed for ≥5 years (OR = 5.27 [1.71-16.18]), who received antiretroviral treatment at some point (OR = 9.38 [1.09-80.45]), and who received information on reproductive health (OR = 4.32 [1.52-12.26]).An important number of pregnancies occurred after HIV diagnosis, reflecting a desire for motherhood in these women. Reproductive and sexual health should be tackled in medical follow-ups.

Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review

Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.

"Out of All of this Mess, I Got a Blessing": Perceptions and Experiences of Reproduction and Motherhood in African American Women Living With HIV

HIV disproportionately impacts African American women of childbearing age residing in the southern United States. Antiretroviral therapy has increased the quantity and quality of life for people living with HIV and produced viable and safe reproduction possibilities for women living with HIV. However, little is known about reproductive decision-making processes for African American women living with HIV. The overall goal of our study was to qualitatively explore perspectives related to reproduction and motherhood in HIV-infected African American women of childbearing capacity. HIV-infected African American women of childbearing capacity in South Carolina (N = 42) participated in in-depth interviews. Our respondents held positive views about pregnancy and motherhood, despite nonsupportive pregnancy messages from interpersonal influences, including health care providers. Study findings uncovered the need for programs and interventions to support women's reproductive autonomy and focus on reducing conception- and pregnancy-related transmission risks to infants and uninfected sexual partners.

Shaping the Conversation: A Secondary Analysis of Reproductive Decision-Making Among Black Mothers with HIV

The purpose of this qualitative secondary data analysis is to examine the major influencers on mothers with HIV in their childbearing decisions, as well as how those influencers shape conversations with clinicians and health-care providers regarding HIV treatment and prevention. The original study gained insight into the reproductive decision-making of mothers with HIV. By analyzing a subsample of 15 interviews from an original cohort of 25 participants in the earlier study, three major themes were identified as follows: (1) family members, not health-care providers, influence reproductive decisions; (2) negative attitudes toward subsequent pregnancies are mainly due to HIV transmission; and (3) birth control decisions were predominately supported by family members, while health-care providers were not consulted.

Barriers to communication between HIV care providers (HCPs) and women living with HIV about child bearing: A qualitative study

OBJECTIVES

In the context of HIV clinical care, open discussion regarding sexual health and reproductive plans has become increasingly relevant. The aim of this paper is to explore barriers to communication between providers and women living with HIV regarding childbearing.

METHODS

In-depth interviews (IDIs) were conducted with 48 HIV infected women receiving ART at 7 different HIV clinics providing comprehensive HIV care services in four districts in Uganda, between July and August 2012. All women were aware of their HIV diagnosis prior to pregnancy or had given birth while living with HIV.

RESULTS

Four themes emerged describing barriers to communication, from the HIV-positive women's point of view: (i) provider indifference or opposition to childbearing post HIV diagnosis, (ii) anticipation of negative response from provider, (iii) provider's emphasis on 'scientific' facts, (iv) 'accidental pregnancy'.

CONCLUSION

Existing evidence regarding effective provider-patient communication should be considered for its application for reproductive counseling among HIV infected women.

PRACTICE IMPLICATIONS

These data demonstrate the need for current counseling guidelines to explore approaches that encourage open, non-judgmental, non-directive discussions with HIV positive individuals around their reproductive desires and intentions in a health care setting.

Repeat pregnancy in women with HIV infection in Latin America and the Caribbean

Intended and unintended pregnancies occur frequently among human immunodeficiency virus (HIV)-infected women. We evaluated the occurrence of repeat pregnancy and characteristics associated with this outcome among HIV-infected women in Latin America and the Caribbean who were participating in the National Institute of Child Health and Human Development (NICHD) International Site Development Initiative (NISDI). Of the 1342 HIV-infected pregnant women enrolled in NISDI, 124 (9.2%) had one or more repeat pregnancies on study. Median time between the index delivery and date of conception of the subsequent pregnancy was 1.4 years (range 0.1-5.7). Younger age (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.04-1.11 per one year decrease in age), hospitalization during the index pregnancy or up to six months post-partum [OR = 2.0, 95% CI: 1.2-3.4], and poor index pregnancy outcome (stillbirth or spontaneous/therapeutic abortion; OR = 3.4, 95% CI: 1.4-8.4) were associated with increased occurrence of repeat pregnancy in multivariable analysis. Among women with repeat pregnancies, the proportion receiving antiretroviral treatment (vs. prophylaxis) increased from 39.4% at the time of the index pregnancy to 81.8% at the time of the repeat pregnancy (p < 0.001). These results can help identify women most likely to benefit from reproductive counseling in order to assist with healthy pregnancy planning and prevention of unintended pregnancies.

Fertility Desire in Iranian Women with HIV: A Qualitative Study

BACKGROUND

Childbearing is a cause of concern for women living with HIV. To improve reproductive right of women with HIV and prevent the spread of HIV; it is needed to understand fertility experiences of infected women with HIV. The aim of this study was to explore fertility intentions and experiences of HIV-infected women in Iran.

METHODS

Totally, 15 in-depth interviews were conducted with HIV- infected women who were at reproductive age and had referred to Imam Khomeini Hospital Consultation Center for Clients with Risky Behaviors in Tehran, Iran. Data were analyzed using the conventional content analysis method in MAXQDA 10.

RESULTS

Analysis of the meaning units of interviews showed themes in describing of fertility desires of HIV women as follows: 1) Motherhood as a way for stability of life; 2) Uncertainties about the future; and 3) Unpleasant experience of pregnancy and delivery. This theme has three sub-themes as stigma, discrimination and weakness in health care system.

CONCLUSION

Health care provider and community should respect the right of infected women and inform them on sexual and reproductive health.

Reproductive desires of men and women living with HIV: implications for family planning counselling

The reproductive desires of people living with HIV/AIDS (PLHIV) of low socioeconomic standing attending public health facilities in South Africa were studied. HIV-positive men, pregnant and non-pregnant women were recruited from two clinics at a large public hospital in Tshwane, South Africa. Individual interviews were used to explore the reproductive desires of HIV-positive participants. HIV counsellors' perceptions of their clients' reproductive desires were explored during focus group discussions. Parenthood proved to be an important factor to all participants in continuation of the family and establishing their gender identities, despite the possible risk of HIV transmission and community stigmatization. Different cultural procreation rules for men and women and stigmatizing attitudes towards PLHIV affected their reproductive decision making. Women had the dilemma of choosing which community expectations they wanted to fulfil. Community stigmatization towards PLHIV was visible in the negative attitudes of some HIV counsellors regarding HIV and procreation. Because the reproductive desires of PLHIV are currently not given high priority in HIV prevention and family planning in the public health sector in South Africa, the prevention of HIV transmission may be jeopardized. These results necessitate the integration of HIV and sexual and reproductive health counselling on a primary health care level.

Trajectories of Childbearing among HIV Infected Indian Women: A Sequence Analysis Approach

BACKGROUND

HIV infection closely relates to and deeply affects the reproductive career of those infected. However, little is known about the reproductive career trajectories, specifically the interaction of the timing of HIV diagnosis with the timing and sequencing of reproductive events among HIV infected women. This is the first study to describe and typify this interaction.

METHODS

Retrospective calendar data of ever married HIV infected women aged 15-45 attending a HIV clinic in Pune, Maharashtra, Western India (N=622) on reproductive events such as marriage, cohabitation with the partner, use of contraception, pregnancy, childbirth and HIV diagnosis were analyzed using sequence analysis and multinomial logistic regression.

RESULTS

Optimal matching revealed three distinct trajectories: 1) HIV diagnosis concurrent with childbearing (40.7%), 2) HIV diagnosis after childbearing (32.1%), and 3) HIV diagnosis after husband's death (27.2%). Multinomial logistic regression (trajectory 1 = baseline) showed that women who got married before the age of 21 years and who had no or primary level education had a significantly higher risk of knowing their HIV status either after childbearing or close to their husband's death. The risk of HIV diagnosis after husband's death was also higher among rural women and those who were diagnosed before 2005.

CONCLUSIONS

Three distinct patterns of interaction of timing of HIV diagnosis with timing and sequencing of events in the reproductive career were observed that have clear implications for (i) understanding of the individual life planning process in the context of HIV, (ii) formulation of assumptions for estimating HIV infected women in need of PMTCT services, and (iii) provision of care services.

Factors associated with conception among a sample of HIV-positive women at a hospital in Uganda

Conception among HIV-positive individuals is an important health and social issue. However, the proportion of HIV-positive women who conceive while being aware of their serostatus and the factors that influence this decision is not well documented. In a cross-sectional study, 385 HIV-positive women in the labour ward at Mulago Hospital, Uganda, were interviewed using a structured questionnaire. Data were collected on socio-demographic characteristics, contraception ever used, knowledge of antiretrovirals (ARVs), and ARVs ever used. To assess factors associated with conception among women who know their HIV-positive status, the variables were compared for women in two groups: those who conceived while knowing their HIV-positive status and those who discovered their HIV status during pregnancy. Bivariate and logistic regression analyses were used to assess confounding variables and interactions. The data show that one in every three HIV-positive women in the study population (37.1%) conceived despite being HIV-positive. Women who conceived while knowing they were HIV-positive differed from those who conceived without knowing their HIV status in regard to employment status, marital status, the employment status of their spouse/partner, and their intention to conceive. Logistic regression showed that factors independently associated with conception in this sample of HIV-positive women were: age below 25 years (odds ratio [OR] 2.06; 95% confidence interval [CI]: 1.18-3.62); unemployment (OR 2.7; 95% CI: 1.42-5.04); carrying a first pregnancy (OR 4.53; 95% CI: 2.02-9.94), being unaware of her partner's HIV status (OR 0.26; 95% CI: 0.15-0.44); having an awareness of ARVs (OR 3.66; 95% CI: 2.15-6.25); and having regrets about conceiving while being HIV-positive (OR 0.21; 95% CI: 0.09-0.46).

Prevention of perinatal transmission of human immunodeficiency virus

The reproductive health needs of all women of childbearing age should routinely address effective and appropriate contraception, safer sex practices, and elimination of alcohol, illicit drugs and tobacco should pregnancy occur. Combined antepartum, intrapartum, and infant antiretroviral (ARV) prophylaxis are recommended because ARV drugs reduce perinatal transmission by several mechanisms, including lowering maternal viral load and providing infant pre- and post-exposure prophylaxis. Scheduled cesarean delivery at 38 weeks with IV AZT decreases the risk of perinatal transmission if the HIV RNA is greater than 1000 copies/mL or if HIV levels are unknown near the time of delivery. Oral AZT should generally be given for at least 6 weeks to all infants perinatally exposed to HIV to reduce perinatal transmission of HIV.

Effect of HIV status on fertility intention and contraceptive use among women in nine sub-Saharan African countries: evidence from Demographic and Health Surveys

BACKGROUND

Expanding access to antiretroviral therapy (ART) means that HIV is no longer a death sentence. This change has implications for reproductive decisions and behaviors of HIV-infected individuals.

DESIGN

Using multiple rounds of biomarker data from Demographic and Health Surveys (2004-2012) in nine sub-Saharan African countries, we compare patterns of associations between HIV status and fertility intention and between current use of modern contraception and HIV status in the context of expanding ART coverage.

RESULTS

Generally, results show that knowledge of HIV status and proportion of women ever tested for HIV increased substantially between the two surveys for almost all countries. Whereas modern contraceptive use slightly increased, fertility intentions remained relatively stable, except for Rwanda, where they decreased. RESULTS from the two surveys for the nine countries do however indicate that there is no clear consistent pattern of fertility intention and modern contraceptive use behavior by HIV status, with variations observed across countries. However, multivariate analyses show that for Rwanda and Zimbabwe women who were HIV positive, with knowledge of their status, had lower odds of wanting more children. Similarly only in Rwanda (both surveys) were HIV-positive women who knew their status more likely to be current users of contraception compared with women who were HIV negative. The reverse was observed for Zimbabwe.

CONCLUSIONS

Generally, the results point to the fact that the assumption that reproductive intention and behavior of HIV-positive women will differ compared with that of HIV-negative women may only hold true to the extent that women know their HIV status. Continuous expansion of voluntary counseling and testing services and integration of HIV treatment and care services with reproductive health services are thus warranted.

"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.

Reproductive desire in women with HIV infection in Spain, associated factors and motivations: a mixed-method study

Background

Antiretroviral therapy has created new expectations in the possibilities of procreation for persons living with HIV. Our objectives were to evaluate reproductive desire and to analyze the associated sociodemographic and clinical factors in HIV-infected women in the Spanish AIDS Research Network Cohort (CoRIS).

Methods

A mixed qualitative-quantitative approach was designed. Women of reproductive age (18–45) included in CoRIS were interviewed by phone, and data were collected between November 2010 and June 2012 using a specifically designed questionnaire. Reproductive desire was defined as having a desire to be pregnant at present or having unprotected sex with the purpose of having children or wanting to have children in the near future.

Results

Overall, 134 women were interviewed. Median age was 36 years (IQR 31–41), 55% were Spanish, and 35% were unemployed. 84% had been infected with HIV through unprotected sex, with a median time since diagnosis of 4.5 years (IQR 2.9-6.9). Reproductive desire was found in 49% of women and was associated with: 1) Age (women under 30 had higher reproductive desire than those aged 30–39; OR = 4.5, 95% CI 1.4-14.3); 2) having no children vs. already having children (OR = 3.2; 1.3-7.7 3); Being an immigrant (OR = 2.2; 1.0-5.0); and 4) Not receiving antiretroviral treatment (OR = 3.6; 1.1-12.1). The main reasons for wanting children were related to liking children and wanting to form a family. Reasons for not having children were HIV infection, older age and having children already. Half of the women had sought or received information about how to have a safe pregnancy, 87% had disclosed their serostatus to their family circle, and 39% reported having experienced discrimination due to HIV infection.

Conclusions

The HIV-infected women interviewed in CoRIS have a high desire for children, and the factors associated with this desire are not fundamentally different from those of women in the general population. Maternity may even help them face a situation they still consider stigmatized and prefer not to disclose. Health-care protocols for handling HIV-positive women should incorporate specific interventions on sexual and reproductive health to help them fulfill their procreation desire and experience safe pregnancies.

Desire for fertility among HIV-seroconcordant and -discordant couples in Lusaka, Zambia

Pregnancy rates and the desire to conceive are increasing among women living with HIV in Africa. However, attempts to conceive may increase the risk of HIV transmission or reinfection. A better understanding of factors influencing fertility desires would significantly contribute to programmes to meet the reproductive needs of women living with HIV. Using a couples-based approach, this paper explored fertility desires among HIV-seroconcordant and -discordant couples in Lusaka, Zambia. Participants were 208 heterosexual couples recruited from community health clinics and their respective catchment areas. Couples completed assessments on demographics, condom use, relationship quality and communication. Desire for children was often shared among couple members, and the strongest predictor of participants' desire for children was having a partner who wanted children. Additionally, the number of children participants had, their own reports of positive communication, and their partner's HIV serostatus influenced reproductive desires. Results support the involvement of both couple members in pre-conception counselling and pregnancy planning interventions. The inclusion of both partners may be a more effective strategy to respond to the reproductive needs of couples affected by HIV, enabling them to safeguard the health of both partners and infants.

Unplanned pregnancies among HIV-infected women in care-United States

OBJECTIVE

To examine the prevalence of unplanned pregnancies among HIV-infected women in care in the United States.

METHODS

We used the 2007-2008 cycles of the Medical Monitoring Project, which collected data on HIV-infected adults in care. Women were included if they had an HIV diagnosis before 45 years of age and responded to questions about pregnancies and pregnancy planning after HIV diagnosis. Logistic regression was used to calculate unadjusted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for correlates of unplanned pregnancies among women with ≥ 1 pregnancy at or after an HIV diagnosis.

RESULTS

Of 1492 women, 382 (25.6%) reported ≥ 1 pregnancy after HIV diagnosis (median diagnosis age = 25.0 years; interquartile range = 21.0-30.0); 58% were non-Hispanic black, 22% Hispanic, and 15% non-Hispanic white. Of those, 326 (85.3%) reported ≥ 1 unplanned pregnancy; 124 (32.5%) reported recent unprotected vaginal and/or anal sex with a male partner with either negative or unknown HIV status. Unplanned pregnancies were more likely among women who reported nadir CD4 cell counts <200 cells/μL (AOR = 2.3; 95% CI: 1.2 to 4.8) or did not report nadir CD4 cell counts (AOR = 4.3; 95% CI: 1.9 to 10.5) compared with women who reported nadir CD4 cell counts ≥ 200 cells/μL; and who received public assistance in the most recent year before Medical Monitoring Project interview (AOR = 2.1; 95% CI: 1.1 to 3.8) compared with women who did not receive assistance.

CONCLUSIONS

Unplanned pregnancies were prevalent among our sample. To avoid unplanned pregnancies, HIV-infected women need access to effective family planning services and risk reduction discussions during routine care visits.

Family planning practice and predictors of risk of inconsistent condom use among HIV-positive women on anti-retroviral therapy in Cambodia

Background

In Cambodia, while anti-retroviral therapy (ART) services are increasingly available, the unmet needs of family planning among general population are high. These facts raise concern on possible exposure of many HIV-positive women on ART to the potential risk of unintended pregnancy. This study aimed to clarify family planning practices in Cambodia and determine predictors of risk of inconsistent condom use among women on ART.

Methods

A cross-sectional survey with a structured questionnaire was conducted at five government-run health centers in Phnom Penh, Cambodia, from June to September, 2012. Multiple logistic regression analysis was used to identify predictors of risk of inconsistent condom use among regular users of contraceptive methods.

Results

Of 408 respondents, 40, 17 and 10 used the pill, IUD, and injection, respectively, while 193 used condoms. 374 were not planning to have a child. Among 238 sexually active women who were not planning to have a baby, 59 were exposed to the risk of unintended pregnancy. Multivariate logistic regression analysis that did not include variables related to partners identified "seeking family planning information" (adjusted odds ratio (AOR): 2.6, 95% confidence intervals (95% CI): 1.1-6.2), awareness of mother-to-child transmission (MTCT) (AOR: 4.7, 95% CI: 1.9-11.6) and "having a son" (AOR: 2.0, 95% CI: 1.1-3.9) were significant predictors of inconsistent condom use. Another model that included all variables identified “able to ask a partner to use condom at every sexual intercourse” was the only predictor (AOR: 23.7, 95% CI: 5.8-97.6).

Conclusions

About one-quarter of women on ART are at risk to unintended pregnancy although most do not plan to get pregnant. Furthermore, women on ART could be more empowered through improvement of communication and negotiation skills with partners to demand the use of condom during sexual intercourse. The use of other contraceptive methods that do not need partner involvement should be promoted.

Reproductive health decision-making in perinatally HIV-infected adolescents and young adults

With widespread access to antiretroviral therapy in the United States, many perinatally HIV-infected (PHIV+) children are surviving into adolescence and adulthood, becoming sexually active and making decisions about their reproductive health. The literature focusing on the reproductive decisions of individuals behaviorally infected with HIV can serve as a springboard for understanding the decision-making process of PHIV+ youth. Yet, there are many differences that critically distinguish reproductive health and related decision-making of PHIV+ youth. Given the potential public health implications of their reproductive decisions, better understanding of factors influencing the decision-making process is needed to help inform the development of salient treatment and prevention interventions. To begin addressing this understudied area, a "think tank" session, comprised of clinicians, medical providers, and researchers with expertise in the area of adolescent HIV, was held in Bethesda, MD, on September 21, 2011. The focus was to explore what is known about factors that influence the reproductive decision-making of PHIV+ adolescents and young adults, determine what important data are needed in order to develop appropriate intervention for PHIV+ youth having children, and to recommend future directions for the field in terms of designing and carrying out collaborative studies. In this report, we summarize the findings from this meeting. The paper is organized around the key themes that emerged, including utilizing a developmental perspective to create an operational definition of reproductive decision-making, integration of psychosocial services with medical management, and how to design future research studies. Case examples are presented and model program components proposed.

Contemplating abortion: HIV-positive women's decision to terminate pregnancy

Research on pregnancy termination largely assumes HIV status is the only reason why HIV-positive women contemplate abortion. As antiretroviral treatment (ART) becomes increasingly available and women are living longer, healthier lives, the time has come to consider the influence of other factors on HIV-positive women's reproductive decision-making. Because ART has been free and universally available to Brazilians for more than two decades, Brazil provides a unique context in which to explore these issues. A total of 25 semi-structured interviews exploring women's pregnancy termination decision-making were conducted with women receiving care at the Reference Centre for HIV/AIDS in Salvador, Brazil. Interviews were transcribed, translated into English and coded for analysis. HIV played different roles in women's decision-making. In all, 13 HIV-positive women did not consider terminating their pregnancy. Influential factors described by those who did consider terminating their pregnancy included fear of HIV transmission, fear of HIV-related stigma, family size, economic constraints, partner and provider influence, as well as lack of access to pregnancy termination services and abortifacients. For some HIV-positive women in Brazil, HIV can be the only reason to consider terminating a pregnancy, but other factors are significant. A thorough understanding of all variables affecting reproductive decision-making is necessary for enhancing services and policies and better meeting the needs and rights of HIV-positive women.

The pregnancy decisions of HIV-positive women: the state of knowledge and way forward

Despite the growing number of women living with and affected by HIV, there is still insufficient attention to their pregnancy-related needs, rights, decisions and desires in research, policy and programs. We carried out a review of the literature to ascertain the current state of knowledge and highlight areas requiring further attention. We found that contraceptive options for pregnancy prevention by HIV-positive women are insufficient: condoms are not always available or acceptable, and other options are limited by affordability, availability or efficacy. Further, coerced sterilization of women living with HIV is widely reported. Information gaps persist in relation to effectiveness, safety and best practices regarding assisted reproductive technologies. Attention to neonatal outcomes generally outweighs attention to the health of women before, during and after pregnancy. Access to safe abortion and post-abortion care services, which are critical to women's ability to fulfill their sexual and reproductive rights, are often curtailed. There is inadequate attention to HIV-positive sex workers, injecting drug users and adolescents. The many challenges that women living with HIV encounter in their interactions with sexual and reproductive health services shape their pregnancy decisions. It is critical that HIV-positive women be more involved in the design and implementation of research, policies and programs related to their pregnancy-related needs and rights.

Self-Reported Preconception Care of HIV-Positive Women of Reproductive Potential: A Retrospective Study

OBJECTIVES

We determined the proportion and correlates of self-reported pregnancy planning discussions (that is preconception counseling) that HIV-positive women reported to their family physicians (FPs), HIV specialists, and obstetrician/gynecologists (OB/Gyns).

METHODS

In a cross-sectional substudy, HIV-positive women of reproductive potential were asked whether their care providers discussed pregnancy planning. Logistic regression was used to calculate odds ratios for the correlates of preconception counseling.

RESULTS

A total of 431 eligible participants (median age 38, interquartile range = 32-43) reported having discussion with a physician (92% FP, 96% HIV specialists, and 45% OB/Gyns). In all, 34%, 41%, and 38% had their pregnancy planning discussion with FP, HIV specialist, and Ob/Gyns, respectively; 51% overall. In the multivariable model, significant correlates of preconception counseling were age (P = .02), marital status (P < .01), number of years living in Canada (P < .001), and age of youngest child (P < .01).

CONCLUSIONS

Preconception care in our cohort was suboptimal. We recommend that counseling on healthy preconception should be part of routine HIV care.

Engaging HIV care providers in conversations with their reproductive-age patients about fertility desires and intentions: a historical review of the HIV epidemic in the United States

Provider-initiated conversations with people living with HIV about reproductive plans are lacking. Providers must know whether their patients want to bear children to tailor treatment and refer for HIV preconception counseling to help achieve patients' reproductive goals while minimizing transmission to partners and children. The early focus on men who have sex with men largely excluded consideration of the epidemic's impact on reproductive health. We used a historical review of the US epidemic to describe the problem's scope and understand if this legacy underlies the current neglect of reproductive planning. Drawing on peer-reviewed literature, we discuss key themes relevant to assessing and understanding attention to desires for children among HIV-positive people. We conclude with recommendations for addressing persistent stigma and enhancing patient-provider communication about reproductive intentions.

Fertility desire and intention of people living with HIV/AIDS in Tanzania: a call for restructuring care and treatment services

Background

Scaling up of antiretroviral therapy (ART) is currently underway in sub-Saharan Africa including, Tanzania, increasing survival of people living with HIV/AIDS (PLWHA). Programmes pay little attention to PLWHA’s reproductive health needs. Information on fertility desire and intention would assist in the integration of sexual and reproductive health in routine care and treatment clinics.

Methods

A cross-sectional study of all PLWHA aged 15–49 residing in Kahe ward in rural Kilimanjaro Tanzania was conducted. Participants were recruited from the community and a local counselling centre located in the ward. Data on socio-demographic, medical and reproductive characteristics were collected through face-to-face interviews. Data were entered and analysed using STATA statistical software.

Results

A total of 410 PLWHA with a mean age of 34.2 and constituting 264 (64.4%) females participated. Fifty-one per cent reported to be married/cohabiting, 73.9% lived with their partners and 60.5% were sexually active. The rate of unprotected sex was 69.0% with 12.5% of women reporting to be pregnant at the time of the survey. Further biological children were desired by 37.1% of the participants and lifetime fertility intention was 2.4 children. Increased fertility desire was associated with living and having sex with a partner, HIV disclosure, good perceived health status and CD4 count ≥200 cells for both sexes. Reduced desire was associated with havingmore than 2 children among females, divorce or separation, and having a child with the current partner among both males and females.

Conclusion

Fertility desire and intention of PLWHA was substantially high though lower than that of the general population in Tanzania. Practice of unprotected sexual intercourse with higher pregnancy rate was observed. Fertility desire was determined by individual perceived health and socio-family related factors. With increasing ART coverage and subsequent improved quality of life of PLWHA, these findings underscore the importance of integrating reproductive health services in the routine care and treatment of HIV/AIDS worldwide. The results also highlight a group of PLWHA with potentially high desire for children who need to be targeted during care.

Predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care

OBJECTIVES

To describe predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care.

METHODS

Data were obtained through the linkage of two separate studies: the UK Collaborative HIV Cohort study (UK CHIC), a cohort of adults attending 13 large HIV clinics; and the National Study of HIV in Pregnancy and Childhood (NSHPC), a national surveillance study of HIV-positive pregnant women. Pregnancy incidence was measured using the proportion of women in UK CHIC with a pregnancy reported to NSHPC. Generalized estimating equations were used to identify predictors of pregnancy and assess changes in pregnancy incidence in 2000-2009.

RESULTS

The number of women accessing care at UK CHIC sites increased as did the number of pregnancies. Older women were less likely to have a pregnancy [adjusted relative rate (aRR) 0.44 per 10 year increment in age, [95% confidence interval (CI) (0.41-0.46)], P < 0.001] as were women with CD4 cell count less than 200 cells/μl compared with CD4 cell count 200-350 cells/μl [aRR 0.65 (0.55-0.77), P < 0.001] and women of white ethnicity compared with women of black African ethnicity [aRR 0.67 (0.57-0.80), P < 0.001]. The likelihood that women had a pregnancy increased over the study period [aRR 1.05 (1.03-1.07), P < 0.001). The rate of change did not significantly differ according to age group, antiretroviral therapy use, CD4 group or ethnicity.

CONCLUSION

The pregnancy rate among women accessing HIV clinical care increased in 2000-2009. HIV-positive women with, or planning, a pregnancy require a high level of care and this is likely to continue and increase as more women of older age have pregnancies.

Childbearing Decision Making: A Qualitative Study of Women Living with HIV/AIDS in Southwest Nigeria

Using the PEN-3 model, the purpose of this qualitative study was to understand the factors responsible for the childbearing decisions of women living with HIV/AIDS (WLHA) in Lagos, Nigeria. Sixty WLHA who sought care at a teaching hospital in Lagos were recruited to participate in in-depth interviews. The average age of the participants was 30 years, and 48 participants were receiving antiretroviral therapy. Healthcare and spiritual practices, healthcare provider-patient communication about childbearing, and husband/partner support emerged as factors that contribute to the childbearing decisions of WLHA. The findings reveal the importance of discussing sexual reproductive health and childbearing issues with WLHA in the healthcare context prior to pregnancy.