Rights of HIV positive people to sexual and reproductive health: parenthood

Determinants of health-related quality of life in young adults living with perinatally acquired HIV infection in Botswana

Background

Due to the successful antiretroviral therapy (ART) programme in Botswana, large numbers of perinatally HIV-infected adolescents are emerging into young adulthood. Young adulthood is a critical period of human development. However, there is lack of information on the factors affecting the health-related quality of life (HRQOL) of young adults living with perinatally acquired HIV (YALPH) in Botswana.

Objectives

The objective of this study was to assess the HRQOL and its determinants among YALPH who were enrolled on ART at Botswana-Baylor Children’s Clinical Centre of Excellence in Gaborone, Botswana.

Method

A cross-sectional study assessed the HRQOL of 509 YALPH aged 18–30 years using the WHOQOL-HIV BREF. Data about other variables of interest were abstracted from medical records. Bivariate analyses were performed using t and Chi-square tests to determine the associations between demographic and clinical variables and general HRQOL. The variables that were associated with the general HRQOL at P-value < 0.1 were included in the multivariable analysis using the logistic regression approach.

Results

The majority of participants had good general HRQOL (78.4%). The highest mean HRQOL score was in the Physical domain (5.4 [± 2.9]) and the lowest in the Environment domain (13.8 [± 2.7]). The factors that were significantly associated with the general HRQOL included: level of education attained (P = 0.012), employment status (P = 0.069), viral load suppression (P = 0.073) and self-reported illness (P = 0.001).

Conclusion

Interventions that effectively increase educational attainment, employment opportunities, ART adherence, and prevention or management of illness are needed to promote good HRQOL among YALPH in Botswana.

Understanding the Importance of Fatherhood among Men Living with HIV in Ontario

While pregnancy and motherhood have become paramount clinical issues for women living with HIV, parenting has received less attention among men living with HIV (MLWH). We conducted a secondary analysis of a cross-sectional study assessing fertility desires and intentions of MLWH using a 5-point Likert scale based on the question: "Being a father is important to me". Logistic regression models were fit to calculate unadjusted and adjusted odds ratios (ORs) and confidence intervals (CIs) for significant correlates. Of the 276 respondents, 118 were heterosexual, 158 were gay, bisexual, 2-spirit, or queer (GBTQ), 55% had never parented before, and 65% wanted to parent. 191 (69%) respondents agreed that fatherhood was important to them. In unadjusted analyses, heterosexuality (OR 1.52; 95% CI 1.15 to 2.03), African/Caribbean/Black ethnicity (OR 1.57; 95% CI 1.12 to 2.19), African/Caribbean birthplace (OR 1.48; 95% CI 1.06 to 2.05), and history of parenting (OR 1.60; 95% CI 1.10 to 2.39) were significantly (p < 0.05) associated with importance of fatherhood. However, none of these variables were significant in adjusted analyses. From the unadjusted model, factors such as sexual orientation, ethnicity, and current parenthood may influence how MLWH value fatherhood, suggesting HIV and fatherhood is complex and must be explored further.

Motherhood and decision-making among women living with HIV in developed countries: a systematic review with qualitative research synthesis

BACKGROUND

Women living with HIV (WLH) lack evidence-based information about reproductive options while managing pressures from family, clinicians, and communities to give up the idea of having children. As the reproduction intentions of WLH are not well understood, stigmatizing behaviors force them to hide their disease to avoid rejection by their family, partner, and social networks. Compliance with social norms, fear of stigma, and discrimination influence their experience. Current research is individual qualitative studies lacking the synthesis perspective necessary to guide intervention development. The purpose of this study was to synthesize the evidence to explain the reproductive decision-making process for WLH in developed countries.

METHODS

A systematic review with qualitative research synthesis was conducted through searches in 10 electronic databases (CINAHL, EMBASE, MEDLINE, Scopus, Social Science Citation Index, Web of Science, Google Scholar, Cuidatge, Cuiden Enfispo, and SciELO). Studies published in journals from 1995 to 2019 with qualitative data about reproductive decision-making among WLH in developed countries were eligible for inclusion. Developed country was operationalized by membership in the OECD for comparative conditions of social wellbeing and economic stability. The CASP and JBI checklists for qualitative research were used to assess study quality and methodological integrity. Thematic analysis and qualitative meta-summary techniques were used for the synthesis.

RESULTS

Twenty studies from 12 developed countries were included in the synthesis. Findings were organized into 3 meta-themes from 15 themes and 45 subthemes, including: (1) Shattered identity, (2) Barriers, inequities, and misinformation, (3) Coping, resiliency, and support. Reproductive decision-making was perceived as a complex process influenced by facilitators and barriers. The facilitators helped WLH cope with their new situation to become more resilient, while the barriers made their situation more difficult to manage.

CONCLUSION

WLH encounter reproductive decision-making with knowledge deficits and limited social support. An integrated approach to holistic care with comprehensive multidisciplinary counseling is needed to support WLH. Clinicians could benefit from professional development to learn how to be authentically present for WLH, including engaging in conversations, demonstrating compassion, and understanding situations. Evidence-based clinical practice guidelines need to be tailored for the family planning and sexual health needs of WLH.

Fertility desire concordance and contraceptive use among couples living with HIV in northern Nigeria

OBJECTIVES

We aimed to determine the concordance between own and perceived partner fertility intentions and identify predictors of contraceptive use among couples receiving antiretroviral therapy in Kano, Nigeria.

METHODS

A structured, validated questionnaire was used to interview 399 married men and women receiving antiretroviral therapy. Adjusted odds ratios for predictors of contraceptive use were derived from multivariate logistic regression models.

RESULTS

Most couples (68.9%) had concordant fertility intentions. Only 10.0% of couples had discordant fertility intentions. Among 232 couples (58.1%) at least one partner used contraception. Male condoms were used by 45.9% of couples (n = 183). Female methods were used by 175 couples (43.9%). Contraceptive use was significantly higher in participants who were older (≥30 years), better educated (secondary or post-secondary), had a higher monthly income (NGN ≥30,000), longer marriage duration (≥5 years), at least one living child, >1 year of antiretroviral treatment, and who were living with a serodiscordant partner and in circumstances where the decision on contraception was made by the female partner or jointly by both partners (all p < 0.05). Contraceptive use was significantly lower in participants who had not been sexually active in the last 6 months, where both partners wanted more children, and in situations lacking spousal communication about family planning (all p < 0.05).

CONCLUSION

One in 10 couples had discordant fertility intentions. Contraceptive use was suboptimal and was predicted by age, education, income, length of marriage, number of children, duration of antiretroviral therapy, partner's serostatus, sexual activity, fertility intention, spousal communication and the contraceptive decision-maker. Our findings highlight the need for spousal communication, joint contraceptive decision making and the integration of reproductive health services with antiretroviral therapy services.

US Provider Perceptions of Differences in the Sexual and Reproductive Health Needs of Adolescents with Perinatally Acquired and Behaviorally Acquired HIV: A Mixed Methods Study

This study explores health care providers' perceptions of similarities and differences in the sexual and reproductive needs of adolescents with perinatally acquired HIV (PHIV) and behaviorally acquired HIV (BHIV). Interviews (n = 13) and online surveys (n = 46) were completed by medical and social service providers (n = 30, n = 29, respectively) who care for adolescents with HIV. Eligible providers were recruited using snowball sampling. Responses to open-ended questions were coded for emergent themes. Sixty-eight percent of participants perceived differences in the sexual and reproductive health needs of adolescents with PHIV and BHIV. Differences included factors related to psychosocial, sexual, and medical needs. Providers believed adolescents with PHIV had integrated their diagnosis into their identity, were more adept at communicating with providers, and were more sexually cautious than youth with BHIV. Providers perceived adolescents with BHIV as more comfortable discussing sex-related issues, and suggested youth with PHIV were more comfortable accessing health care. Adolescents with PHIV were thought to have complex medical histories/treatment and greater knowledge of illness/medications. Existing research on adolescent-reported sexual and reproductive health knowledge and experiences in care suggests that provider and adolescent perspectives do not always align. Mode of transmission may provide some information about psychosocial functioning and sexual behavior. However, assumptions about sexual and reproductive health needs based solely on mode of transmission may contribute to gaps in sexual and reproductive health care. Future research is needed to examine whether these differing perspectives indeed lead to discrepancies in the care provided to adolescents with HIV.

Socioeconomic Inequalities in the HIV Testing during Antenatal Care in Vietnamese Women

Although HIV (human immunodeficiency virus) testing for all women has been promoted by Vietnam's Ministry of Health since 2000, test acceptance rates in this country were reported to be less than 30% in the community. This country has been facing the barriers to approach the national services towards transmission prevention from mother to child including HIV testing during antenatal care (ANC) towards mothers. Here, we aim to assess the socioeconomic inequalities in HIV testing during ANC among Vietnamese women. This study used available data from the Vietnam Multiple Indicator Cluster Survey 2014. Overall, the prevalence of HIV testing during antenatal care was 30% and the concentrate index (CCI) was 0.1926. There was significant inequality between women classified as poor and rich, and when stratified by social characteristics, inequality was found in women aged 15-49 years (CCI: 0.4), living in rural areas (CCI: 0.3), belonging to ethnic minorities (CCI: 0.5) and having primary or less education (CCI: 0.4). In the multivariate logistic regression analysis, ethnicity and socioeconomic status were significant factors associated with HIV testing during ANC. We found the prevalence of HIV testing during ANC was low, and its inequalities were associated with age, living area, ethnicity, education, and economic status.

Unintended Pregnancy in Women Living with HIV in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In 2014, about 1.5 million pregnancies occurred among HIV-positive women in low and middle-income countries. To pool magnitude and factors associated with unintended pregnancy in women living with HIV in sub-Saharan Africa, a systematic search of electronic databases was undertaken in November 2016. Pooling the magnitude of unintended pregnancy reported by 14 studies yielded a crude summary prevalence of 55.9%. The magnitude of unwanted pregnancy and mistimed pregnancy in six studies ranged from 14 to 59 and 9 to 47.2%, respectively. Contraceptive failure was an important factor for many unintended pregnancies. The magnitude of unintended pregnancy was significantly higher in HIV-positive women than for HIV-negative women in three out of six studies. The available evidence suggests that there is a high magnitude of unintended pregnancy in this population. Improving effective contraceptive utilization is thus a priority to address unintended pregnancies and to prevent mother to child transmission of HIV. PROSPERO Number: CRD42016051310.

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.

Prevalence of fertility desire and its associated factors among 15- to 49-year-old people living with HIV/AIDS in Addis Ababa, Ethiopia: a cross-sectional study design

Background

The magnitude of unprotected sex to satisfy the desire for fertility among people living with HIV/AIDS (PLHIV) may rise more due to the availability of antiretroviral therapy (ART) in most HIV-affected countries. This could, however, have the risk of passing on HIV to sexual partners and children. The aim of this study, therefore, was to determine the magnitude and factors associated with the fertility desire of reproductive-age PLHIV in Addis Ababa, Ethiopia, for research-based and timely actions.

Methods

A cross-sectional study was carried out from April to June 2016 among 442 randomly selected, reproductive-age PLHIV who had been attending ART clinics in Addis Ababa. Twelve experienced and trained nurses collected the data. The questionnaire was pretested and interviewer-administered, and the interview was executed after obtaining voluntary consent from each study subject. The data were then cleaned and analyzed by using Epi Info version 3.5.4 and SPSS version 20.0, respectively. Binary logistic regression was done in order to describe the association of fertility desire with some sociodemographic and sexual behavior-related factors.

Results

Among the total 441 respondents, 54.6% reported the desire for fertility, 87% disclosed their HIV status, 24.3% had two or more sexual partners in the earlier year, and only 55.6% used a condom during their last sexual intercourse. In addition, current health status (AOR=2.03; 95% CI: 1.01–4.07) and partner being tested for HIV (AOR=6.31; 95% CI: 1.35–29.64) showed statistically significant associations with fertility desire during multivariate logistic regression analysis.

Conclusion

A considerable number of PLHIV in the study area reported a desire for having children. Current health status and partner being tested for HIV were found to be factors associated with the fertility desire among PLHIV. Thus, more efforts to effectively address the health concerns related to fertility desire and risky sexual behavior among HIV-infected people of reproductive age could play a significant role in prevention and control measures against HIV/AIDS epidemic.

Access to fertility services in Canada for HIV-positive individuals and couples: a comparison between 2007 and 2014

In the modern era of HIV care, a multitude of clinical needs have emerged; one such need is the growing sub-specialty of HIV and reproductive health. In 2007, a study surveying Canadian fertility clinics found limited access to fertility services for HIV-positive patients. Given the extensive efforts made to address this lack of services, a follow-up assessment was warranted. This study aimed to compare the access to Canadian fertility clinics and services for HIV-positive individuals and couples in 2014 and 2007. Surveys were sent to medical or laboratory directors of assisted reproductive technology (ART) clinics in 2014 and results were compared to those sent in 2007. Main outcome measures included: the proportion of fertility clinics willing to provide ART to people with HIV, the specific services offered, and whether the 2012 Canadian HIV Pregnancy Planning Guidelines were implemented to inform practice. Across Canadian provinces, 20/34 (59%) clinics completed the survey. Ninety-five percent (19/20) of clinics accepted HIV-positive patients for consultation. Only 50% (10/20) of clinics in four provinces offered a full range of ART (defined as including in vitro fertilization [IVF]). Ten clinics (50%) in five provinces were aware that guidelines exist; half (n = 5) having read them and four reporting implementation of all the guidelines' recommendations in their practice. Compared to 2007, more clinics had implemented separate facilities (p = 0.028) to treat HIV-positive individuals, offered IVF (p = 0.013) for HIV-positive female partners, sperm washing (p = 0.033) for HIV-positive male partners, and risk reduction techniques to couples with HIV-positive men and women (p = 0.006). Access to fertility clinics for people with HIV has improved over time but is still regionally dependent and access to full ART remains limited. These findings suggest the need for advocacy targeted towards geographical-specific areas and optimizing access to comprehensive services.

Parenting Among Adolescents and Young Adults with Human Immunodeficiency Virus Infection in the United States: Challenges, Unmet Needs, and Opportunities

Given the realistic expectations of HIV-infected adolescents and young adults (AYA) to have children and start families, steps must be taken to ensure that youth are prepared to deal with the challenges associated with their HIV and parenting. Literature reviews were conducted to identify published research and practice guidelines addressing parenting or becoming parents among HIV-infected AYA in the United States. Research articles or practice guidelines on this topic were not identified. Given the paucity of information available on this topic, this article provides a framework for the development of appropriate interventions and guidelines for use in clinical and community-based settings. First, the social, economic, and sexual and reproductive health challenges facing HIV-infected AYA in the United States are summarized. Next, family planning considerations, including age-appropriate disclosure of HIV status to those who are perinatally infected, and contraceptive and preconception counseling are described. The impact of early childbearing on young parents is discussed and considerations are outlined during the preconception, antenatal, and postnatal periods with regard to antiretroviral medications and clinical care guidelines. The importance of transitioning AYA from pediatric or adolescent to adult-centered medical care is highlighted. Finally, a comprehensive approach is suggested that addresses not only medical needs but also emphasizes ways to mitigate the impact of social and economic factors on the health and well-being of these young parents and their children.

Practice of sumo kodhi among the Luo and implications for HIV transmission in western Kenya

This paper discusses the practice of sumo kodhi among the Luo ethnic group and its implications for spread of HIV in western Kenya. Sumo kodhi is a practice in which a woman arranges to have sex with a man other than her legitimate sexual partner (husband or levir/inheritor) to give birth to children with specific qualities she wants in them. Data were drawn from a 16-month ethnographic study on reproductive aspirations of women living with HIV/AIDS (WLWHA). The study found that WLWHA engaged in sumo kodhi as they believe they will get gender balanced, beautiful, and academically talented and healthy children who are free from HIV. The WLWHA targeted agnates of their husbands living in distant villages, former boyfriends (before marriage) and other men who were new in the area such as civil servants, employees in local institutions and businessmen who would not suspect their HIV status. These WLWHA kept their HIV status secret and exposed the targeted men to the risk of being infected with HIV. It can be deduced that having knowledge of HIV status does not always translate into taking action towards protecting sexual partner(s). Moreover, continued childbearing is not always as a result of unmet contraceptives needs. It is apparent from this study that social factors sometimes overrule health considerations. The study recommends that further research be conducted among other ethnic groups to gauge whether they also have a practice similar to sumo kodhi. Women living with HIV/AIDS should be involved in HIV/AIDS control and prevention strategies. There is also need for an intervention that would ensure that WLWHA meet their reproductive aspirations without putting their sexual partners at risk of contracting HIV.

Contraceptive need and use among individuals with HIV/AIDS living in the slums of Nairobi, Kenya

Objective

To understand contraceptive need and use among individuals with HIV/AIDS living in slums.

Methods

A sequential mixed-methods study was conducted in two slums in Nairobi, Kenya, from November 6th, 2009 to April 18th, 2010. Data were obtained by quantitative survey (n = 513), qualitative in-depth interviews (n = 41), and key informant interviews (n = 14).

Results

In all, 250 (55.5%) participants used contraceptives. Condoms were the most frequently reported modern method (n = 142; 60.4%), followed by injectables (n = 55; 23.4%) and dual methods (n = 38; 15.3%). Unmet need was reported by 151 (33.6%) individuals. Factors associated with contraceptive use were education, marital status, number of living children, discussion of contraception with a provider, and social support. Personal, conceptual, and structural barriers to contraceptive use were identified.

Conclusions

Individuals with HIV/AIDS wished to limit their fertility but experienced high unmet need for contraception. Multi-level interventions, including educational campaigns and integration of HIV and family planning services, are required to overcome barriers.

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.

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.

Dating, marriage, and parenthood for HIV-positive heterosexual Puerto Rican men: normalizing perspectives on everyday life with HIV

HIV-positive men are living long and healthier lives while managing HIV as a chronic illness. Although research has extensively documented the experiences of illness of people living with HIV, dating, marriage, and fatherhood among heterosexual Latino men has not been examined. To address this gap, this study used a qualitative study design to examine patterns and strategies for dating, marriage, and parenthood among 24 HIV-positive heterosexual Puerto Rican men living in Boston. The findings in our study indicate that an HIV diagnosis does not necessarily deter men from having an active sexual life, marrying, or having children. In fact, for some of the men, engaging in these social and life-changing events is part of moving on and normalizing life with HIV; these men planned for, achieved, and interpreted these events in the context of establishing normalcy with HIV. Although the HIV diagnosis discouraged some men from engaging in sexual relations, getting married, or having children, others fulfilled these desires with strategies aimed to reconciling their HIV status in their personal life, including dating or marrying HIV-positive women only. Additional important themes identified in this study include the decision to disclose HIV status to new sexual partners as well as the decision to accept the risk of HIV transmission to a child or partner in order to fulfill desires of fatherhood. Understanding the personal struggles, decision-making patterns, and needs of HIV-positive heterosexual men can aid in designing interventions that support healthy living with HIV.

HIV+ men need reproductive counseling too: Assessing childbearing goals and provider communication among HIV+ male patients in Rio de Janeiro, Brazil

We assessed reported communication with HIV providers about reproductive plans among HIV+ men in Rio de Janeiro, Brazil, and factors associated with having had such communication. A total of N=311 HIV+ men (18-50 years) receiving HIV care at one of six public primary care clinics in Rio de Janeiro between 2008-2009 were surveyed. We used descriptive statistics, and multivariate logistic regression to identify factors associated with communication about childbearing with an HIV provider. HIV+ male patients (mean age=42.7 years, 57% mixed race; 23% bisexual, 51% married/committed partner, 61% with at least one biological child, 77% on ART) reported accepting attitudes of HIV and childbearing (51%), the desire (39%), and/or intention (19%) to have a future child, and reported communication with the HIV provider (14%) or their primary partner (28%) about having children. There were no significant differences between the responses of HIV+ heterosexual and bisexual men on the above outcomes. Men who discussed childbearing with their HIV provider were more likely to have accepting attitudes about HIV and childbearing [AOR 2.8, 95%CI (1.2-6.4), p=0.014], and intend to have a child [AOR 2.6, 95% CI (1.2-5.6), p=0.018], but less likely to have discussed this topic with their partner [AOR 0.32 (0.15-0.68), p=0.003]. Among men reporting communication, 40% (17/42) reported advice against having a child. An unmet need for collaborative, nonjudgmental, and provider-initiated communication about childbearing goals exists for HIV+ men in clinical care.

HIV-Related discrimination in European health care settings

This cross-sectional European study assessed self-reported HIV-related discrimination and its associated factors in health care settings. Socio-demographics, health status, support needs relating to sexual and reproductive health (SRH), and self-reported HIV-related discrimination were measured using an anonymous survey in a sample of 1549 people living with HIV from 14 countries. Thirty-two per cent of the participants had experienced HIV-related discrimination during the previous 3 years; almost half of them felt discriminated against by health care providers. For this type of discrimination, logistic regression analysis revealed significant associations with not being a migrant (OR: 2.0; IC 1.0-3.7; p<0.05), having been forced into sexual activities (OR: 1.6; IC 1.2-2.2; p<0.001), reporting lack of time to discuss SRH during service provision (OR: 1.7; IC 1.0-2.7; p<0.05), and insufficient openness among service providers to discuss SRH (OR: 2.0; IC 1.1-3.4; p<0.05). Other significant associations related to unmet support needs on safer sex practices (OR: 1.8; IC 1.0-3.2; p<0.05), partner communication about sexuality (OR: 2.0; IC 1.1-3.4; p<0.05), and prevention of sexually transmitted infections (OR: 1.7; IC 1.0-3.0; p<0.05). Female gender had a protective effect (OR: 0.2; IC 0.0-0.9; p<0.05). Being denied the opportunity to discuss SRH may translate in feelings of discrimination. Improving health care providers' communication skills, and fostering openness about SRH topics in HIV care could contribute to destigmatization of PLHIV.

Ryan White CARE Act Part D: matches and gaps in political commitment and local implementation

This article demonstrates the opportunities for and challenges of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Part D to implementing its mandate for comprehensive family-centered systems of care for women, infants, children, and youth with HIV/AIDS. Part D legislation should promote practices addressing families with models for basic security, judiciously embrace those universal public health policies aiming to improve children's overall welfare, and consistently repudiate those policies infringing on human rights of women infected with HIV, or ignoring their children's basic needs. The proposed revisions to Part D implementation may renew its political commitment to serving the needs of families who are HIV affected.

Living with HIV postdiagnosis: a qualitative study of the experiences of Nairobi slum residents

OBJECTIVES

To characterise the experiences of heterosexual men and women living with HIV postdiagnosis and explain these experiences in relation to their identity and sexuality.

DESIGN

Qualitative study using in-depth interviews and a theoretically informed biographic disruption theory.

SETTING

Interviews were conducted in two Nairobi slums (Kenya).

PARTICIPANTS

41 HIV-infected heterosexual men and women aged 18 years or older.

RESULTS

People living with HIV have divergent experiences surrounding HIV diagnosis. Postdiagnosis, there are multiple phases of identity transition, including status (non-)disclosure, and attempts at identity repair and normalcy. For some people, this process involves a transition to a new self-identity, incorporating both HIV and antiretroviral treatment (ART) into their lives. For others, it involves a partial transition, with some aspects of their prediagnosis identity persisting, and for others it involves a rejection of HIV identity. Those people who were able to incorporate HIV/AIDS in their identity, without it being disruptive to their biography, were pursuing safer sexual and reproductive lives. By contrast, those people with a more continuous biography continued to reflect their prediagnosis identity and sexual behaviour.

CONCLUSIONS

People living with HIV/AIDS (PLWHA) had to rework their sense of identity following diagnosis in the context of living in a slum setting. Men and women living with HIV in slums are poorly supported by health systems and services as they attempt to cope with a diagnosis of HIV. Given the availability of ART, health services and professionals need to support the rights of PLWHA to be sexually active if they want to and achieve their fertility goals, while minimising HIV transmission risk.

Reproductive decision-making and periconception practices among HIV-positive men and women attending HIV services in Durban, South Africa

Understanding reproductive decisions and periconception behavior among HIV-discordant couples is important for designing risk reduction interventions for couples who choose to conceive. In-depth interviews were conducted to explore reproductive decision-making and periconception practices among HIV-positive women with recent pregnancy (n = 30), and HIV-positive men (n = 20), all reporting partners of negative or unknown HIV-status, and attending HIV services in Durban, South Africa. Transcripts were coded for categories and emergent themes. Participants expressed strong reasons for having children, but rarely knew how to reduce periconception HIV transmission. Pregnancy planning occurred on a spectrum ranging from explicitly intended to explicitly unintended, with many falling in between the two extremes. Male fertility desire and misunderstanding serodiscordance contributed to HIV risk behavior. Participants expressed openness to healthcare worker advice for safer conception and modified risk behavior post-conception, suggesting the feasibility of safer conception interventions which may target both men and women and include serodiscordance counseling and promotion of contraception.

The Linked Response: Lessons Emerging from Integration of HIV and Reproductive Health Services in Cambodia

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission.

Perceived discrimination, social support, and perceived stress among people living with HIV/AIDS in China

Perceived stress among people living with HIV/AIDS (PLWH) was associated with severe mental health problems and risk behaviors. Discrimination toward PLWH in China is prevalent. Both perceived discrimination and social supports are determinants of the stress level among PLWH. Psychological support services for PLWH in China are scarce. It is unknown whether social support is a buffer between the perceived discrimination and perceived stress. With written consent, this study surveyed 258 PLWH recruited from multiple sources in two cities in China. Instruments were validated in previous or the present study, including the perceived stress scale for PLWH (PSSHIV), the perceived social support scale (PSSS), and the perceived discrimination scale for PLWH (PDSHIV). Pearson correlations and multiple regression models were fit. PDSHIV was associated with the Overall Scale and all subscales of PSSHIV, whilst lower socioeconomic status in general and lower scores of PSSS were associated with various subscales of PSSHIV. The interaction item (PSSS×PSDHIV) was nonsignificant in modeling PSSHIV, hence no significant moderating effect was detected. Whilst perceived discrimination is a major source of stress and social support can reduce stress among PLWH in China, improved social support cannot buffer the stressful consequences due to perceived discrimination. The results highlight the importance to reduce discrimination toward PLWH and the difficulty to alleviate its negative consequences. It is warranted to improve mental health among PLWH in China and it is still important to foster social support among PLWH as it has direct effects on perceived stress.

Creating continuity out of the disruption of a diagnosis of HIV during pregnancy

AIM

To understand the uniqueness of the experience of testing HIV positive from the perspective of pregnant women.

BACKGROUND

As more people learn of their HIV diagnosis through routine screening processes, it is timely to reflect on the impact of receiving an unexpected positive result.

DESIGN

A prospective qualitative study.

METHODS

This paper draws on the case studies of four women who were participating in a larger prospective qualitative study of reproductive decision-making, pregnancy and childbirth following HIV diagnosis. Multiple interviews were conducted following diagnosis during pregnancy, and, after the birth of their babies. Thematic data analysis was undertaken.

RESULTS

Drawing on Becker's theory of disruption, we document the 'sudden disjuncture' of their antenatal diagnosis and the embodied emotional struggle the women engaged in to create continuity in their lives. A diagnosis of HIV disrupted the women's biographies in terms of their health, relationships and social identity. As pregnant women, the threat of HIV was experienced most significantly in relation to their unborn child. However, their narratives also revealed how a diagnosis of HIV in the context of pregnancy, whilst traumatic, provided a focus for regaining continuity in their lives, as the baby became a metaphor for hope and orientation toward the future.

CONCLUSIONS

As HIV testing becomes more 'routine', the findings of this study serve to remind health professionals that a positive diagnosis continues to constitute a major trauma to individuals and families.

RELEVANCE TO CLINICAL PRACTICE

We propose that appropriately educated nursing and midwifery staff could facilitate the 'meaning making' process that is required for newly diagnosed HIV positive persons to find a subjective sense of well-being in their lives.

Faidha gani? What's the point: HIV and the logics of (non)-disclosure among young activists in Zanzibar

Most HIV treatment guidelines advise people who test positive to disclose their status to improve adherence and garner psychosocial care and support. Similarly, advocacy groups for people living with HIV encourage disclosure as a key component of fighting self- and community-based stigma. Although there is arguably much to be gained by disclosing, there is also much at stake, including issues of individual and family honour and the possibility of living a 'normal' life. Starting with the question, Faidha gani? or 'What's the point?' this paper attempts to shed light on motives for disclosure and non-disclosure. The arguments draw from a qualitative study among young HIV-positive adults in eastern Africa and, most specifically, an in-depth case study of one couple in Zanzibar.

Discussing childbearing with HIV-infected women of reproductive age in clinical care: a comparison of Brazil and the US

Despite long term access to highly active antiretroviral therapy in Brazil and the US, little is known about women's communication with their HIV provider regarding childbearing or the unmet need for reproductive counseling. We utilized identical survey questions to collect data from HIV-infected women of reproductive age in Rio de Janeiro (n = 180) and Baltimore (n = 181). We conducted univariate analyses to compare findings between samples of women and multivariate logistic regression to determine factors associated with childbearing desires, childbearing intentions, and provider communication among the combined sample of women (n = 361). Over one-third of women in Rio de Janeiro and nearly one-half of women in Baltimore reported the desire for future childbearing. Nevertheless, the majority of women in clinical care had not discussed future childbearing with their HIV provider. Even in countries with an advanced approach to HIV care, we found low and inadequate communication between providers and female patients about childbearing.

High occurrence of HIV-positive siblings due to repeated mother-to-child transmission in Brazil

Pregnancies in women without knowledge of their HIV-positive status increase the risk of mother-to-child transmission, and of disease progression. This study aimed to characterize the frequency of multiple pregnancies and of HIV-positive children in the family, during HAART era. We analyzed data of a national multicenter cohort study among Brazilian children with AIDS diagnosed between 1999 and 2002. In total, 945 children and their 928 mothers were included. Five hundred and ninety (64.6%) women had a history of multiple pregnancies, and 49.5% attended prenatal care (mean: 3.5 consultations; SD 3.6). In 483 child cases, HIV status of the sibling was known; 130 (26.9%) of these were infected with HIV. In 38.5% of cases, the child with AIDS included in the cohort study was the first case in the family. Despite the overall positive results of the Brazilian control policy of HIV/AIDS, our study shows that HIV infection in pregnant women was often undetected and that consequently there was a high frequency of repeated HIV-infected children. There is a need to improve comprehensive prenatal and postnatal care of Brazilian women. HIV-affected families are most vulnerable and should be targeted by specific control programs, preventing additional HIV infections in other children.

Access to safe abortion: building choices for women living with HIV and AIDS

In many areas of the world where HIV prevalence is high, rates of unintended pregnancy and unsafe abortion have also been shown to be high. Of all pregnancies worldwide in 2008, 41% were reported as unintended or unplanned, and approximately 50% of these ended in abortion. Of the estimated 21.6 million unsafe abortions occurring worldwide in 2008 (around one in 10 pregnancies), approximately 21.2 million occurred in developing countries, often due to restrictive abortion laws and leading to an estimated 47,000 maternal deaths and untold numbers of women who will suffer long-term health consequences. Despite this context, little research has focused on decisions about and experiences of women living with HIV with regard to terminating a pregnancy, although this should form part of comprehensive promotion of sexual and reproductive health rights.

In this paper, we explore the existing evidence related to global and country-specific barriers to safe abortion for all women, with an emphasis on research gaps around the right of women living with HIV to choose safe abortion services as an option for dealing with unwanted pregnancies. The main focus is on the situation for women living with HIV in Brazil, Namibia and South Africa as examples of three countries with different conditions regarding women's access to safe legal abortions: a very restrictive setting, a setting with several indications for legal abortion but non-implementation of the law, and a rather liberal setting.

Similarities and differences are discussed, and we further outline global and country-specific barriers to safe abortion for all women, ending with recommendations for policy makers and researchers.

Family planning among people living with HIV in post-conflict Northern Uganda: A mixed methods study

Background

Northern Uganda experienced severe civil conflict for over 20 years and is also a region of high HIV prevalence. This study examined knowledge of, access to, and factors associated with use of family planning services among people living with HIV (PLHIV) in this region.

Methods

Between February and May 2009, a total of 476 HIV clinic attendees from three health facilities in Gulu, Northern Uganda, were interviewed using a structured questionnaire. Semi-structured interviews were conducted with another 26 participants. Factors associated with use of family planning methods were examined using logistic regression methods, while qualitative data was analyzed within a social-ecological framework using thematic analysis.

Results

There was a high level of knowledge about family planning methods among the PLHIV surveyed (96%). However, there were a significantly higher proportion of males (52%) than females (25%) who reported using contraception. Factors significantly associated with the use of contraception were having ever gone to school [adjusted odds ratio (AOR) = 4.32, 95% confidence interval (CI): 1.33-14.07; p = .015], discussion of family planning with a health worker (AOR = 2.08, 95% CI: 1.01-4.27; p = .046), or with one's spouse (AOR = 5.13, 95% CI: 2.35-11.16; p = .000), not attending the Catholic-run clinic (AOR = 3.67, 95% CI: 1.79-7.54; p = .000), and spouses' non-desire for children (AOR = 2.19, 95% CI: 1.10-4.36; p = .025). Qualitative data revealed six major factors influencing contraception use among PLHIV in Gulu including personal and structural barriers to contraceptive use, perceptions of family planning, decision making, covert use of family planning methods and targeting of women for family planning services.

Conclusions

Multilevel, context-specific health interventions including an integration of family planning services into HIV clinics could help overcome some of the individual and structural barriers to accessing family planning services among PLHIV in Gulu. The integration also has the potential to reduce HIV incidence in this post-conflict region.

Access of people living with HIV to infertility services: perspective of Brazilian healthcare professionals

OBJECTIVE

To evaluate the perspective of professionals in university and public assisted reproductive technology (ART) and HIV/AIDS services in Brazil, on the demand of people living with HIV wishing to conceive.

DESIGN

Mixed qualitative and quantitative, descriptive, cross-sectional and case study.

METHODS

The quantitative component was based on telephone interviews to women's health and HIV/AIDS program managers at state and municipal level. For the qualitative case study, semi-structured interviews were conducted with health professionals of ART and HIV/AIDS services.

RESULTS

Only one university ART service provided care for seropositive couples, but 64% of the HIV/AIDS services at state level and 73% of municipal HIV/AIDS services offered reproductive counseling focused on preventing pregnancy. Difficulty in discussing desire to conceive, lack of political decision and of human and financial resources were the main reasons given by service managers for not offering the opportunity for HIV couples. Lack of appropriate referrals and of updated knowledge on reproductive options were constrains according to the interviews.

CONCLUSION

Desire to reproduce among people living with HIV is poorly addressed in public services in Brazil.

Number and timing of antenatal HIV testing: evidence from a community-based study in Northern Vietnam

BACKGROUND

HIV testing for pregnant women is an important component for the success of prevention of mother-to-child transmission of HIV (PMTCT). A lack of antenatal HIV testing results in loss of benefits for HIV-infected mothers and their children. However, the provision of unnecessary repeat tests at a very late stage of pregnancy will reduce the beneficial effects of PMTCT and impose unnecessary costs for the individual woman as well as the health system. This study aims to assess the number and timing of antenatal HIV testing in a low-income setting where PMTCT programmes have been scaled up to reach first level health facilities.

METHODS

A cross-sectional community-based study was conducted among 1108 recently delivered mothers through face-to-face interviews following a structured questionnaire that focused on socio-economic characteristics, experiences of antenatal care and HIV testing.

RESULTS

The prevalence of women who lacked HIV testing among the study group was 10% while more than half of the women tested had had more than two tests during pregnancy. The following factors were associated with the lack of antenatal HIV test: having two children (aOR 2.1, 95% CI 1.3-3.4), living in a remote rural area (aOR 7.8, 95% CI 3.4-17.8), late antenatal care attendance (aOR 3.6, 95% CI 1.3-10.1) and not being informed about PMTCT at their first antenatal care visits (aOR 7.4, 95% CI 2.6-21.1). Among women who had multiple tests, 80% had the second test after 36 weeks of gestation. Women who had first ANC and first HIV testing at health facilities at primary level were more likely to be tested multiple times (OR 2.9 95% CI 1.9-4.3 and OR = 4.7 95% CI 3.5-6.4), respectively.

CONCLUSIONS

Not having an HIV test during pregnancy was associated with poor socio-economic characteristics among the women and with not receiving information about PMTCT at the first ANC visit. Multiple testing during pregnancy prevailed; the second tests were often provided at a late stage of gestation.

Influence of culture on contraceptive utilization among HIV-positive women in Brazil, Kenya, and South Africa

Contraceptive choice and discontinuation are poorly understood among HIV-positive women, and HIV disease and culture may influence decisions. We assessed factors influencing contraceptive decision-making among HIV-positive women in three countries. This qualitative assessment of 108 HIV-positive women (36/site, selected by age and parity strata) was conducted in Rio de Janeiro, Brazil; Kericho, Kenya; and Soweto, South Africa. Freelist interviews assessed knowledge and attitudes towards contraception and were analyzed enumerating frequency and saliency of mentions. There was intersite consensus around list items but priority and themes varied. Site-specific factors influencing contraceptive choice were male partner wishes and fertility desire (Brazil), side-effects (South Africa), and impact on health and HIV progression (Kenya). Age, parity, and taking antiretroviral therapy (ART) impacted some themes. Contraceptive use among HIV-positive women is substantially influenced by culture and other factors. Counseling efforts should consider individual factors in method selection and offer method variety to accommodate changing needs.

Patient-provider communication and reproductive health among HIV-positive women in Rio de Janeiro, Brazil

OBJECTIVE

To qualitatively assess the influence of patient-provider communication on contraceptive choice among HIV-positive women in the context of universal antiretroviral therapy (ART) access.

METHODS

Focus group discussions (FGD; n=3), in-depth (IDI; n=15) and freelist interviews (FLI; n=36) were conducted with HIV-positive women aged 18-40 years recruited from public health units in Rio de Janeiro/Brazil.

RESULTS

Of 70 participants, 49 used ART and the median time since HIV diagnosis was 6 years (range: 1-18). The majority of participants (71.4%) reported some degree of dissatisfaction with their health providers (usually lack of open dialogue) and a few reported experiences of stigma/prejudice during appointments. Intra, interpersonal and social factors modulated behaviors and reproductive health decisions, and those issues were rarely addressed by providers during HIV clinical care.

CONCLUSION

Despite dramatic increases in survival and life quality after universal ART implementation in Brazil, reproductive health issues are neglected by multiple cadres of HIV health providers. Communication on reproductive health issues remains fragmented and potentially contradictory, compromising care in these settings.

PRACTICE IMPLICATIONS

Adequate provider training to address reproductive health-related issues in a comprehensive, culturally sensitive manner and improved integration of HIV and reproductive health care are urgently needed in this setting.

Posttest counseling and social support from health staff caring for HIV-infected pregnant women in Vietnam

Women with HIV who want to have children face a range of challenges, quandaries, and hard decisions. This article examines the role of health staff in supporting HIV-infected pregnant women who desire to maintain their pregnancies. The article is derived from anthropological research conducted in Vietnam's Quang Ninh Province, an area that has a high HIV prevalence rate and is covered under the government's prevention of mother-to-child transmission program. The study included in-depth interviews with 23 HIV-infected women who had either recently given birth or were pregnant at the time of the research. Results showed that women were satisfied with the services they received from the program. The women believed that health care staff offered them not only medical care but also social and emotional support. The article concludes that the health care system is a vital point of support for pregnant women with HIV.

HIV and pregnancy intentions: do services adequately respond to women's needs?

Too little is known about how an HIV diagnosis and access to care and treatment affect women's childbearing intentions. As access to antiretroviral therapy improves, greater numbers of HIV-positive women are living longer, healthier lives, and many want to have children. Effectively supporting women's reproductive decisionmaking in the context of HIV requires understanding how pregnancy, reproduction, and HIV intersect and asking questions that bridge the biomedical and social sciences. Considering women to be at the center of decisions on health policy and service delivery can help provide an appropriate constellation of services. A clear research agenda is needed to create a more coordinated approach to policies and programs supporting the pregnancy intentions of women with HIV.

'Even if you're positive, you still have rights because you are a person': human rights and the reproductive choice of HIV-positive persons

Global debates in approaches to HIV/AIDS control have recently moved away from a uniformly strong human rights-based focus. Public health utilitarianism has become increasingly important in shaping national and international policies. However, potentially contradictory imperatives may require reconciliation of individual reproductive and other human rights with public health objectives. Current reproductive health guidelines remain largely non prescriptive on the advisability of pregnancy amongst HIV-positive couples, mainly relying on effective counselling to enable autonomous decision making by clients. Yet, health care provider values and attitudes may substantially impact on the effectiveness of non prescriptive guidelines,particularly where social norms and stereotypes regarding childbearing are powerful, and where providers are subjected to dual loyalty pressures, with potentially adverse impacts on rights of service users. Data from a study of user experiences and perceptions of reproductive and HIV/AIDS services are used to illustrate a rights analysis of how reproductive health policy should integrate a rights perspective into the way services engage with HIV-positive persons and their reproductive choices. The analysis draws on recognised tools developed to evaluate health policies for their human rights impacts and on a model developed for health equity research in South Africa to argue for greater recognition of agency on the part of persons affected by HIV/AIDS in the development and content of policies on reproductive choices. We conclude by proposing strategies that are based upon a synergy between human rights and public health approaches to policy on reproductive health choices for persons with HIV/AIDS.