Cultural expectations and reproductive desires: experiences of South African women living with HIV/AIDS (WLHA)

Social impacts experienced by women with HIV and infertility in sub-Saharan Africa: A scoping review

BACKGROUND

In Sub-Saharan Africa (SSA), HIV (Human Immunodeficiency Virus) prevalence among reproductive-aged women remains high, and infertility among these women is common. The social consequences for these women are yet to be explored. This scoping review summarises the social consequences of living with HIV and infertility for SSA women.

METHODS

This scoping review of published peer-reviewed literature focused on the intersection of infertility and living with HIV among women in SSA. We followed the PRISMA guidelines for scoping reviews. We searched PubMed, Web of Science and SCOPUS and included all original research reports which met the inclusion criteria; women in Sub-Saharan Africa, living with HIV, and infertility.

RESULTS

Fourteen papers met the inclusion criteria. Both HIV diagnosis and infertility were reported as stigmatising experiences for women who desire to have children. The stigma of infertility had a greater negative impact on women than that of an HIV diagnosis. Familial, community support, and medical intervention were perceived vital to ensure women feel de-stigmatised and in control of their future, even without children.

CONCLUSION

This is the first review demonstrating the social consequences of HIV and infertility on SSA women. Further research and interventions are needed to reduce the social consequences of infertility within SSA.

The effect of education based on PEN-3 cultural model on students' menstrual health behaviors: a mixed method study

Menstruation is a natural process in girls, but sometimes it is accompanied by beliefs and behaviors with cultural roots that result in poor health consequences; this study aimed to consider perceptions of individual, families and community to current cultural beliefs, and to determine the effect of education based on the PEN-3 cultural model on students' menstrual health behaviors in Iran. Study had a mixed method design. In the qualitative phase, data were collected from students, their mothers and teachers through focused group discussion and in-depth interviews. In the quantitative phase, training was done in four 2-h sessions for intervention group. The data were collected immediately and 2 months after the training by a questionnaire and they were analyzed by Friedman and Wilcoxon non-parametric tests. Training was effective on all of the model structures and significantly increased mean score of the health behavior after training and 2 months later by 8.74 and 13.86, respectively, in intervention group (P<0.05). The perception and behavior of the others and access to sanitary services and products, especially cultural factors affect girls'' menstrual health behaviors, therefore, it is necessary to design the health plans regarding each of these factors, and the cultural context of each community.

Societal and individual drivers of fertility desires and intentions among people living with HIV: a cross sectional study of HIV clinic attendees in Soweto, South Africa

Background

High proportion of people living with HIV (PLHIV) who are in the prime of their reproductive years desire to have children. There are limited studies that explore the range of fertility intentions for PLHIV. This study investigated the fertility desires and intentions of PLHIV and the associated factors.

Methods

This was a cross-sectional study of 442 PLHIV receiving antiretroviral treatment (ART) in health facilities in Soweto, an urban township that is situated in the City of Johannesburg in South Africa. STATA version 13 was used to analyze the data.

Results

The participants' mean age was 36.3 years, 70% were females, 79.6% had at least one biological child, and 36% had 3+ children. Almost half (47%) expressed the desire for children, saying that this was because they had no biological children, or their partners wanted children, or they wanted children of a particular sex, or were feeling healthy after taking ART. An increased fertility desire was associated with absence of biological children (AOR = 5.06, 95% CI: 2.11–12.1) and with being married (AOR = 2.63, 95% CI: 1.31–5.27). A decreased fertility desire was associated with being aged 36+ (AOR = 2.63, 95% CI: 1.31–5.27), having primary education (AOR = 0.11, 95% CI: 0.01–1.30) and having ≥4 years of ART duration (AOR = 0.45, 95% CI: 0.24–0.81).

Conclusion

Individual factors played a significant role in shaping the fertility desires of PLHIV in this setting. The high desire for children underscore the need to integrate reproductive health services in HIV and AIDS care and treatment services and develop safer conception programmes to help PLHIV to conceive and have children safely.

Patient-provider communication about pregnancy and HIV among female sex workers living with HIV in Santo Domingo, Dominican Republic

Background

Health providers can play an important role in communication about pregnancy, particularly for women at increased risk for pregnancy complications, including female sex workers (FSWs) living with HIV. This study explored factors related to patient-provider communication about pregnancy among 253 FSWs living with HIV of reproductive age in Santo Domingo, Dominican Republic.

Methods

A cross-sectional design was employed including structured socio-behavioral surveys. Data were analyzed utilizing bivariate and multivariate logistic regression.

Results

Of the 253 FSWs living with HIV in this study, 95.7% had been pregnant at least once (median: 4; IQR: 3,6), 28.0% wanted more children and 36% reported a pregnancy after HIV diagnosis. Over half of participants (58.0%) reported having ever spoken to a health provider about pregnancy while living with HIV. Multivariate logistic regression found significant associations between having spoken to a health provider about HIV in pregnancy and a more positive perception of their provider (AOR: 2.0; 95% CI: 1.0, 2.5) and years since HIV diagnosis (AOR: 1.1; 95% CI: 1.0, 1.1). Participants were less likely to speak with a provider if they had a history of drug use (AOR: 0.4; 95% CI: 0.2, 0.9) or current alcohol use (AOR: 0.5; 95% CI: 0.3, 0.9).

Conclusion

Findings highlight the importance of non-judgmental and tailored provider-initiated conversations surrounding pregnancy. Future research is needed to better understand how and when pregnancy communication is initiated, as well as the content of clinical care conversations, to address the reproductive health of FSWs living with HIV.

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.

A Prospective Cohort Study of Fertility Desire, Unprotected Sex, and Detectable Viral Load in HIV-Positive Female Sex Workers in Mombasa, Kenya

BACKGROUND

Little is known about fertility desire in HIV-positive female sex workers. Fertility desire could increase HIV transmission risk if it was associated with condomless sex or lower adherence to antiretroviral therapy.

METHODS

A prospective cohort study was conducted among 255 HIV-positive female sex workers in Mombasa, Kenya. Using generalized estimating equations, fertility desire was evaluated as a risk factor for semen detection in vaginal secretions by prostate-specific antigen (PSA) test, a biomarker of condomless sex, detectable plasma viral load (VL), and HIV transmission potential, defined as visits with positive PSA and detectable VL.

RESULTS

The effect of fertility desire on PSA detection varied significantly by nonbarrier contraception use (P-interaction < 0.01). At visits when women reported not using nonbarrier contraception, fertility desire was associated with higher risk of semen detection [82/385, 21.3% vs. 158/1007, 15.7%; adjusted relative risk (aRR) 1.58, 95% confidence interval (CI): 1.12 to 2.23]. However, when women used nonbarrier contraception, fertility desire was associated with lower risk of PSA detection (10/77, 13.0% vs. 121/536, 22.6%; aRR 0.58, 95% CI: 0.35 to 0.94). Fertility desire was not associated with detectable VL (31/219, 14.2% vs. 128/776, 16.5%; aRR 0.82, 95% CI: 0.46 to 1.45) or higher absolute risk of transmission potential (10/218, 4.6% vs. 21/769, 2.7%; adjusted risk difference = 0.011, 95% CI -0.031 to 0.050).

CONCLUSIONS

Fertility desire was associated with higher risk of biological evidence of semen exposure when women were not using nonbarrier contraceptives. Low HIV transmission potential regardless of fertility desire suggests that the combination of condoms and antiretroviral therapy adherence was effective.

Reproduction and Fertility Beliefs, Perceptions, and Attitudes in People Living with HIV

People living with HIV (PLWH) have distinct needs when it comes to reproductive health, specifically regarding fertility, family planning, and pregnancy, and these needs are often complicated by HIV status. While there is ample research that focuses on reproductive health in PLWH through a quantitative lens, there is a lack of research using qualitative methods, namely, the narrative interview model. We searched PubMed and relevant abstracts to identify 72 articles published from 1997 to 2016 that described a qualitative framework for exploring the behaviors and perceptions regarding family planning, abortion, pregnancy, parenthood, fertility, and forced sterility in PLWH. The inclusion criteria initially showed 147 articles, which were further screened to exclude those that did not address fertility and family planning specifically. Our final sample of articles included articles related to qualitative research on reproductive attitudes, beliefs, and behaviors of PLWH. Several of these articles were mixed-methods analyses, but our focus was on the qualitative portion only. Further qualitative works in this area will not only contribute to gaps quantitative research in the field cannot capture by design, but also inform clinical practice, policy, and interventions through systematic, in-depth evaluation.

Factors influencing the experience of sexual and reproductive healthcare for female adolescents with perinatally-acquired HIV: a qualitative case study

BACKGROUND

Young people living with perinatally-acquired HIV require age-appropriate support regarding sex and relationships as they progress towards adulthood. HIV affects both genders but evidence suggests that young women are particularly vulnerable to sexual abuse and more prone to engaging in sexual behaviours to meet their daily survival needs. This can result in poor sexual and reproductive health (SRH) outcomes. HIV services in Malawi provide support for young women's HIV-related clinical needs, but it is unclear whether there is sufficient provision for their SRH needs as they become adults. This paper explores the sex and relationship experiences of young women growing up with perinatally-acquired HIV in order to understand how to improve SRH care and associated outcomes.

METHODS

A qualitative case study approach was adopted in which each 'case' comprised a young woman (15-19 years) with perinatally acquired HIV, a nominated caregiver and service provider. Participants were purposively selected from three multidisciplinary centres providing specialised paediatric/adolescent HIV care in Malawi. Data was collected for 14 cases through in-depth interviews (i.e. a total of 42 participants) and analysed using within-case and cross-case approaches. The interviews with adolescents were based on an innovative visual method known as 'my story book' which encouraged open discussion on sensitive topics.

RESULTS

Young women reported becoming sexually active at an early age for different reasons. Some sought a sense of intimacy, love, acceptance and belonging in these relationships, noting that they lacked this at home and/or within their peer groups. For others, their sexual activity was more functional - related to meeting survival needs. Young women reported having little control over negotiating safer sex or contraception. Their priority was preventing unwanted pregnancies yet several of the sample already had babies, and transfer to antenatal services created major disruptions in their HIV care. In contrast, caregivers and nurses regarded sexual activity from a clinical perspective, fearing onward transmission of HIV and advocating abstinence or condoms where possible. In addition, a cultural silence rooted in dominant religious and traditional norms closed down possibilities for discussion about sexual matters and prevented young women from accessing contraception.

CONCLUSION

The study has shown how young women, caregivers and service providers have contrasting perspectives and priorities around SRH care. Illumination of these differences highlights a need for service improvement. It is suggested that young women themselves are involved in future service improvement initiatives to encourage the development of culturally and socially acceptable pathways of care.

A Systematic Review and Narrative Synthesis of Interventions for Parental Human Immunodeficiency Virus Disclosure

INTRODUCTION

Disclosure of parental human immunodeficiency virus (HIV) infection to their children remains a difficult process for parents living with HIV (PLWH). In order to identify the best strategies to facilitate parental HIV disclosure, it is necessary to examine the efficacy of existing interventions designed to help PLWH parents with the disclosure process to their children.

OBJECTIVES

To systematically review the efficacy of interventions designed to assist PLWH disclose their HIV status to their children.

METHODS

We conducted a systematic review and narrative synthesis of interventions designed to assist PLWH disclose their HIV status to their children. MEDLINE/PubMed, PsycINFO, Embase, Global Health, and Web of Science were searched.

RESULTS

Studies were eligible for inclusion if they evaluated an intervention for parental HIV disclosure. Five studies published between 2001 and 2015 met the inclusion criteria. The interventions were conducted in South Africa, China, and the United States. Three of the studies used two-arm randomized controlled trials, in which the intervention group was given enhanced care while the control group received standard care. Four of the five studies included a theoretically informed intervention and three were limited to mothers. Results showed that four of the interventions increased parental HIV disclosure.

CONCLUSION

The findings suggest that parental HIV disclosure interventions are successful in assisting parents with the disclosure process and can be adapted in different cultural context. Future parental HIV disclosure interventions should include fathers in order to assist men with parental HIV disclosure.

Role of healthcare in childbearing decision-making of WLHA in Nigeria: Application of PEN-3 cultural model

Healthcare experiences among women living with HIV/AIDS (WLHA), determine their utilisation of sexual and reproductive health services, which ultimately influences their decisions on childbearing. This study aimed to understand the importance of healthcare support in the childbearing decision-making processes of WLHA, and its impact on eliminating new paediatric HIV infections. We conducted in-depth interviews between July and August 2012 with 15 WLHA receiving clinical HIV care at a teaching hospital in Lagos. Using PEN-3 cultural model, as a guide we explored perceptions of healthcare support pre- and post-partum. Findings indicate that faith in God for the delivery of a healthy child is significant during the pre-partum period, while the advice of healthcare workers concerning childbearing and access to available healthcare services carry more weight post-partum. Our findings have important implications for HIV treatment and care programmes geared towards WLHA considering childbearing, and ultimately the UN Global plan to eliminate mother-to-child transmission of HIV, as we move towards the 2030 agenda for sustainable development.

Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV

INTRODUCTION

Globally, women constitute 50% of all persons living with HIV. Gender inequalities are a key driver of women's vulnerabilities to HIV. This paper looks at how these structural factors shape specific behaviours and outcomes related to the sexual and reproductive health of women living with HIV.

DISCUSSION

There are several pathways by which gender inequalities shape the sexual and reproductive health and wellbeing of women living with HIV. First, gender norms that privilege men's control over women and violence against women inhibit women's ability to practice safer sex, make reproductive decisions based on their own fertility preferences and disclose their HIV status. Second, women's lack of property and inheritance rights and limited access to formal employment makes them disproportionately vulnerable to food insecurity and its consequences. This includes compromising their adherence to antiretroviral therapy and increasing their vulnerability to transactional sex. Third, with respect to stigma and discrimination, women are more likely to be blamed for bringing HIV into the family, as they are often tested before men. In several settings, healthcare providers violate the reproductive rights of women living with HIV in relation to family planning and in denying them care. Lastly, a number of countries have laws that criminalize HIV transmission, which specifically impact women living with HIV who may be reluctant to disclose because of fears of violence and other negative consequences.

CONCLUSIONS

Addressing gender inequalities is central to improving the sexual and reproductive health outcomes and more broadly the wellbeing of women living with HIV. Programmes that go beyond a narrow biomedical/clinical approach and address the social and structural context of women's lives can also maximize the benefits of HIV prevention, treatment, care and support.

"Getting tested is almost like going to the Salem witch trials": discordant discourses between Western public health messages and sociocultural expectations surrounding HIV testing among East African immigrant women

Washington, DC, has the highest AIDS diagnosis rate in the USA, and Black women are disproportionately affected. Although HIV testing is the first entryway into vital treatment services, evidence reveals that foreign-born blacks have a lower rate of recent HIV testing than US-born blacks. To date, however, there are no studies that examine the culture-specific perceptions of HIV testing among East African immigrant women (who comprise a large share of Black Africans in DC) to better understand their potential barriers to testing. Adopting the PEN-3 cultural model as our theoretical framework, the main objective of this study was to examine East African women's HIV testing perceptions and partner communication norms. Between October 2012 and March 2013, trained interviewers conducted a total of 25 interviews with East African women in the Washington, DC, metropolitan area. For triangulation purposes, data collection consisted of both in-depth, semi-structured interviews and cognitive interviews, in which participants were administered a quantitative survey and assessed on how they interpreted items. Qualitative thematic analysis revealed a systematic pattern of discordant responses across participants. While they were aware of messages related to Western public health discourse surrounding HIV testing (e.g., Everyone should get tested for HIV; One should talk to one's spouse about HIV testing), divergent sociocultural expectations rooted in cultural and religious beliefs prevailed (e.g., Getting an HIV test brings shame to the person who got tested and to one's family; it implies one is engaging in immoral behavior; One should not talk with one's spouse about HIV testing; doing so breaks cultural norms). Implications of using a culture-centered model to examine the role of sociocultural expectations in HIV prevention research and to develop culturally responsive prevention strategies are discussed.

Implementing comprehensive prevention of mother-to-child transmission and HIV prevention for South African couples: study protocol for a randomized controlled trial

BACKGROUND

In rural South Africa, only two-thirds of HIV-positive pregnant women seeking antenatal care at community health centers took full advantage of 'prevention of mother-to-child transmission' (PMTCT) services in 2010. Studies generally support male involvement to promote PMTCT, but the nature and impact of that involvement is unclear and untested. Additionally, stigma, disclosure and intimate partner violence pose significant barriers to PMTCT uptake and retention in care, suggesting that male involvement may be 'necessary, but not sufficient' to reduce infant HIV incidence. This study expands on a successful United States President's Emergency Plan for AIDS Relief (PEPFAR)-supported PMTCT couples intervention pilot study conducted in the Mpumalanga province, targeting HIV-positive pregnant women and their partners, the primary objective being to determine whether male partner involvement plus a behavioral intervention will significantly reduce infant HIV incidence.

METHODS/DESIGN

The study follows a cluster randomized controlled design enrolling two cohorts of HIV-positive pregnant women recruited from 12 randomly assigned Community Health Centers (CHC) (six experimental, six control). The two cohorts will consist of women attending without their male partners (n = 720) and women attending with their male partners (n = 720 couples), in order to determine whether the influence of male participation itself, or combined with a behavioral PMTCT intervention, can significantly reduce infant HIV infection ante-, peri- and postnatally.

DISCUSSION

It is our intention to significantly increase PMTCT participation from current levels (69%) in the Mpumalanga province to between 90 and 95% through engaging women and couples in a controlled, six session ante- and postnatal risk-reducing and PMTCT promotion intervention addressing barriers to PMTCT (such as stigma, disclosure, intimate partner violence, communication, infant feeding practices and safer conception) that prevent women and men from utilizing treatment opportunities available to them and their infants. Based upon the encouraging preliminary results from our pilot study, successful CHC adoption of the program could have major public health policy implications for containing the epidemic among the most vulnerable populations in rural South Africa: HIV-positive pregnant women and their infants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02085356 (registration date: 10 March 2014).

Safer conception needs for HIV prevention among female sex workers in Burkina Faso and Togo

Background. Reproductive health programming for female sex workers (FSW) may include contraceptive services but rarely addresses safer pregnancy planning. Methods. Adult FSW were enrolled into a cross-sectional study across four sites in Burkina Faso and Togo using respondent-driven sampling. Sociobehavioral questionnaires and HIV counseling and testing were administered. Sample statistics and engagement in HIV treatment were described and compared using Chi-squared statistics. Results. 1,349 reproductive-aged FSW were enrolled from January to July 2013. Overall, 267 FSW (19.8%) were currently trying to conceive. FSW trying to conceive were more likely to test positive for HIV at enrollment as compared to women not trying to become pregnant (24.5% versus 17.7%, P < 0.01); however awareness of HIV status was similar across groups. Among FSW trying to conceive, 79.0% (211/267) had previously received HIV testing, yet only 33.8% (23/68) of HIV-infected FSW reported a previous HIV diagnosis. Overall 25.0% (17/68) of HIV-infected FSW trying to conceive were on antiretroviral therapy. Conclusion. FSW frequently desire children. However engagement in the HIV prevention and treatment cascade among FSW trying to conceive is poor potentiating periconception transmission risks to partners and infants. Programs to facilitate earlier HIV diagnosis for FSW and safer conception counseling are needed as components of effective combination HIV prevention services.

Sociocultural factors influencing HIV disclosure among men in South Africa

In South Africa, more than 2 million people living with HIV are men aged 15 years and older, and heterosexual intercourse remains the predominant mode of HIV transmission. Knowledge of the sociocultural factors that influence men's decisions about whether, when, or how to disclose seropositive status remains incompletely understood. Using the PEN-3 cultural model as a guide, this study explored the sociocultural factors influencing HIV disclosure among men in South Africa. Four focus group discussions with 27 participants were used to determine the perceptions, enabling and nurturing factors that influence how men chose to reveal or conceal knowledge of their seropositive status. The results revealed that notions of male identity in the South African context, family, and community factors contribute to disclosure and nondisclosure of seropositive status among men living with HIV/AIDS. Future interventions should work to address these factors, as they are necessary with supporting disclosure among men living with HIV.

Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions

OBJECTIVE

This paper reviews available studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors.

METHODS

We search electronic databases and conducted a thematic analysis of empirical studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. Studies were mapped to describe their methods, target population and the health behaviors or health outcomes studied. Forty-five studies met the inclusion criteria.

RESULTS

The studies reviewed used the PEN-3 model as a theoretical framework to centralize culture in the study of health behaviors and to integrate culturally relevant factors in the development of interventions. The model was also used as an analysis tool, to sift through text and data in order to separate, define and delineate emerging themes. PEN-3 model was also significant with exploring not only how cultural context shapes health beliefs and practices, but also how family systems play a critical role in enabling or nurturing positive health behaviors and health outcomes. Finally, the studies reviewed highlighted the utility of the model with examining cultural practices that are critical to positive health behaviors, unique practices that have a neutral impact on health and the negative factors that are likely to have an adverse influence on health.

DISCUSSION

The limitations of model and the role for future studies are discussed relative to the importance of using PEN-3 cultural model to explore the influence of culture in promoting positive health behaviors, eliminating health disparities and designing and implementing sustainable public health interventions.