Date Published: June 13, 2018
Publisher: Public Library of Science
Author(s): Jamie W. Krashin, Lisa B. Haddad, Hannock Tweya, Jane Chiwoko, Wingston Ng’ambi, Bernadette Samala, Thomas Chaweza, Jennifer H. Tang, Mina C. Hosseinipour, Sam Phiri, Marcel Yotebieng.
As access to antiretroviral therapy increases, more HIV-infected patients in sub-Saharan Africa may desire fertility. We conducted a cross-sectional study of reproductive health knowledge, attitudes and practices to identify factors associated with desired fertility among women and men receiving care at two large public HIV clinics in Lilongwe, Malawi. Research assistants administered questionnaires to participants. We performed descriptive, bivariable and multivariable analysis of factors related to desired fertility and of factors related to contraceptive non-use among participants who did not desire fertility. One-third of participants desired future children. Having a partner who desired fertility and having lower parity were associated with desiring children among both genders. For women, believing that pregnancy was unhealthy was associated with decreased fertility desire. Fifty-five percent of women and 69% of men who did not want children in the future reported using contraception at last intercourse. Increasing age, lower parity, and making the decision to use contraception herself were associated with contraceptive non-use among women who did not desire fertility. Having discussed family planning with his partner was associated with contraceptive use among men who did not desire fertility. Knowledge of these factors can guide reproductive health counseling and service provision.
As more people access antiretroviral therapy (ART) and live healthier and longer lives with human immunodeficiency virus (HIV) in sub-Saharan Africa, their desire for future pregnancy may be increasing [1–6]. HIV prevalence and ART use in Malawi is similar to much of sub-Saharan Africa: 10.6% of reproductive-aged adults are HIV-positive, and two-thirds of those eligible receive ART . Among people living with HIV in sub-Saharan Africa, 35–75% desire children in the future [2,3,8–16]. In addition, people living with HIV, especially reproductive-age women on ART, tend to access health care more regularly than their peers . HIV-positive women and men are a large and accessible group in need of reproductive life planning discussions . These discussions would allow for targeted provision of contraception and medical guidance for achieving the healthiest possible pregnancy.
Between September and December 2013, we screened 349 women and 274 men, and enrolled 308 (88%) and 254 (93%), respectively, for a total of 562 participants. Fewer men attended clinic during these 3 months than anticipated when planning our convenience sample. Of the 562 participants enrolled, 308 women and 250 men had data on our primary outcome and are included in this report (S1 Fig).
Our study highlights several critical reproductive health issues that need to be addressed for people living with HIV. A third of participants in our study desired fertility and this was similar for both women and men. Lower parity and having a partner who desired fertility were associated with this desire for both genders. Women who thought that pregnancy was unhealthy were less likely to desire fertility. For those not desiring children, the unmet need for contraception among our study participants was high. These findings raise three important issues. First, addressing desired fertility among HIV-positive patients is important, especially because knowledge of safer conception and prevention of maternal-to-child transmission has been shown to be low in other low and middle income countries [23–25]. Second, clinical factors most easily accessible to providers, such as time since HIV diagnosis and ART use, may be less relevant to patients desiring fertility than reproductive history and personal relationships. Third, decreasing the unmet need for contraception is crucial.
Our findings provide guidance for medical providers and community workers caring for HIV-positive people in Malawi. People living with HIV deserve a full discussion of reproductive life planning. Although the majority of HIV positive patients need access to contraception to meet their reproductive goals, many desire and achieve future childbearing. Knowledge of factors associated with the desire for pregnancy may help frame discussions with this population and address gaps in knowledge about safer conception and prevention of maternal-to-child transmission of HIV. Future studies that evaluate the best way to deliver reproductive life planning to this population are necessary.