Fertility desires of antiretroviral therapy-attending HIV-positive women and its associated factors in Harari region, Ethiopia

Abstract

Background

The desire to have children among mothers living with HIV remains a serious public health issue in nations with low coverage for antiretroviral therapy and the prevention of mother-to-child transmission, even if it is feasible to have an HIV-negative child. Therefore, this study aimed to assess fertility desire and associated factors among antiretroviral therapy-attending HIV-positive women at Hiwot Fana Specialized University Hospital, in Harari, Ethiopia.

Methods

A facility-based cross-sectional study design was employed among 639 anti retro-viral therapy attending HIV - positive women by systematic random sampling method selected from June 15 to November 30, 2020. A binary logistic regression model was fitted to identify the associated factors with fertility desire. Descriptive results were presented in percentages, whereas analytical results were reported in adjusted ORs (AORs) with a 95% CI. At p=0.05, statistical significance was declared.

Results

A total of 639 participants were included in the study; 69.5%(95% CI 65.7 to 72.9%) of the participants had fertility desire. Younger age (<35 years) (AOR=2.35, 95% CI 1.27 to 4.35), married women (AOR=3.02, 95% CI 1.32 to 12.25), childless women (AOR=2.86, 95% CI 1.17 to 4.82) and women whose duration of HIV diagnosis was ≤5 years (AOR=0.41, 95% CI 0.20 to 0.71) were significantly associated with fertility desire.

Conclusion

The majority of the study participants have a desire to have children. In light of the high prevalence of fertility desire among antiretroviral therapy-attending HIV-positive women, it is recommended to counsel younger women on reproductive planning and encourage partner testing.

Introduction

Reproductive desires remain inescapable in HIV-infected individuals. Fertile HIV-infected women struggle between maintaining their fertility and coping with the stigma related to their HIV status in societies where reproduction determines one's social worth.¹ Maintaining the safety of HIV-positive women's reproduction through proven evidence-based intervention would enhance the prevention of mother-to-child transmission (PMTCT) of HIV services. These include giving antiretroviral therapy (ART) to women living with HIV for the rest of their lives to sustain their health and halt transmission during pregnancy, childbirth and lactation, and HIV infection among women of reproductive age is also prevented.²

If HIV-positive women attend the appropriate therapy, they should be able to carry their pregnancy to term and deliver a healthy baby without incident of transmission of HIV to their newborn. However, many HIV-positive women who are aware of their status seek out contraceptive services particularly because they are worried about infecting their unborn child or abandoning children, whether or not they are HIV-positive, as orphans.³

According to studies, women with HIV have a variety of reproductive goals, with the majority of them being to have children. Understanding the desire for children among women living with HIV is crucial to reducing the mother-to-child transmission of HIV.^4,5 HIV's effect on fertility is controversial: some evidence argued that HIV/AIDS contributes to reducing fertility, mainly by minimizing sexual exposure, while other evidence supports that, due to decreased lactation and a desire for more children as a result of greater infant and child mortality, HIV boosts fertility.⁶ In Ethiopia, the fertility desire pooled prevalence was 42.21%.⁷ The fertility desire of 27 HIV-positive mothers was associated with age, culture, gender, domestic violence, partner's desire and the number of children.^3,8,9

The WHO established the 2030 deadline for the AIDS epidemic to be eliminated as a threat to public health to guarantee healthy lives and promote well-being for all individuals regardless of age.¹⁰ The Ethiopian government also implemented many measures to stop the spread of the disease and to improve access to HIV care, treatments and support for those who are living with the virus.¹¹ The national human resources development strategy places a strong emphasis on educating and advancing frontline, low-level and mid-level healthcare professionals who will work in primary healthcare institutions to reduce HIV/AIDS prevalence; in keeping with this, appropriate HIV care and ART training, vigorous follow-up and efficient clinical mentorship should continue to be ensured to preserve the quality of HIV care and ART services at all levels and the consistent application of the treatment guidelines.¹¹

The national HIV prevalence in Ethiopia is 0.9%, according to the Ethiopian Demographic and Health Survey 2016, and it is 2.9% and 0.4% in urban and rural Ethiopia, respectively.¹² The DHS 2016 data were taken as the baseline for the target taken by the Ethiopian national HIV prevention roadmap to reduce adult new HIV infections by 50%.¹³ Despite those goals and targets, the prevalence of HIV in Ethiopia has stagnated and slightly increased recently.^13,14 More people are becoming infected each day, with about 5000 new infections globally each day according to UNAIDS 2018 data.¹⁵ HIV is becoming a neglected issue in our country and so are people living with HIV/AIDS. HIV-positive people have the same health and fertility needs as HIV-negative people.

It is crucial for stakeholders engaged in Sexual and Reproductive Health (SRH) programs who are working on HIV/AIDS, PMTCT and family planning to formulate evidence-based decisions among ART-attending HIV-positive women. However, preventing further HIV transmission and supporting HIV-positive women through PMTCT to get children free from HIV and reproductive health services are vital. The overall capacity of the local health services to provide PMTCT in Ethiopia was 53.7%.¹⁶ Previous studies reported that the utilization of PMTCT in health facilities of the Afar region and East Hararge Zone, Oromia region, was 67.7% and 72.8%, respectively.^17,18 There is a paucity of information on fertility desire among ART-attending HIV-positive women. This study assessed the fertility desires of ART-attending HIV-positive women and associated factors in Hiwot Fana Specialized University Hospital (HFSUH) in Harar, eastern Ethiopia.

Methods

Study design, period and setting

A facility-based cross-sectional study design was employed from June 15 to November 30 at HFSUH in the Harari region, which is 526 km from Addis Ababa to the east. The Central Statistical Agency's 2007 census estimates that the region's whole population is estimated to be 183 415, of whom 91 099 (49.7%) are females.¹⁹ There is a total of 1435 HIV-positive women enrolled in the ART follow-up care unit and 1293 of them are in the reproductive age (15–49 year) group.

Population

The study population consisted of ART-attending HIV-positive women aged 15 to 49 years; those who had ≥1 visit to the hospital ART unit at HFSUH were included.

Sample size determination and sampling procedures

The sample size was determined by considering the following assumptions: 4% margin of error (d); the level of fertility desire in Jimma in 2019 was 46.8% (p)²⁰; a 95% significance level; and a 10% non-response rate. A final sample size of 657 was calculated by using the single population proportion formula (n=[(Z_α/2)² × P (1-P)]/d²). A systematic random sampling technique was used to select the study participants.

Data collection procedure

A structured questionnaire that had been prepared from prior studies was used to collect the data.^4,5,20–22 To ensure consistency, the questionnaire was first written in English, then translated into Amharic and Afan Oromo (the local languages) and finally back into English. The questionnaire has five parts consisting of 40 questions that include sociodemographic characteristics, information on child desire, knowledge and attitude on mother-to-child transmission (MTCT) and PMTCT, HIV/AIDS and treatment conditions and reproductive characteristics. Three data collectors were selected among ART counselors to interview the respondents. The data collectors were supervised by one MSc nurse.

Study variables

The dependent variable was fertility desire.

Independent variables

Sociodemographic characteristics (age, religion, education, marital status, income), number of alive children, partner's HIV status, duration since HIV diagnosis, partner's desire for children, knowledge about PMTCT and MTCT, duration of ART use, recent CD4 cell count, self-reported health condition and discussion of SRH issues with healthcare providers were the independent variables.

Operational definitions

ART attending HIV-positive women: all women living with HIV/AIDS who had ≥1 visit to ART units for chronic care and who have started ART.

ART: the use of a combination of HIV medicine to treat HIV. ART is a treatment that lowers the body's amount of HIV, lowers the risk of HIV transmission, keeps HIV from turning into AIDS and safeguards the immune system.²³

The desire for a child: ART-attending HIV-positive women on follow-up who would like to have a child in the future. Fertility desire was investigated by using the ‘Would you like to have children in the future?’ question; then those who answered ‘Yes’ were declared to have fertility desire and those who answered ‘No’ were declared as having no fertility desire.

Data quality assurance

The data collectors were trained for 2 days by a principal investigator on the benefit of the study and items in the questionnaire. At Dilchora General Hospital, the questionnaire was pretested on 5% of the sample size, and amendments and modifications were made as a result. Throughout the whole data-collecting period, the investigators and supervisors continuously monitored the data-gathering process. The gathered data were reviewed for completeness and any necessary corrective actions were carried out. Double data entry was performed and consistency was cross-checked.

Data analysis

The collected data (Odense, Denmark) were cleaned and entered into the Epi data version 4.6.0.2 software and exported to SPSS version 26 for analysis. Descriptive data were presented via frequency tables and figures. All variables with p<0.25 during bivariate analysis were considered for multivariate logistic regression analysis to determine factors for fertility desire. Hosmer and Lemeshow's goodness of fit test was used to assess the model's fitness, and it was determined to be fit (0.65). The standard error and variance inflation factor (VIF) were used to examine the possibility of multicollinearity among independent variables, and indicated there was no multicollinearity. In multivariate analysis, AOR and 95% CI were estimated to identify factors related to fertility desire, and the level of statistical significance was set at p=0.05.

Results

Sociodemographic characteristics

A total of 639 respondents participated, giving a response rate of 97.3%. The mean (SD) respondents’ age was 33.2 (5.2) years, ranging from 18 to 45 years. More than one-half (63.7%) of the respondents were in the ≤35 years age category. Also, 233 (36.5%) of respondents had attended secondary school. Regarding marital status, the majority of participants (419 [65.6%]) were married (Table 1).

Table 1.

Sociodemographic characteristics of (n=639) ART-attending HIV-positive women in HFSUH, Harar Town, Ethiopia 2020

Variable	Number	%
Age
≤35	407	63.7
>35	232	36.3
Educational Status
No formal education	75	11.7
Primary school	207	32.4
Secondary school	233	36.5
College and above	124	19.4
Ethnicity
Oromo	197	30.8
Amhara	361	56.5
Othersa	81	12.7
Religion
Orthodox	340	53.2
Muslim	201	31.5
Othersb	98	15.3
Marital status
Married	419	65.6
Divorced	106	16.6
Otherc	114	17.8
Occupation
Housewife	139	21.8
Government employee	199	31.1
Merchant	130	20.3
Otherd	171	26.8
Income
500–1999 ETB	283	44.3
2000–3999 ETB	261	40.8
≥4000 ETB	95	14.9

^aAdere, Gurage, Tegrie and Wolayta.

^bProtestant and catholic.

^cSingle, widowed and separated.

^dUnemployed, daily laborers, house servants, students and private employees. ETB, Ethiopian birr.

HIV/AIDS, treatment and reproductive health characteristics of respondents

Approximately three-quarters of respondents (74.2%) had known their HIV status for >5 years and 63.7% of study participants have been on treatment for >5 years. Also, 77% of respondents had a recent CD 4 count of >500, and almost all respondents (98.9%) said that their overall health condition had improved after starting ART (Table 2).

Table 2.

HIV/AIDS, treatment and reproductive health characteristics of ART-attending HIV-positive women in HFSUH, Harar Town, Ethiopia 2020 (n=639)

Variable	Number	%
Number of currently alive children
1	201	31.5
2	166	26.0
≥3	109	17.1
0	163	25.5
Time since diagnosis in years
≤5	165	25.8
>5	474	74.2
Time since starting ART in years
≤5	232	36.3
>5	407	63.7
Recent CD4 count
≤500	147	23.0
>500	492	77.0
Get support from different community groups
Yes	299	46.8
No	340	53.2
Overall health status after starting ART
Improved	632	98.9
No change	7	1.1
Aware of MTCT
Yes	625	97.8
No	8	1.3
Do not know	6	0.9
Aware of PMTCT (n=625)
Yes	579	87.4
No	46	12.6

Sexual behavior, discussion with the care provider and partner status

Of the respondents, 430 (67.3%) were sexually active during the past 6 months preceding the study, of whom 327 (76.0%) used condoms. Most respondents, 573 (89.9%), discussed sexuality, childbearing and family planning with their healthcare provider and a majority (78.1%) reported that it had been an adequate session. A higher proportion of study participants (460 [72.0%]) had disclosed their serostatus to their partners. Also, 442 (92.9%) of the respondents’ partners had been tested for HIV and 76.9% turned out to be reactive (Table 3).

Table 3.

Sexual behavior, discussion with the care provider and partner status of ART-attending HIV-positive women in HFSUH, Harar Town, Ethiopia 2020 (n=639)

Variable	Number	%
Sexually active in the past 6 months
Yes	430	67.3
No	209	32.7
Have used a condom*
Yes	327	76.0
No	103	24.0
How oftena
Always	242	74.0
Sometimes	85	26.0
Reason for not using a condomb
Wanted to have children	62	60.2
Partner does not like it	11	10.7
Other	30	29.1
Serostatus disclosure to partner (n=639)
Yes	460	72.0
No	21	3.3
No partner	158	24.7
Partner tested for HIVc
Yes	442	92.9
No	34	7.1
Partner's HIV statusd
Positive	340	76.9
Negative	102	23.1
Discussion of SRH with healthcare provider (n=639)
Yes	573	89.7
No	66	10.3
Adequately discussed SRH with healthcare providere (n=573)
Yes	499	87.1
No	74	12.9

*430 observations.

^a327 observations.

^b103 observations.

^c476 observations; 16 observations from non-disclosure group.

^d442 observations.

^e573 observations.

Fertility desire

Out of 639 ART-attending HIV-positive women who participated in the study, 444 (69.5%, 95% CI 65.7 to 72.9%) expressed their desire for children (Figure 1). Of those who desire to have children, 154 (24.1%) want to have one child, 169 (26.4%) want to have two children and 102 (16.0%) want to have >2 children. Also, 140 (21.9%) want to have a child in <1 year, 121 (18.9%) in 1 to 2 years, 49 (7.7%) in >2 years and 134 (21.0%) do not know the exact time. More than one-half of the respondents’ partners (381 [59.6%]) also desire children (Table 4).

Figure 1.

Fertility desire of anti retro-viral therapy attending HIV positive women at Hiwot Fana Specialized University Hospital in Harar, Ethiopia 2020 (n=639).

Table 4.

Information on fertility desire of ART-attending HIV-positive women in HFSUH, Harar Town, Ethiopia 2020 (n=639)

Variable	Number	%
Partner's fertility desiresa
Yes	381	59.6
No	100	15.6
Number of children desiredb
1	154	34.7
2	169	38.1
>2	102	23.0
Do not know	19	4.3
When to have a childc
<1 year	140	31.5
1–2 years	121	27.3
>2 years	49	11.0
Do not know	134	30.2
Reason for non-desired
Have the desired number of children	93	47.7
Fear of MTCT	15	7.7
Inadequate income	59	30.3
Healthcare providers advised me not to have another child	12	6.2
Childbearing may further compromise my/my partner's health	16	8.2

^a481 observations.

^b444 observations.

^c444 observations.

^d195 observations.

Factors associated with fertility desire of ART-attending HIV-positive women in binary and multivariate logistic regression

In bivariate analysis, age, marital status, number of alive children, duration since diagnosis with HIV, duration since started ART, overall health status after starting ART and discussion of SRH were associated with fertility desire.

In multivariate analysis, age, marital status, number of alive children and duration of HIV diagnosis were significantly associated with fertility desire at p<0.05. Women aged ≤35 y were 2.35 (AOR=2.35, 95% CI 1.27 to 4.35) times more likely to desire children than women aged >35 y. Married women were 3.02 (AOR=3.02, 95% CI: 1.32 to 9.25) times more likely to desire children than divorced women. The odds of fertility desire for women who had no children were 2.86 (AOR=2.86, 95% CI 1.17 to 4.82) times more likely to desire children than women who had ≥3 children. Women whose duration of diagnosis with HIV was >5 years were 1.51 (AOR=1.51, 95% CI 1.11 to 2.41) times more likely to desire children than women whose duration of diagnosis was ≤5 years (Table 5).

Table 5.

Multivariate logistic regression of associated factors of fertility desire of ART-attending HIV-positive women in HFSUH, Harar Town, Ethiopia 2020 (n=639)

	Fertility desire
Variable	Yes	No	COR (95% CI)	AOR (95% CI)
Age
≤35	319 (78.4%)	88 (21.6%)	3.10 (2.19 to 4.40)	2.35 (1.27 to 4.35)**
>35	125 (53.9%)	107 (46.1%)	1	1
Marital status
Married	336 (80.2%)	83 (19.8%)	2.45 (1.52 to 3.59)	3.02 (1.32 to 9.25)*
Divorced	66 (62.3%)	40 (37.7%)	1	1
Other	64 (56.1%)	50 (43.9%)	0.78 (0.48 to 2.21)	0.73 (0.51 to 3.74)
Educational level
No formal education	47 (62.7%)	28 (37.3%)	0.89 (0.49 to 1.62)
Primary education	153 (73.9%)	54 (26.1%)	1.50 (0.93 to 2.44)
Secondary education	163 (70.0%)	70 (30.0%0	1.24 (0.78 to 1.97)
College and above	81 (65.3%)	43 (34.7%0	1
Number of alive children
0	107 (65.6%)	56 (34.4%)	3.72 (1.5 to 0.31)	2.86 (1.17 to 4.82)**
1	120 (59.7%)	81 (40.3%)	2.88 (0.98 to 2.12)	2.68 (0.92 to 2.31)
2	95 (57.2%)	71 (42.8%)	2.60 (0.88 to 3.49)	2.07 (0.82 to 3.27)
≥3	37 (433.9%)	72 (66.1%)	1	1
Income
500–1999 ETB	193 (68.2%)	90 (31.8%)	0.90 (0.54 to 1.49)
2000–3999 ETB	184 (70.5%)	77 (29.5%)	0.99 (0.59 to 1.67)
>4000 ETB	67 (70.5%)	28 (29.5)	1
Duration of diagnosis in years
≤5	120 (79.8%)	93 (20.2%)	0.64
>5	274 (64.3%)	152 (35.7%)	1.40 (1.10 to 2.53)	1.51 (1.11 to 2.41)*
ART duration in years
≤5	229 (80.1%)	57 (19.9%)	2.58 (1.79 to 3.69)	3.45 (0.92 to 12.95)
>5	215 (60.9%)	138 (39.1%)	1	1
Discussion on SRH
Yes	409 (71.4%)	164 (28.6%)	2.21 (1.32 to 3.70)	1.06 (0.30 to 3.71)
No	35 (53.0%)	31 (47.0%)	1	1
Recent CD4 count
≤500	106 (72.1%)	41 (27.9%)	1.18 (0.78 to 1.77)
>500	338 (68.7%)	154 (31.3%)	1
Overall health status after starting ART
Improved	437 (70.1%)	186 (29.9%)	3.02 (1.68 to 13.89)	2.89 (0.98 to 13.58)
No change	7 (43.8%)	9 (56.2%)	1	1

*Significant at P<0.05; **p<0.001.

Abbreviations: AOR, adjusted OR; COR, crude OR; ETB, Ethiopian birr.

Discussion

This study reveals that more than two-thirds (69.5%) of ART-attending HIV-positive women have fertility desire. This means that the majority of the women attending HFSUH ART clinic have the desire to have a child/children in the future. This indicates that there is better counseling on PMTCT and sexual and reproductive health issues. Most study participants in this study reported that they are aware of PMTCT services and that they had an adequate discussion about SRH issues with their healthcare provider.

The prevalence of fertility desire in this study is in line with a study conducted in Uganda (63.1%).²⁴ It was higher than in studies performed in northwest Ethiopia (40.3%), Tigray (45.5%) and Finoteselam (33.4%).^21,25,26 The higher proportion of uneducated individuals in the study conducted in Finoteselam and northwest Ethiopia (38.4% and 35.6%, respectively) than in this study (11.7%) could be the reason for the reduced fertility desire than in this study. It is also higher than in studies carried out in India, South Africa and Malawi, in which the fertility desire of women living with HIV/AIDS was 33.5%, 46% and 31%, respectively.^27–29 The higher proportion of unemployment (57%) in the study conducted in South Africa, the smaller sample size (230) in the study conducted in India and the fact that the majority of the women (65%) in the study conducted in Malawi believed that childbearing may compromise their health might contribute to the lesser fertility desire than in the current study.

By contrast, it was lower than the studies performed in South Florida, UK and Nigeria (82%, 75.8% and 72.2%, respectively).^4,30,31 This might be due to study site, time and study population differences. It could also be due to different sociodemographic characteristics of the populations and cultural differences.

In this study, among women who did not desire child/children, the possible reasons mentioned were already having the desired number of children (47.7%), not having an adequate income (30.3%), fear of mother-to-child transmission (7.7%) and healthcare providers advice to not have another child (6.2%). This finding is the same as that for the study in western Ethiopia.³² Most of the respondents desired to have another child/children in >1 year.

The finding of this study shows that age is one of the factors that determines fertility desire. Clients in the ≤35 years age group were more likely to desire a child/children compared with women aged >35 years. This finding is supported by the studies performed in Ethiopia, Uganda, Osogbo Nigeria and India,^24,28,33,34 which revealed that younger age is positively associated with fertility desire. This might be due to older women living with HIV having already achieved their desired family size than younger women living with HIV.

Another associated factor of fertility desire in this study was marital status; married women were more likely to desire children than divorced women. This is in line with studies conducted in Gondar and Woreilu, Ethiopia, Uganda (Kenya, Namibia, Tanzania) and India.^{22,28,33,35,36} This might be due to the social expectation that married couples should have children or it could also be to maintain their marriage.

The current study has shown that the number of alive children was another associated factor for fertility desire; women who had no alive children were 2.86 more likely to desire children than those women who had ≥3 children. This was the same as from study results in northwest Ethiopia.²⁵ This may be because those who had no children might desire to experience parenthood to have a purpose in life and to have someone to care for.

This study revealed that the duration of HIV diagnosis is associated with fertility desire. Women whose duration of diagnosis with HIV is >5 years were 1.51 times more likely to desire children than women whose duration of diagnosis is ≤5 years. This finding is in line with the study result in south Wollo.³⁷ This might be due to learning that a normal life can be lived despite being HIV-positive and over time getting used to daily medication. Also, longer stays might expose them to receiving adequate discussions on SRH issues. But this finding is in contrast to a study carried out in Fitche, in which those with a duration of diagnosis with HIV of <5 years are five times more likely to desire children than those whose duration of diagnosis was >5 years.³⁸ This difference might be due to more than one-half of the participants’ duration of HIV diagnosis in the study conducted in Fitche being <5 years, whereas in the current study the majority of respondents’ duration of diagnosis was >5 years.

Limitations

There may be a possibility of social desirability bias, whereby HIV-positive women may underreport their desire for reproduction under pressure from healthcare professionals who support the use of contraceptives and protected sex. Any respondents’ recent pregnancy outcomes (no transmission of HIV to the child, or not) since becoming HIV-positive was not incorporated, which may influence current fertility desires. Additionally, the study excluded men, who play a significant role in fertility desire.

Conclusion

Generally, more than two-thirds of ART-attending HIV-positive women have fertility desire. Age, marital status, number of alive children, partner's desire, duration of diagnosis and partner's serostatus were identified as determinant factors of fertility desire. Considering women attending ART, there need to be reproductive planning, particularly on elimination of mother to child transmission and contraceptive counseling and use to meet their diverse reproductive need. It is better to provide education on the importance of partners' involvement in SRH issues. Moreover, assessing the reproductive desire of WLWHA during their follow-up, identifying their needs and counseling, as well as supporting their decision to be safe, in addition to providing ART services, is vital.

Authors’ contributions

SA conceived the idea and had significant roles in the manuscript's data review, drafting and editing. MD, ML, BB and TA worked on proposal writing, project administration, methodology, data analysis and drafting. SA, MD, ML, BB, HM, AS, AN, TB, AE, AD, TG and TA contributed to data management, review and analysis. SA, MD, ML, HM, AS, AD, TG and TA contributed to the results in writing, manuscript preparation and revision of the manuscript. All the authors read and approved the final version of the manuscript to be published, agreed upon and are accountable for all aspects of the work.

Funding

No funding.

Conflicts of interests

The authors declare that they have no conflicts of interest regarding this work or the publication of this paper.

Ethical approval

Before embarking on any steps of the study, an officially written approval letter was obtained from the Institutional Health Research Ethical Review Committee (IHRERC) of Haramaya University, College of Health and Medical Sciences. The ethical approval number was ref.no. IHRERC/138/2020, and letters of authorization were obtained from the relevant offices and Hiwot Fana Specialized Comprehensive University Hospital. Once the objective and contents of the investigation had been explained, informed consent was obtained from all the study participants and/or their legal guardians. They received sufficient information about their full rights to decline participation in the study and/or to withdraw at any time. All respondents' identities have been anonymized, and the data were only used for research. All data were used by following relevant guidelines and regulations (such as the Declaration of Helsinki). All protocols for COVID-19 were kept to prevent the transmission of the virus during the data collection process.

Data availability

In this manuscript, all pertinent information is included. However, the corresponding author will provide more information upon reasonable request.