Abstract
As access to anti-retroviral therapy (ART) increases in sub-Saharan Africa, fertility and contraception patterns are likely to change. Two hundred HIV-positive women at an ART roll-out site in Zimbabwe responded to a questionnaire on fertility desires and condom use. Ten women (5%) reported planning a pregnancy in the next year, comprising 0% of women not yet eligible for ART, 8.22% of women on the waitlist for ART, and 4.17% of women on ART. Younger age, fewer living children, and higher quality of life were individually associated with intended pregnancy in the next year; however in multivariate analysis only the association with higher quality of life remained significant. Reported ever use of condoms was relatively low (46.5%) and condom use varied by neither ART status nor by fertility desires. In conclusion, our data demonstrates fertility desires among HIV-positive women in Zimbabwe correlate with higher perceived quality of life.
Keywords: Antiretroviral therapy, fertility desires, condom use, quality of life
INTRODUCTION
Of the 33 million people living with HIV/AIDS worldwide, 67% live in sub-Saharan Africa (SSA)1, creating an unparalleled burden of disease on the region. Southern Africa has borne a disproportionate share of this disease burden, experiencing 35% of global HIV infections and 38% of AIDS deaths in 20071. In Zimbabwe, an estimated 21.1% of women and 14.5% of men aged 15–49 are HIV-positive, with the highest prevalence at 35.5% among women aged 30–342. Sexual transmission is the primary means of HIV infection in Zimbabwe, followed by vertical transmission2, and the effects of the HIV epidemic have been particularly profound on women and men of reproductive age and their reproductive lives.
The consequences of the HIV/AIDS epidemic on fertility desires have been documented prior to public anti-retroviral therapy (ART) roll-out programs in SSA; however, the impact of increased access to ART on women’s fertility desires remains largely unclear 3,4,5,6. Qualitative studies have shown that being HIV-positive often makes women feel that they should avoid pregnancy despite their desire to have another child, often due to concerns over their health status or how their community may react3,5. Among our cohort of HIV positive women in Zimbabwe, being on ART was associated with higher quality of life7, which is likely to make women feel healthier and more optimistic about their future. This, in turn, may make them feel more secure in their ability to bear and care for a child and therefore more likely to desire a pregnancy. As ART can substantially increase life expectancy8, longer reproductive life spans for women will yield more opportunity for both planned and unplanned pregnancies. These effects of ART will impact individual women, as they consider and plan for their future childbearing, as well as communities and public health programs, as the demand for prevention of mother-to-child transmission (PMTCT) and family planning services changes8.
One anticipated outcome of increased fertility desires among HIV positive women may be decreased rates of condom use. While less condom use may enable women to achieve desired pregnancies, it may also increase rates of sexual HIV transmission. This effect may be somewhat offset by lowered viral load among those on ART. Rates of condom use remain low in Zimbabwe, particularly within marriage. While 22% of married women and 64% of married men surveyed in the 2006 Zimbabwe Demographic and Health Survey (DHS) report ever use of condoms, only 1.4% of married women and 4.3% of married men report current use of condoms2. Previous studies in Zimbabwe have documented women’s and men’s feelings of the inappropriateness of condom use within marriage9,10 yet for HIV-positive women, condoms provide a dual role of HIV transmission prevention and contraception. Theoretically, without the need for contraception, those women who were previously using condoms for dual protection may have little incentive to use condoms with their partners, which may then potentially increase sexual HIV transmission and reinfection. Therefore, while increased access to ART may increase fertility desires, it may also decrease condom use, presenting a complex dilemma to public health programs in SSA.
In this cohort of HIV-positive Zimbabwean women attending a national ART roll-out site, we hypothesize that HIV positive women on ART will be more likely than women not yet on ART to have higher quality of life and also more likely to plan a pregnancy in the next year. We additionally sought to perform an explorative analysis of the factors associated with condom use to elicit any relationships between access to ART, fertility desires, and reported use of condoms.
METHODS
Two hundred study participants were recruited between June and August 2007 at the Opportunistic Infections Clinic at the Chitungwiza Regional Hospital, 25 km from Harare. The study was designed to examine quality of life outcomes, results published elsewhere7. Eligibility for the study included age over 18 years, being HIV positive, and speaking English, Shona, or Ndebele. Trained interviewers administered a one-hour questionnaire and study nurses obtained blood samples and assessed for HIV-related symptoms. The Stanford University Institutional Review Board and the Medical Research Council of Zimbabwe approved the study.
All statistical analyses were carried out using SAS version 9.1 (Cary, North Carolina). ANOVA or Fisher’s Exact tests were used when testing categorical variables, Wilcoxon rank sum test for ordinal variables, and student t-test for continuous variables. All variables significant in univariate analysis were added to the multivariate logistic regression model. These regression analyses excluded seven women older than 50 years.
The Medical Outcomes Study-HIV (MOS-HIV) QOL questionnaire was used to measure perceived health-related quality of life11, which has been validated in Zimbabwe12. Fertility desire was assessed with the question “Do you plan to get pregnant or have a child in the next twelve months?” Condom use was assed by asking “Have you ever used condoms?”
RESULTS
General characteristics
In the cross-sectional study of 200 HIV-positive women, 31 (15%) were not eligible for ART (Group 1), 73 (37%) were eligible for ART but had not yet started due to drug shortages (Group 2), and 96 (48%) were on ART (Group 3). The ages of the women ranged from 22 to 69 years, with a median of 35. The majority (70%) had completed at least some secondary schooling. Thirty-seven percent of the women were married, 20.5% were divorced, and 41% were widowed. Over half (54.5%) of the women reported some form of employment, either formal or self-employment.
The three groups of women were similar in most baseline socio-demographic characteristics, including education level, marital status, employment, economic status as measured by household commodities, household members, and religion (all p>0.05) with only mean age differing (Group 1=34.2 years, Group 2=35.2, and Group 3=36.4; p = 0.0029). Predictably, clinical characteristics differed between the three groups. As expected, the ART treatment group had the lowest (pre-treatment) baseline CD4 counts (medians Group 1=386, Group 2=353, and Group 3=176; p<0.0001) and highest current CD4 counts (medians Group 1=315, Group 2=145, and Group 3=327; p<0.0001). The mean number of AIDS-related symptoms reported at baseline was highest in the treated group and lowest in the ineligible group (p<0.0001), but current reported AIDS-related symptoms were lowest in the treated group (p=0.053) (data not shown; see results published elsewhere)7.
Quality of life
The mean quality of life scores on the MOS-HIV QOL questionnaire were 37% in Group 1, 38% in Group 2, and 52% in Group 3 (p<0.0001). The domain scores, except for social function, were generally highest in Group 3 as well (data not shown; see results published elsewhere)7.
Fertility desires
The women reported a median number of three pregnancies and the median age of sexual debut was 19 years. Women who were eligible for ART were more likely to indicate planning a pregnancy in the next year than their non-eligible cohort: 0% of Group 1, 8.22% (n=6) of Group 2, and 4.17% (n=4) of Group 3 (p>0.05, Table 1). There were no significant differences in ever use of family planning methods, pregnancy history, or sexual history between the three groups of women (all p>0.05; Table 1). In logistic regression, younger age, having fewer living children, and higher perceived health-related quality of life were all independently associated with planning a pregnancy in the next year (all p<0.05), although in multivariate analysis only quality of life remained significantly associated with planning a pregnancy (p<0.05; Table 2).
Table 1.
Reproductive and sexual health characteristics by ART groups, mean (SD) or percent (n).
| Variable | Entire cohort (n=200) | G1: No ART, not eligible (n=31) | G2: No ART but eligible (n=73) | G3: On ART (n=96) | p-value |
|---|---|---|---|---|---|
| Family Planning | |||||
| Percent ever used family planning | 93.00 (186) | 87.10 (27) | 94.52 (69) | 93.75 (90) | 0.38a |
| Percent ever used the following: | |||||
| Pills/tablets | 74.00 (148) | 77.42 (24) | 69.86 (51) | 76.04 (73) | 0.60a |
| Injectables (Depo) | 28.50 (57) | 22.58 (7) | 27.40 (20) | 31.25 (30) | 0.67a |
| Condoms | 46.50 (93) | 45.16 (14) | 49.32 (36) | 44.79 (43) | 0.84a |
| IUD/loop | 2.50 (5) | 3.23 (1) | 2.74 (2) | 2.08 (2) | 0.85a |
| Withdrawal | 1.00 (2) | 0 | 0 | 2.08 (2) | 0.65a |
| Tubal ligation | 0.50 (1) | 0 | 1.37 (1) | 0 | 0.52a |
| Norplant | 1.00 (2) | 3.23 (1) | 1.37 (1) | 0 | 0.14a |
| Traditional | 0.50 (1) | 3.23 (1) | 0 | 0 | 0.16a |
| Percent planning pregnancy in the next yearb | 5.00 (10) | 0 | 8.22 (6) | 4.17 (4) | 0.21a |
| Pregnancy History | |||||
| Percent ever pregnant | 99.00 (198) | 100.00 | 98.63 (72) | 98.96 (95) | 1.00a |
| No. of pregnancies | 3.24 (1.75) | 3.35 (1.70) | 3.07 (1.81) | 3.34 (1.72) | 0.57 |
| No. of living children | 2.47 (1.57) | 2.32 (1.33) | 2.29 (1.52) | 2.65 (1.67) | 0.28 |
| Sexual History | |||||
| Age at sexual initiation | 19.19 (2.95) | 18.94 (2.92) | 18.79 (2.73) | 19.56 (3.09) | 0.22 |
| No. of sexual partners in last year | 0.60 (0.66) | 0.81 (0.91) | 0.58 (0.5) | 0.54 (0.67) | 0.14 |
| No. of lifetime sexual partners | 3.36 (9.67) | 5.45 (14.55) | 2.47 (4.95) | 3.35 (10.39) | 0.36 |
| Percent ever treated for STI | 64.50 (129) | 67.74 (21) | 63.01 (46) | 64.58 (62) | 0.92a |
P-values calculated for three-way comparisons between G1, G2, and G3 using Fisher’s Exact test, two-sided; all others tested with ANOVA, two sided
When excluding women out of reproductive age (age ≥50), the percent planning pregnancy in the next year are: G1 0.00%, G2 8.33% (n=6), G3 4.82% (n=4), p=0.27.
Table 2.
Logistic regression modeling of correlates of intended pregnancy in the next year
| Variable | Univariate Analysis | Multivariate Analysis | ||
|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Age, continuous | 0.89 (0.79, 0.99) | 0.032 | 0.88 (0.76,1.02) | 0.090 |
| Currently married | 0.57 (0.16, 2.04) | 0.39 | -- | -- |
| Number of living children | 0.47 (0.24, 0.91) | 0.026 | 0.57 (0.27,1.20) | 0.14 |
| Number of pregnancies | 0.66 (0.40, 1.11) | 0.12 | -- | -- |
| Ever used condom | 1.78 (0.49, 6.50) | 0.39 | -- | -- |
| Duration since HIV diagnosis (in years) | 0.85 (0.55, 1.31) | 0.46 | -- | -- |
| ART status, category | 1.17 (0.47, 2.88) | 0.74 | -- | -- |
| Duration of ART (in months) | 0.26 (0.041, 1.64) | 0.15 | -- | -- |
| No. of self-reported AIDS-related illnesses in last year, category | 0.87 (0.68, 1.11) | 0.25 | -- | -- |
| No. of medically-assessed symptoms in last week at baseline, category | 0.99 (0.92, 1.06) | 0.67 | -- | -- |
| Quality of life (QOL) mean score | 1.05 (1.002, 1.10) | 0.039 | 1.06 (1.007,1.12) | 0.027 |
| Depression, category | 0.98 (0.88, 1.10) | 0.75 | -- | -- |
Condom use
In the entire cohort, less than half (47%) reported ever-use of condoms, though 93% reported ever use of some method of family planning, of which oral contraceptives, or “pills or tablets”, (74%) were the most popular method (Table 1). When comparing the group of women reporting ever use of condoms vs. those who did not, younger women, being currently married, living with current husband/partner, religion, longer duration since HIV diagnosis (years), greater total number of disclosures, greater percent of disclosure of HIV status to current husband/partners, ever use of any form of family planning, and greater number of sexual partners in the past year correlated with condom use (all p<0.05; Table 3). Percent condom use did not vary significantly by ART group, number of pregnancies, nor percent ever treated for STIs (Table 3). Of the total ten women in our cohort who reported planning a pregnancy in the next year, six (6.5%) of them reported ever use of condoms as opposed to four (3.7%) who denied ever use of condoms (p=0.52).
Table 3.
Cohort characteristics by condom use, mean (SD) or percent (n)
| Variable | Entire cohort (n=200) | G1: Ever used condoms (n=93) | G2: Not used condoms (n=107) | p-value |
|---|---|---|---|---|
| Socio-demographic Measures | ||||
| Age | 36.41 (8.32) | 33.84 (6.86) | 38.65 (8.84) | <0.0001 |
| Marital Status, percent | <0.0001a | |||
| Currently married | 37.00 (74) | 56.99 (53) | 19.63 (21) | |
| Divorced/separated | 20.50 (41) | 15.05 (14) | 25.23 (27) | |
| Widowed | 41.00 (82) | 25.81 (24) | 54.21 (58) | |
| Single/never married | 1.00 (2) | 1.08 (1) | 0.93 (1) | |
| Cohabitating | 0.50 (1) | 1.08 (1) | 0.00 | |
| Percent living with husband or boyfriend | 29.50 (59) | 48.39 (45) | 13.08 (14) | <0.0001a |
| Religion | 0.053 a | |||
| Catholic/Anglican/Methodist | 37.19 (74) | 27.96 (26) | 45.28 (48) | |
| Pentecostal churches | 35.68 (71) | 43.01 (40) | 29.25 (31) | |
| Apostolic | 18.09 (36) | 19.35 (18) | 16.98 (18) | |
| Other/Traditional/No religion | 9.04 (18) | 9.68 (9) | 8.49 (9) | |
| Clinical Measures | ||||
| ART status | 0.83 a | |||
| Ineligible | 15.50 (31) | 15.05 (14) | 15.89 (17) | |
| Eligible but awaiting ART | 36.50 (73) | 38.71 (36) | 34.58 (37) | |
| On ART | 48.00 (96) | 46.24 (43) | 49.53 (53) | |
| Duration since HIV diagnosis (years) | 1.56 (1.97) | 2.40 (2.42) | 1.58 (1.38) | 0.014 |
| Duration since ART initiation (months) | -- | 15.77 (10.01) | 14.08 (8.64) | 0.60 |
| No. of self-endorsed AIDS-related illnesses in last year (out of 12) | 5.46 (2.72) | 5.32 (2.85) | 5.58 (2.60) | 0.48 |
| Psychosocial Measures | ||||
| Total number of disclosures | 4.16 (2.48) | 4.69 (2.60) | 3.70 (2.29) | 0.0052 |
| Percent disclosed to current husband or partner | 78.38 (87) | 85.71 (60) | 65.85 (27) | 0.018 a |
| SSQ14 Depression score (out of 48) | 28.44 (9.28) | 28.02 (9.19) | 28.79 (9.38) | 0.56 |
| MOS HIV QOL (out of 100) | 44.60 (16.02) | 45.66 (14.78) | 43.69 (17.04) | 0.38 |
| Family Planning | ||||
| Percent ever used family planning | 93.00 (186) | 100.00 | 86.92 (93) | <0.0001a |
| Percent planning pregnancy in the next year | 5 (10) | 6.45 (6) | 3.74 (4) | 0.52a |
| Pregnancy History | ||||
| No. of pregnancies | 3.24 (1.75) | 3.17 (1.65) | 3.30 (1.84) | 0.72 |
| No. of children alive | 2.47 (1.57) | 2.30 (1.26) | 2.61 (1.79) | 0.42 |
| No. of miscarriages/abortions | 0.36 (0.63) | 0.43 (0.73) | 0.29 (0.52) | 0.32 |
| Sexual History | ||||
| Age at sexual initiation | 19.19 (2.95) | 19.24 (3.10) | 19.14 (2.82) | 0.82 |
| No. of sexual partners in last year | 0.60 (0.66) | 0.84 (0.45) | 0.39 (0.74) | <0.0001 |
| No. of lifetime sexual partners | 3.36 (9.67) | 2.62 (4.79) | 4.00 (12.44) | 0.91 |
| Percent ever treated for STI | 64.50 (129) | 66.67 (62) | 62.62 (67) | 0.56 a |
P-values calculated with Fisher’s Exact test, two-sided; all others tested with Student t-test, two sided.
DISCUSSION
The 2006 Zimbabwe DHS found that 16% of women between 15–49 desired another child in the next two years2. Our study demonstrates that HIV positive women may have lower fertility desires than the general population, as only 5.0% of our cohort (n=10) indicated desiring another child in the next year.
All ten of the women desiring to become pregnant in the next year were either awaiting treatment initiation or taking ART, however proportionally the group that was ineligible for ART was the smallest. Increases in fertility desires after initiation of ART have been seen elsewhere. One study in eastern rural Uganda found that while 3.2% of HIV positive women wanted more children before starting ART, it grew to 6.7% after 24 months of ART6. A cross-sectional study in western rural Uganda found that women on ART were more likely to desire pregnancy but less likely to be pregnant in the last three years than women not yet on ART13. A study in South Africa found that a much greater proportion (26%) of HIV positive women on ART indicated wanting another child after a median of 11 of months on ART14.
The South African cohort’s fertility desires were associated with longer duration of ART14, which one might anticipate, as increased duration of ART treatment may confer greater health and quality of life benefits, making women feel more enabled to have another child. While our data did not demonstrate duration on ART to be significantly correlated with fertility desires, the mean duration of 14 months may be too short to demonstrate its full effects on fertility desires.
Additionally in this South African study, median age was significantly younger (p < 0.001), by four years, for those women desiring another child14, an association that we also found in our cohort in univariate analysis. With every year increase in age, the odds of a woman desiring another child in the coming year was 0.89 (p=0.03; Table 2).
We find it unsurprising that younger women may feel more desire to have and care for a child than their older counterparts. This factor may also be mediated by the number of children the women currently have, a variable which was also significantly associated with intended pregnancy in the next year (OR 0.47, p=0.02; Table 2). Neither of these variables remained statistically significant in the multivariate analysis. This is likely because they measure a common concept, as younger women are more likely to have fewer children than their older counterparts simply due to their younger age and therefore more likely to desire another child.
In our cohort, higher perceived quality of life was the only significant predictive factor in multivariate analysis of positive fertility desire. Though our cohort was small and the cross-sectional data cannot demonstrate causality, from these associations we infer that ART may increase women’s fertility desires, potentially as a result of its positive impact on perceived quality of life7. As ART improves women’s qualify of life, they may feel healthier and more optimistic, and are more likely to feel secure in pursuing additional pregnancies. We anticipated that those women on ART would have the highest rate of intended pregnancies within the next year, however we found similar rates among women on ART and those on a waitlist for ART. While those women eligible but on a waitlist for ART would not yet have received the ART-induced health improvements of their peers who began treatment, we suggest that being on the waitlist for ART may make the women optimistic about their future quality of life and ability to pursue a pregnancy. Anticipation of receiving life-extending therapy, as well as seeing their peers’ health improve on treatment, may improve these women’s outlook on their health and future, including childbearing desires. Ultimately, the total number of women reporting intended pregnancies in the next year was so low (n=10) that caution is required in interpreting this analysis.
Unexpectedly, condom use was low among this cohort of HIV-positive, above-average educated women. Although all the women in the cohort knew their HIV status and lived in a peri-urban environment in which they had contact with health workers and regular exposure to health prevention messages, only 46.5% reported having ever used condoms. In contrast, 74% reported having ever used oral contraceptives, indicating perhaps that the vast majority of these women do not use condoms for contraception. The condom usage rates are nonetheless higher among these women than the 20.1% of Zimbabwean women of reproductive age who reported ever use of condoms in the 2006 DHS2.
Reported ever use of condoms did not vary by ART group nor by intended pregnancy in our cohort. A major limitation of our study is that we failed to measure current or near future intended condom use, which is more informative regarding behavior for intended pregnancy. Previous studies have shown that advocating for condom use as a contraceptive method rather than a means of preventing HIV transmission is more effective at initiating and maintaining condom use within partnerships5,16. If HIV-positive women are actively seeking to conceive, however, they may only use condoms intermittently for HIV transmission prevention or forgo their use altogether. In light of this, HIV transmission prevention programs targeted towards positive women who may seek pregnancy will require nuanced messages to promote continued condom use.
In our study, factors significantly associated with ever use of condoms were: younger age, being currently married, living with husband/partner, religion (Catholic, Anglican, or Methodist women were less likely to have ever used condoms), longer duration since HIV diagnosis, greater number of HIV status disclosures, disclosure to current husband/partner, and greater number of sexual partners in the past year. Most interestingly, currently married women were more likely to have ever used condoms than their widowed or divorced peers. Our ability to infer from this finding is limited by the measure of “ever use”, rather than current use, but we suggest two possibilities. Women who have ever used condoms were on average five years younger than those women who had not ever used condoms (p<0.0001). In this cohort, currently married women were on average 3.5 years younger than their non-married counterparts. The younger women may have benefited from greater exposure to condom promotion, resulting in greater condom usage before or within marriage. Alternatively, condom promotion programs may be more effectively targeting married than divorced or widowed women. In either case, it is clear that barriers remain for HIV-positive women to use condoms. Integration of contraceptive and condom promotion in ART programs may help address some of the barriers to condom use8.
In conclusion, our study indicates that some women on ART or waiting to initiate ART desire fertility in the future, potentially mediated through greater perceived quality of life. While our data did not detect any differences in condom use based on fertility desires, it is plausible that women desiring pregnancy may forego condom use in order to increase chances of conception. In light of these effects, we anticipate that as ART programs expand to provide more women with therapy, greater integration between PMTCT, family planning, and STI prevention services will be needed to provide these women with comprehensive care.
Acknowledgments
We acknowledge foremost the Zimbabwean women’s participation in this project and Zimbabwean AIDS Prevention Project (ZAPP) staff for providing support during study implementation. Thank you to Dr. Michael Chirenje for reading a draft of the manuscript.
This study was funded by the Medical Scholars Fellowship at Stanford University School of Medicine, National Institutes of Health (NIAID R01 AI060399), and the Fogarty International Center (ICOHRTA U2R TW006878).
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