Factors influencing reproductive choices of HIV positive individuals attending primary health care facilities in a South African health district

The HIV & AIDS epidemic continues to rank among the top ten priority conditions that contribute to the global disease burden [1], with sub-Saharan Africa accounting for 66% of the global HIV burden [2]. Although there is new optimism of achieving an AIDS-free generation by 2030 [3], there is also recognition that a rapid scale-up of existing programmes is needed to achieve this ambitious goal [3, 4]. South Africa continues to be a priority country for intervention [4], with an estimated 6.4 million People Living with HIV (PLHIV) [5‐9].

Sexual transmission of HIV infection continues to account for the majority of global HIV infections [10]. The improvement in HIV management especially the introduction of anti-retroviral therapy (ART) has resulted in improved quality of life and increased life expectancy of HIV positive persons [4]. In recent years, the sexual and reproductive health rights of PLHIV have been re-iterated, especially the responsibilities of governments to ensure that health care and legal systems support these rights [11]. Consequently, there has been the re-emergence of debates regarding reproductive choices and desires of HIV positive people [12‐14]. The WHO has indicated that the unmet need for family planning remains high among HIV positive women, and has emphasised the strengthening of linkages between HIV and sexual and reproductive health programmes [4].

There is a significant body of literature on reproductive choices of and challenges faced by PLHIV [15‐25]. Existing evidence suggests that a sizable proportion of PLHIV, regardless of geographical location, have an expressed desire for biological children [17, 21‐27]. Factors that influence this desire included younger age, personal health status, having a regular partner, perception that the partner wanted children, knowledge of ART effectiveness, ethnicity, knowledge about contraception or the cultural issues [17, 24, 26, 27]. In sub-Saharan Africa, studies have reported the immense pressure on women to have children regardless of their HIV status [17, 19, 21, 23]. However, another study found that the situation for men was grave as well, with not having children often resulting in stigmatisation and loss of social status among peers [28].

Several studies have found that the attitudes of health care providers influence the reproductive choices of PLHIV [19, 29‐35]. Many PLHIV want to discuss sexual and reproductive health needs with their health care providers, but reportedly feel uncomfortable about doing so [19, 29‐35]. The study findings suggest that access to sexual and reproductive health services is critical, while advocacy groups have argued that weak health systems deny PLHIV their sexual and reproductive health and rights [11].

In South Africa, major health sector reforms towards universal health coverage (UHC) underscore the centrality of primary health care (PHC) [36, 37]. It is envisaged that a comprehensive range of health care services, including sexual and reproductive health services, would be delivered at PHC level [37]. In light of the global emphasis on addressing the sexual and reproductive health needs of PLHIV, and the importance of PHC to achieving UHC, the aim of this research study was to explore the reproductive choices, and the factors influencing these choices, of HIV positive patients attending primary health care (PHC) facilities in the Ekurhuleni health district of the Gauteng Province of South Africa.

The majority of the participants were 25–49 years of age, thus supporting existing evidence that HIV primarily affects the economically active section of the population [7, 39, 42, 43]. The findings underscore the importance of addressing the sexual and reproductive health needs of this sub-group of the population. There were high levels of unemployment and a high proportion of the population without private health insurance (uninsured) which implies dependence on the public health facilities [39, 40, 42, 43]. Hence, the importance of attending to the sexual and reproductive health needs of PLHIV, particularly in the public health sector.

In this study, 50% of men and 44% of women expressed a desire to have children. This expressed desire for children is similar to the findings of other studies. Cooper et al. found that in Cape Town, 55% of female and 43% of male participants in their study wanted children [19]. Similarly Beyeza-Kashesya et al. [17], found that 64% of female and 55% of male HIV positive participants expressed the desire for children. Rispel et al. found that the desire to have children was high amongst HIV-discordant couples interviewed in South Africa and Tanzania [22]. Chen et al. reported similar high rates in their study of fertility desires and intentions of PLHIV in the United States of America [24]. Oladapo et al. likewise reported a high expressed desire for children in their study in Nigeria [44].

Numerous studies have found that the desire for children among Africans is higher, compared to non-Africans [45‐48]. Heard et al., reported that men and women of African ethnicity living in France expressed desire for children was three times higher compared to Europeans [27]. This was attributed to the socio-cultural background of people of African origin: for women, motherhood is considered as a high social status and identity, and as a prestige among peers while for men, on the other hand, fatherhood is critical as it ensures the continuation of the family name and lineage [47‐53]. In this study, the population was homogeneous and ethnicity was not a considered variable.

In this study, the multi-variate analysis found that age below 49 years, being married or living together; and having no child were the predictors of reproductive desire (Table 3).

The study found that at age younger than 25 years of age, 80% of respondents expressed the desire for children, compared to 6% at age 50 years and above. These research findings are similar to those of other research studies [47‐54]. Oladapo et al., found that the reason why younger HIV positive patients had a greater desire for children, was the socio-cultural pressure on young adults for fulfilment because of the fear of dying early from the disease [44].

Marriage or living together was also found to be one of the predictors of the desire for children. This may imply stability in a relationship and thus increase the desire for wanting children. However, the desire for children decreased among participants with more than one child compared to those with none, so these factors have to be looked at in combination. The inverse relationship between number of children and desire for children was reported by Cooper et al. and Chen et al. [19, 24].

A further argument could be advanced that those in marriage or living together might be of advanced age and/or having many children already and consequently may not desire more children. On the other hand, married couples might view the main outcome of marriage as having children and so will desire to have children despite their HIV status. The explanation for the increased desire for children among PLHIV who are either married or living together as independent variable observed in this study cannot be explained easily. Further research may be necessary to determine which of these variables are more strongly correlated to reproductive desires.

This study did not find self-reported health status or being on HAART to be a predictor of reproductive desire. This contrasts with other research findings [47, 55, 56]. In the study by Oladapo et al., ill-health due to advancing HIV infection, evidenced by low CD4 count, was found to be an independent predictor of fertility desire [44]. The socio-cultural fulfilment of child bearing made very sick individuals want to have children before dying [44].

In this study 44% of participants indicated that they do not want to have children. Among the reasons given by participants for not wanting children were: already had own children, lack of enough resources to care for another child, fear of a baby being born with HIV infection, old age and lack of a stable partner. However, among those not desiring children only 36% reported contraceptive use. This low usage of contraception was also reported by Smits et al. [44] and Nakayiwa et al. [47].

Most of the respondents who expressed a desire to have children were in favour of the natural method of reproduction (20%). This could be that the natural method is the only one known by the majority of participants. Although natural reproduction is recommended for PLHIV especially HIV sero-discordant couples on effective HAART regimen, there are specific requirements and guidelines which may not be understood by PLHIV [19, 57]. Hence, the research participants favouring natural methods may need guidance on the most appropriate method [19].

Thirteen present of respondents did not know the various types of reproductive options available. This lack of knowledge of PLHIV on fertility options may limit their ability to make informed reproductive decisions. It could be due to lack of information on reproductive issues among these PLHIV. The knowledge of available reproductive options by PLHIV has not been a focus of most research studies; hence, this finding could not be compared with the findings of other studies.

Most of the respondents (55%) wanted guidance from the medical personnel on the appropriate reproductive options available to them. This could be due to participants’ lack of knowledge about other options such as artificial insemination and assisted reproductive technologies (ART). In several instances the inadequacy on the part of HCWs on the provision of reproductive assistance and their negative attitudes towards PLHIV on sexual and reproductive health made it difficult to meet the needs of their patients [58, 59].

The possibility of adoption was not explored in our study but it would be interesting to understand how the situation in Ekurhuleni compares with the negative attitude towards adoption found in a study in Cape Town, South Africa [19].

This was a cross-sectional study carried out in a resource-limited district in Gauteng province, and the findings cannot be generalised to all districts in South Africa, except those with similar features to Ekurhuleni. The respondents in this research were those who attended the public clinics for care and treatment and therefore their responses may differ from those attending private facilities or private general medical practices. The study relied on self-reported information from PLHIV in a health care setting. Hence, there may be social desirability bias, as respondents may have been concerned about possible victimisation or negative consequences for subsequent care at the clinics. However, considerable efforts were made to use trained fieldworkers, and not the staff that provide care at these facilities where the study was conducted. All participants were given clear information and assured of their privacy and confidentiality during and after the interviews.

There are numerous strengths of this research study. This was one of the first studies to examine various aspects of sexual and reproductive health issues of HIV positive patients at a PHC level in Ekurhuleni district. A 100% response rate was obtained, and collection of data via face-to-face interviews ensured that the views of PLHIV who are not literate were elicited. This study also determined the preferred setting for information sharing and counselling on reproductive desires, an element hitherto unexplored in other studies on SRH and PLHIV.

This study found that there is expressed desire for children among PLHIV and their knowledge on the available reproductive options was limited. However, the participants expressed desire for information on reproductive options was also high. The respondents in this study indicated preference for men or women group discussions on reproductive health information.

There are encouraging developments within South Africa: the national strategic plan (NSP) for HIV/ AIDS and tuberculosis, 2012–2016, overseen by the South African National AIDS Council (SANAC), provides guidance on interventions and activities that will change the incidence and prevalence of HIV, STIs and TB [60]. However, the NSP falls short of guidelines on sexual and reproductive needs of PLHIV [60]. In the short term, sexual and reproductive health service guideline/protocols on reproductive options should be made available to HCWs. All health professionals (doctors and nurses, and other categories) should receive training on the reproductive needs and rights of PLHIV in other to improve their capacity and change their attitudes towards the SRH needs of HIV positive patients [53]. The clinics should also be equipped with educational and demonstration tools and audio-visual materials and equipment to educate PLHIV. In the medium term, the next version of the NSP should include specific goals, objectives, and outcome measures for the sexual and reproductive health needs of PLHIV. This will enable, provincial and district health plans to address the reproductive needs of PLHIV in line with SANAC strategic plan.

The study generated locally, context specific information in a health district in Gauteng Province on the choices of HIV patients with regards to reproduction and the motivating factors for these choices and as well as their knowledge of fertility options. The study findings suggest that HCPs at primary health care level are critical to ensure that the sexual and reproductive health service needs of PLHIV are met.