Background
The global prevalence of HIV among female sex workers is estimated at 11.8% and is estimated at 13.5 times that of the general female population (women aged 15–49) in low and middle-income countries [
1]. Despite this significant burden of disease there is limited research specifically on female sex workers living with HIV, particularly with regard to sexual and reproductive health.
Among marginalized women, including women living with HIV, motherhood has been described as a way to feel valued by the woman herself and within her social or familial context [
2,
3]. With the discovery and accessibility of antiretroviral treatment (ART), both length and quality of life, as well as prevention of mother-to-child transmission (MTCT) of HIV was possible [
4], impacting family planning decisions. Many women living with HIV globally desire children and in some regions this desire is similar to women in the general population [
5]. Fertility desire among women living with HIV has been associated with younger age, fewer current children, increased desire for motherhood, having lost a child, how healthy they feel and stigma [
5]. More consistently, however, culture, social expectation and the importance of a woman’s identity as a mother are found as strongly influential across settings [
2,
6,
7]. Women have increased fertility desire in cultures that place high importance, expectation and value on fertility or where women without children face stigma and discrimination [
5,
8]. Internalized and societal stigma have also been found to influence fertility desire [
2,
7]. Women with a higher degree of HIV-related internalized stigma were more likely to want children, which would conceal their positive status and improve perceived self-worth, while those with higher HIV-related social stigma were less likely to want children to avoid societal judgment and criticism from others [
5]. Having children was described as providing a sense of fulfillment, increased self-esteem, and a reason to keep living [
2,
3,
6]. However, women also describe concern about the inability to care for children due to an HIV-related sickness or for fear of mother-to-child transmission of HIV [
8]. Therefore, many times women find themselves making childbearing decisions amidst tension between self-image, culture, social expectation and fears about health for themselves and future children [
3].
Children and pregnancy have been found to play an important role among female sex workers as well, where sex workers may seek pregnancy through sex work [
1,
9,
10], exit sex work due to pregnancy [
9,
10], or enter into sex work to support children [
10,
11]. Fertility intentions among female sex workers have been linked to both demographic and socio-environmental factors related to their relationships and places of work [
12,
13]. Sex workers are at increased risk for unintended pregnancy, abortion [
11], may continue sex work throughout pregnancy, [
14] and face barriers to health services [
15], increasing risk for poor maternal-child health outcomes.
The emerging literature on female sex workers living with HIV has documented significant health concerns including increased risk for other sexually transmitted infections, violence, poor mental health outcomes, HIV care interruption and multiple forms of stigma and discrimination [
8,
11,
16]. Despite the call for non-discriminatory services by UNAIDS [
17], female sex workers living with HIV have encountered barriers to care due to both occupational and HIV-related stigma. They were more likely to have reported experiencing humiliation, being demeaned by health workers [
18] having felt socially isolated, being refused medical care or feared seeking health services compared to female sex workers without HIV [
19].
In the Dominican Republic (DR), the exchange of sex for money among those over 18 years old is not explicitly criminalized and organizations exist to educate and empower female sex workers. HIV prevalence among female sex workers is estimated at 4 to 5% [
20,
23] but varies depending on region, reach and intensity of prevention intervention coverage. Family and childbearing are culturally important, forming the basis of social support, particularly in low-income populations [
21]. The DR has strict abortion laws, prohibiting all abortions (The Penal Code of 1948, section 317) except in situations where the woman’s life it at risk. Those who perform, consent to or cause their own abortion face harsh penalties, particularly medical professionals [
22]. Reproductive health services for the general population in the DR continues to be an issue. The maternal mortality ratio in the DR (159/100,000 live births) is higher than other countries in Latin America and the Caribbean and most affects underserved, low-income younger women [
23]. Modern contraceptive prevalence is high for the general population of the DR at 73% with sterilization accounting for almost half of all the methods used [
23]. For women living with HIV/AIDS (WLHA), access to non-discriminatory services is especially important in order to access to education and services for themselves as well as for their partners and their children. ARTs for adults were available in 60% of hospitals, though they were not always fully stocked. In terms of contraception services, only 36% of providers in Integral Care Units interviewed in the DR said they provided contraceptive counseling to WLHA and of those that responded, only 41% offered contraceptive services [
24]. A study of health providers in the DR who counseled WLHA found that providers most commonly recommended consistent condom use for contraception. However, a large proportion of providers who counseled WLHA on family planning believed that WLHA should not have children and about 36% said they emphasized sterilization. Qualitative results from this study uncovered that discrimination against WLHA by providers was observed in subtle and more aggressive ways [
24].
Knowing that both women living with HIV and female sex workers have and desire children while facing increased health risks and significant barriers to care, it is essential that we understand more about pregnancy and childbearing among this population. This study aim is to understand factors associated with fertility desire among female sex workers living with HIV in Santo Domingo, DR.
Methods
This study used a cross-sectional analysis of baseline data from a longitudinal intervention study, named
Abriendo Puertas (Opening Doors
). Abriendo Puertas was guided by formative research, [
25] and aimed to assess a multi-level intervention to promote HIV protective behaviors and foster adherence to care and treatment among female sex workers living with HIV in Santo Domingo. The intervention included individual counseling and education, peer navigation, clinical provider sensitivity training and community mobilization and aimed to promote HIV care and preventive behaviors on HIV outcomes and behaviors [
16].
Study sample & recruitment
Female sex workers were defined as women who reported having exchanged sex for money in the last month. Participants were at least 18 years old, spoke Spanish, and reported HIV infection, confirmed prior to enrollment by an HIV test (Retrocheck). Recruitment occurred predominantly through peer navigators both in the community and in HIV clinics, with a small minority of participants recruited via participant referrals. Peer navigators were current/former sex workers with experience with HIV outreach, prevention and support. Enrollment occurred from November 2012 to February 2013, resulting in a sample size of 268 participants. This paper focuses on participants of reproductive age (15 to 46 years old), totaling 247 participants. Due to the high number of participants who reported permanent contraception and fertility desire, analysis was run on the full sample and on those who reported not having had a permanent contraceptive procedure (
n = 125). If participants indicated that they had had a tubal ligation or a hysterectomy and reported the year of the procedure were determined as having had a permanent contraceptive method. Studies in the DR have found that women living with HIV sometimes did not understand the permanence of sterilization [
26] or reported regret, which is of concern [
27].
Survey description
The baseline socio-behavioral survey included several sections including demographics, employment, HIV testing experience, disclosure, health care services, clinic and provider dynamics, ART experiences, sexual behavior, social support, reproductive and sexual health, HIV intervention exposure, HIV knowledge, alcohol/drug use, violence, community engagement and stigma/discrimination.
Data collection
Surveys were conducted in Spanish within private offices of the HIV Vaccine Research Unit by female Dominican field staff. All surveys were de-identified and kept in a locked cabinet at Instituto Dermatologico y Cirugia de Piel Dr. Humberto Bogart Diaz (IDCP). The survey was entered into an electronic database by trained staff onto a password secured computer and external hard drive. Viral load was assessed through blood samples at the Dominican National Reference Laboratory using polymerase chain reaction (PCR) methods.
Ethics and collaborative partners
This study partnered with IDCP, and the non-governmental organizations Movimiento de Mujeres Unidas (MODEMU), a sex worker rights group, and Centro de Orientacion e Investigacion Integral (COIN), an HIV prevention organization. Participants provided oral consent rather than written consent to protect confidentiality of a highly stigmatized population group. All participants were offered 10 USD for completion. The Johns Hopkins Bloomberg School of Public Health, University of North Carolina and IDCP Institutional Review Boards approved the study.
Results
Descriptive characteristics are highlighted in Table
1. The mean age of participants was 34 years (range: 18,49 years) with most reporting a current primary male spouse, live-in or regular partner (201/247, 81.4%). Almost all participants had some education (243/247, 98.4%) with most having only a primary education (153/247, 61.9%).
Table 1
Descriptive characteristics of the study population (n = 247)
Age | | | 34.3 | 18,46 |
Civil status |
Single/Wid/Div | 46/247 | 18.6 | | |
Current partner | 201/247 | 81.4 | | |
Education (ever) | 243/247 | 98.4 | | |
Primary | 153/247 | 61.9 | | |
Secondary/tertiary | 94/247 | 38.1 | | |
Residence |
Santo Domingo | 192/247 | 77.7 | | |
Other | 55/247 | 22.3 | | |
Behavioral characteristics |
Sex work entry age (years) | | | 20 | 10,46 |
Average income/salida (pesos) | | | 889a | 200,4000 |
Work Locations |
Establishment | 149/247 | 59.6 | | |
Street | 140/247 | 55.3 | | |
Partner conflict | 89/247 | 36.0 | | |
HIV and sexual health |
Years since HIV diagnosis (n = 245) | | | 5.8 | 0,18 |
Current ART | 177/247 | 71.7 | | |
Detectable viral load (n = 243) | 131/243 | 53.9 | | |
Any pregnancy prevention | 200/247 | 81.0 | | |
Contraception methods |
Oral contraceptive | 11/247 | 4.5 | | |
Injectables (Depo-Provera or Nuristerate) | 6/247 | 2.4 | | |
IUD | 3/247 | 1.2 | | |
Diaphragm | 3/247 | 1.2 | | |
Reported permanent contraception (hysterectomy or tubal ligation) | 121/247 | 49.2 | | |
Consistent condom use | 157/247 | 64.1 | | |
Stigma scales |
HIV-internalized stigma | | | 2.42 | 1,4 |
Sex work-internalized stigma | | | 2.38 | 1,4 |
The mean age for sex work entry was 20 years (range: 10,46 years). Most of participants engaged in street-based (140/247, 55.3%) and/or establishment-based (eg. club, bar, hotel, colmadon or billar) (149/247, 59.6%) sex work. Participants could respond to more than one work location. The average income from each salida (sex work date) was 890 Dominican pesos (approximately 20 USD), (range: 200,4000 Dominican pesos/salida). About a third (89/247, 36.0%) reported a conflict, or disagreement, with a partner (last 6 months). About a quarter of those (23/89, 25.8%) reported that conflicts were physically, mentally, verbally, emotionally and/or economically abusive- where their partner controls access to resources, creating economic dependency and coercion.
On average participants self-reported living with HIV for 6 years (range: < 1 year,18 years). While most reported current antiretroviral therapy (ART) use (177/247, 71.7%), about 46.0% had an undetectable viral load (< 50 copies/mL) and 74/193 (38.3%) reported ever stopping ART. Many participants reported contraceptive use specifically for pregnancy prevention (past 6 months) (200/247, 80.9%), and consistent condom use with all partners was 64.1% (157/247). However, current non-permanent self-reported contraceptive methods were low, including oral contraceptives at 4.5% (11/247), Injectables at 2.4%, and IUD and Diaphragm independently at 1.2% (3/247). About half (121/247, 49.2%) reported a permanent contraceptive procedure (sterilization: 115/247, 46.6%, hysterectomy: 8/247, 3.2%). One participant reported both tubal ligation and a hysterectomy but was only counted once in the permanent contraceptive measure. Stigma scale averages revealed HIV-related internalized stigma at 2.42/4.0 and sex work internalized stigma at 2.38/4.0.
Table
2 describes fertility and childbearing characteristics. Almost all participants had been pregnant (236/247, 95.5%, mean: 4.4, range: 1,12) and 93.1% (230/247) reported at least one child (mean: 2.8, range: 1,8). About 64.0% (152/236) of participants reported at least one pregnancy loss. Over a third of participants reported a pregnancy since HIV diagnosis (91/247, 36.8%, mean: 1.6, range: 1,5).
Table 2
Fertility and childbearing characteristics (n = 247)
Currently have children | 230/247 | 93.1 | | |
Number of children (n = 230) | | | 2.8 | 1,8 |
Child loss (ever) | 51/247 | 20.7 | | |
Ever pregnant | 236/247 | 95.5 | | |
Number of pregnancies (n = 236) | | | 4.4 | 1,12 |
Any pregnancy loss | 152/236 | 64.4 | | |
Pregnant since HIV diagnosis | 91/247 | 36.8 | | |
Number of pregnancies (n = 91) | | | 1.6 | 1,5 |
Any pregnancy loss | 32/91 | 35.2 | | |
Fertility desire | 70/247 | 28.3 | | |
Number of children desired (n = 68) | | | 1.6 | 1,5 |
Reported permanent contraception | 24/70 | 34.3 | | |
Currently pregnant | 5/247 | 2.0 | | |
Negative perception of pregnancy and HIV | 136/247 | 55.1 | | |
aPartner would be upset about pregnancy | 30/201 | 14.9 | | |
Of those pregnant after HIV diagnosis, about a third (32/91, 35.2%) reported a pregnancy loss. Five women reported currently being pregnant (5/247, 2.0%) and three were unsure (3/247, 1.2%). Almost 30% of the participants (70/247) desired more children (range: 1,5; average: 1.6). Among those wanting children, 34.3% (24/70) also reported a permanent contraceptive procedure. While many indicated fertility desire, 55.0% (136/247) had a negative perception of HIV and pregnancy. Among those reporting a partner, 14.9% (30/201) felt a pregnancy would upset their partner.
Table
3 highlights bivariate logistic regression results for the total sample and for those who reported not having a permanent contraception procedure. In the bivariate analysis, older age (OR: 0.88; 95% CI: 0.8, 0.92), having more children (OR: 0.5; 95% CI: 0.39,0.64), living with HIV longer (OR: 0.89; 95% CI: 0.83, 0.96) and current ART use (OR: 0.46; 95% CI: 0.25,0.82) were all negatively associated with fertility desire in the total sample. Having a detectable viral load (OR: 2.16; 95% CI: 1.21,3.87) was positively associated with fertility desire. Civil status, education, alcohol/drug use, knowledge of mother-to-child transmission and years in sex work were not significantly associated with fertility desire. Participants reporting a positive perception of pregnancy and HIV were 6.14 times more likely to desire children compared to those who did not (OR: 6.14, 95% CI: 3.19,11.79) and those who reported a pregnancy loss were less likely to want children than those that haven’t (OR: 0.40, 95% CI: 0.23,0.71). There was marginally non-significant association between child loss and fertility desire (OR: 0.67; 95% CI: 0.40,1.1). Participants who perceived a pregnancy would upset their partners had lower odds of fertility desire compared to perceived support (OR: 0.10; 95% CI: 0.02,0.45). Lastly, participants reporting higher HIV-related internalized stigma were 1.6 times more likely per unit increase in the scale to want more children (OR: 1.60, 95% CI: 1.26,5.7).
Table 3
Bivariate associations with fertility desire among female sex workers living with HIV
Age | 0.88*** | (0.84,0.92) | 0.90*** | (0.86,0.95) |
Civil status (partner) | 1.00 | – | 1.00 | – |
Single/wid/div | 1.00 | (0.49,2.05) | 0.79 | (0.57,1.08) |
Education | 1.12 | (0.63,1.97) | 0.92 | (0.44,1.91) |
Number of children | 0.50*** | (0.39,0.64) | 0.51*** | (0.36,0.72) |
HIV and sex work |
Years HIV positive (n = 245) | 0.89* | (0.83 0.96) | 0.91 | (0.82,1.01) |
Age first engaged in sex work | 0.96 | (0.93,1.01) | 0.91 | (0.82,1.01) |
Partner conflict | 1.61 | (0.92,2.85) | 1.76 | (0.83,3.75) |
Current ART | 0.46* | (0.25,0.82) | 0.51 | (0.23,1.09) |
Viral load (ref = undetectable) | 2.16* | (1.21,3.87) | 2.30* | (1.07,4.92) |
Sexual and reproductive health |
Perception of pregnancy and HIV (ref = negative) | 6.14*** | (3.19,11.79) | 5.21*** | (2.24,12.13) |
Mother-to-child transmission knowledge | 0.68 | (0.36,1.27) | 0.55 | (0.23,1.29) |
Pregnancy loss (ever) | 0.40* | (0.23,0.71) | 0.44* | (0.20,0.93) |
Child loss (ever) | 0.67 | (0.40,1.10) | 0.71 | (0.27,1.87) |
Perceived provider support for pregnancy and HIV (ref = little/no support) | 1.21 | (0.37,3.91) | 1.25 | (0.30,5.19) |
Perceived partner would be upset about pregnancy (ref = supportive) | 0.10* | (0.02,0.45) | 0.13* | (0.03,0.63) |
Don’t know | 0.18* | (0.06,0.54) | 0.33 | (0.08,1.33) |
Stigma scales |
HIV-internalized | 1.60* | (1.26,5.70) | 1.67 | (0.86,3.24) |
Sex work-internalized | 1.30 | (0.84,2.02) | 1.47 | (0.81,2.66) |
For participants who reported not having a permanent contraceptive procedure, older age (OR:0.90; 95% CI: 0.86,0.95), having more children (OR:0.51; 95% CI: 0.36,0.72), detectable viral load (OR:2.30; 95% CI:1.07,4.92), negative perception of pregnancy and HIV (OR:5.21; 95% CI: 2.24,12.13), pregnancy loss (OR:0.44; 95% CI:0.20,0.93) and perception that pregnancy would upset their partner (OR:0.13; 95% CI:0.03,0.63) were associated with fertility desire. Living with HIV longer (OR:0.91; 95% CI:0.82,1.01) and ART use (OR:0.51; 95%CI:0.23,1.09) were marginally non-significant. HIV-internalized stigma (OR:1.67; 95% CI:0.86,3.24) was not significantly associated with fertility desire.
Table
4 highlights multivariate logistic regression results for both samples. Factors that retained significance for the total sample included age, number of children, positive perception of pregnancy and HIV, pregnancy loss, perceived partner feelings about pregnancy and HIV-related internalized stigma. Participants who were older (AOR: 0.94; 95% CI: 0.88,0.99) and who currently had more children (AOR 0.61; 95% CI: 0.44,0.84) had decreased odds of fertility desire. Those reporting a positive perception of pregnancy and HIV had increased odds of fertility desire (AOR: 6.49, 95% CI: 2.27,15.39), while participants reporting a pregnancy loss were less likely to want children than those who had not (AOR: 0.437; 95% CI: 0.17,0.84). Participants who felt their partners would be upset (AOR: 0.12; 95% CI: 0.02,0.66) or were unsure about a partner’s reaction (AOR: 0.14; 95% CI: 0.03,0.58) as compared to perceived partner support about pregnancy were less likely to desire children. Participants who reported a higher degree of HIV-related internalized stigma had increased odds for fertility desire (AOR: 3.19, 95% CI: 1.5,6.78).
Table 4
Multivariate logistic regression associations with fertility desire among female sex workers living with HIV
Age | 0.94* | (0.88,0.99) | 0.95 | (0.88,1.03) |
Education | 0.96 | (0.44,2.10) | 1.10 | (0.38,3.23) |
Number of children | 0.61* | (0.44,0.84) | 0.61* | (0.38,0.98) |
HIV and sex work |
Years HIV positive | 0.94 | (0.85,1.03) | 0.96 | (0.83,1.11) |
Viral load (ref = undetectable) (n = 122) | 1.08 | (0.79,4.12) | 1.90 | (0.66,5.49) |
Sexual and reproductive health |
Perception of pregnancy and HIV (ref = negative) | 6.49*** | (2.27,15.39) | 3.72* | (1.23,11.16) |
Pregnancy loss (ever) | 0.37* | (0.17,0.84) | 0.67 | (0.22,1.77) |
Perceived provider support for pregnancy and HIV (ref = little/no support) | 1.26 | (0.28,5.67) | 1.09 | (0.15,7.53) |
Perceived partner would be upset about pregnancy (ref = supportive) | 0.12* | (0.02,0.66) | 0.13* | (0.02,0.81) |
Don’t know | 0.14* | (0.03,0.58) | 0.25 | (0.04,1.37) |
Stigma scale |
HIV-internalized | 3.19* | (1.5,6.78) | 3.29* | (1.21,8.94) |
For participants not reporting a permanent contraceptive procedure, number of current children (AOR:0.61; 95% CI:0.38,0.98), positive perception of pregnancy and HIV (AOR:3.72; 95% CI:1.23,11.16), perception that partner would be upset by a pregnancy (AOR:0.13; 95% CI:0.02,0.81) and greater HIV-internalized stigma (AOR:3.29; 95% CI: 1.21,8.94) all maintained significance in the final model. Older age (AOR:0.95; 95% CI:0.88,1.03), pregnancy loss (AOR:0.67; 95% CI:0.22,1.77) and being unsure of partner’s reaction to pregnancy (AOR:0.25; 95% CI:0.04,1.37) were not significantly associated with fertility desire.