Fertility desire and intention of people living with HIV/AIDS in Tanzania: a call for restructuring care and treatment services

An estimated total of 33 million people are currently living with HIV/AIDS worldwide. Sub-Saharan Africa with only 10% of the population of the world is home to 60% of people living with HIV/AIDS (PLWHA) [1]. Tanzania is among the countries severely affected by the epidemic with 5.7% of the 40 million population infected with the HIV virus[2]. Antiretroviral therapy (ART) has improved health status and life expectancy of PLWHA making them enjoy life similar to uninfected individuals [3‐6]. Some studies have even reported that some antiretroviral drugs may increase sexual activity among women increasing their likelihood of pregnancies [7]. Scaling up of ART treatment is currently underway in sub-Saharan Africa increasing survival of PLWHA with little attention on their reproductive health needs [1]. Unprotected sex has been discouraged among PLWHA due to risk of transmission or acquisition of new viral strains and vertical transmission. Policies and stigma have discouraged reproductive intentions of PLWHA. However, studies suggest that PLWHA desire and continue to have children equally to those without HIV infection [8, 9]. A limited number of studies mostly in developed countries involving selected groups of people such as women in ART centres and/or urban settings where socio-cultural pressures are less have speculated that most of pregnancies of PLWHA could be intentional [9‐12]. In rural areas, cultural values are attached to fertility and a significant social status is assigned to people with children [13]. In this era of HIV infection, the level of desire and intention to have children in the rural general population is not well understood. Additionally, there are a few insights in to factors affecting desire and intentions to have children among PLWHA in Africa. Lack of information has slowed down efforts to integrate reproductive health services in the routine HIV/AIDS care and treatment.

The study aimed at estimating the size of fertility desire and intention, and to identify factors associated with fertility desire among PLWHA. The findings can be used to promote efforts for provision of reproductive health services in HIV care and treatments clinics in Tanzania.

A total of 410 PLWHA aged between 18 and 49 were identified and recruited in the study. The overall mean age was 34.2 (standard deviation (SD), 7.6), with males significantly older than females (Mean 36.7 ± 7.6 for males and 32.7 ± 7.2 for females, p < 0.001). Females constituted 64.4% (264) of all study participants.

A total of 410 PLWHA with mean age of 34.2 were recruited and interviewed in this study. Half of the participants were in relationship with 73.9% of them living with their sexual partners. About 60% of the participants reported to engage in sexual act with their partners with only 29.0% reported condom use during last sexual act. In this study, 37% of the respondent desired a child or additional child and the fertility intention was 2.4 children. Positive predictors of fertility desire were living with partner, disclosure of HIV status, having sex, not having more than one child with the partner, perceived good health status and CD4 cell count ≥200 cells. Negative predictors of fertility desire were being divorced or separated (both sexes), and having ≥2 children (for females).

Over 80% of people living with HIV/AIDS are in their reproductive years and many continue to want children after learning of their positive status (whether to start a family or to have more children) [1, 2]. It is therefore imperative to examine their reproductive health needs to be able to design programmes for safe reproduction while reduced HIV transmission.

In this study, the level of fertility desire was similar with what was reported in other studies elsewhere [16]. In contract, our estimate was relatively higher than the 29% reported in South Africa [17]. On the other hand, our estimate was lower than that of the general population in Tanzania which is estimated to be 60% [18]. This could partly be explained by previous efforts to discourage child bearing among PLWHA in most countries [19, 20].

Our study population largely constituted of PLWHA who were enrolled in a special counselling group where they received counselling on safe sex, drug adherence and family planning services and this might have impacted safer reproductive health knowledge and practice among the participants. This could also explain the observed lower fertility desire and intention estimates as compared to the general population.

Lifetime fertility desire of 2.4 children in this population was substantially lower than that of the general population of 5.4 [18]. This could be explained by the fact that PLWHA have lower desire for children with reasons explained above as well as other medical and psychosocial reasons[21, 22]. Moreover, there has been a general decline in fertility intention in the general population in Tanzania from 5.7 in 2005 to 5.4 in 2010 [18].

For public health purposes, a fertility desire of 37% amongst PLWHA is higher enough to warrant a special attention by promoting a “one-stop shopping” for both HIV/AIDS care and reproductive health services for PLWHA. This is corroborated by the unprotected nature of sexual activity reported in this population (69%) which indicates a potential for HIV transmission in the case of discordant couples. This is substantiated by the pregnancy rate of 12.5% in this population which is on the higher side as compared to that of the general population (9-10%)[18]. Although we did not directly establish what proportion of these pregnancies were intentional, the relatively higher desire for children indicate that majority of these pregnancies could be intentional. All pregnant women in Tanzania are offered voluntary counselling and testing and those testing positive are enrolled in the prevention of mother to child transmission programmes. However, no special reproductive health services are available in care and treatment clinic to offer appropriate services to PLWHA [22]. The programmes to be developed should address one stop access to contraception methods, counselling on reproductive related decision and safer conception, pregnancy, and delivery.

As expected, we found that younger participants and those who were never married or in marriage to have relatively higher desire for children in this population. This finding conforms to findings reported in Nigeria and South Africa [23, 24]. Higher fertility desires among married individuals can be explained by the social expectation of marriage as reported elsewhere in Tanzania and beyond [18, 23]. Moreover, younger unmarried individual who are still in their early reproductive age would be expected to desire children than older ones who are more likely to already have children. In the current shortage of human resource for health in the country, this study indicates that a focus on younger individuals would be beneficial. Health personnel could identify and offer special reproductive health services to these individuals as they attend care and treatment clinics.

Previous studies have shown that higher self-ratings of overall personal health status and physical functioning were associated with increased fertility desires [6, 23]. These previous reports support the findings in this study where perceived health status was found to be associated with fertility desire. Having CD4 cells ≥200 cells is clinically associated with better health hence normal sexual activity and desire for family. Higher number of CD4 cells is a surrogate measure of a stronger immunity and better health status among PLWHA.

It has been observed in other studies that not having own children to be an important determinant of increased fertility desires [23, 25‐27]. This was also observed in this study where a tendency to desire children was higher for those participants who did not have children or those without children with current partner. Participants with more than two children, the intended number of children, had 40% lower likelihood to desire children as compared to those without children as reported in other previous studies [6, 17, 24].

Disclosure of HIV status was associated with desire for children in this population. HIV disclosure, open doors to support, access to counselling and reproductive health information and options to facilitate the ability to make informed decision on children bearing [24, 28].

We found a non-significant association between ART use and fertility desire in this study. This may indicate that, regardless of ART status of the person, actual feeling, physical status of the person and socio-family related predictors such as number of children, having children with the partner and age are more important drivers of fertility desire[6, 29]. As reported in other studies, [21] the actual use of ART may not have a greater impact on fertility desires but rather the optimism of longer life due to ART could impact more on the desire.

The interpretation of the findings of this study should consider the following potential limitations; Firstly, the cross sectional nature of this study may limit the causal and effect interpretation of the factors observed. Secondly, reported behaviours especially those related to sexual life may be affected by desirability bias. Lastly, the fact that our population had an opportunity for counselling in the KIWAKKUKI group with better services than those offered in the public sector, and this may have increased their reproductive risk assessments affecting their desire.

A substantial proportion of PLWHA living in rural Tanzania continue to desire children albeit at lower rate than that of the general population. Practice of unprotected sexual intercourse with high pregnancy rate was observed. Fertility desire seems to be determined more by perceived health status and socio-family related factors. With increasing ART coverage that improves health status of PLWHA, more unprotected sex and pregnancies shall be expected. These findings provide more evidence for the need to increase efforts to integrate reproductive health services (contraception, counselling on decision to have a child and safer conception) in the routine HIV/AIDS care and treatment in sub Saharan countries and beyond. These strategies my not only improve reproductive health outcomes of PLWHA but also complement on going HIV prevention efforts.