Fertility Desire and Associated Factors among HIV Positive Women in University of Gondar Comprehensive Specialized hospital, Northwest Ethiopia. Institution based cross-sectional study. CURRENT STATUS: POSTED

Background: HIV positive individuals may or may not have fertility desire to have children. But the extent of these desires and how it varies by is not well understood. Objective: To assess fertility desire and its associated factors among HIV positive women in Gondar referral hospital, Northwest Ethiopia; 2019. Method: Institutional -based cross-sectional study design was conducted from May-June 2019 on 351 HIV positive women at Gondar comprehensive specialized referral hospital. Interview based, pre-tested and structured questionnaires was used to collect the data. Data consistency was checked and entered into Epi-info seven then exported to SPSS versions 20 for further analysis. Bivariable and multivariable logistic regression was used to determine the association between dependent and independent variables. P-values less than 0.05 with 95% CI was taken to declare a statistically significant. Result: Among study participants, 183(52.1%) HIV positive women had fertility desire. Women in the age 15-19 years (AOR: 6.88, CI=1.84-25.79), being married (AOR: 4.42, CI=1.47-13.28), unable to read and write (AOR: 0.39, CI=0.18-0.82), having no partners fertility desire and discussion with health care provider (AOR: 0.04, CI=0.02-0.12) and (AOR=0.31, CI=0.17-0.57), respectively were significantly associated factors. Conclusion: Being young age and married, educational status of women, partner desire and discussion with health care provider were obtained as significant factors of fertility desire. Hence health care providers have to give health information and education about fertility desire and other reproductive issue to clients.


Background
Fertility desire is an intention to have children despite the diagnosis of HIV (1).Globally, HIV/AIDS is the leading cause of death among women of reproductive age (aged 15-49). In 2017, new infections among young women (aged 15-24 years) were 42% higher than they were among men in the same age group, and around 80% of pregnant women living with HIV received antiretroviral medicines to prevent the transmission of the virus to their children (2,3).
Women in Sub-saharan Africa between the ages of 15 and 24 years constitute 76% of those at risk for contracting HIV, and the risk of infection in this group is three times that of the general population (2).
Most of these women are particularly vulnerable to HIV due to the complex burdens they face, physiological and social vulnerability and gender inequalities. Since these vulnerable women are in the child bearing age, the risk of infecting their children and thus facing difficult choices about childbearing is huge (4).
Prior to the implementation of the Prevention to Mother to Child Transmission (PMTCT) programs, health care providers used to discourage women living with HIV from having children in order to avoid new infections in children though many women continued to bear children despite the knowledge about for the consequences. Even after antiretroviral treatment, there is evidence that healthcare providers have advised women living with HIV to avoid pregnancy. However, it is evidenced in a number of studies that many HIV positive women have children and to have wish more, indicating the need for comprehensive care, so such women can have safe and healthy pregnancy (5) The major mode of HIV transmission in Ethiopia is heterosexual, decisions about child bearing among women living with HIV/AIDS (WLHA) continue to be a subject of debate in resource constrained settings. Many findings show that HIV/AIDS is integrated-in the minds of many developing countries as they confront the very real and present danger posed by heterosexual transmission of the virus.
Yet, many women who participate in studies spontaneously mention the influence of HIV/AIDS in reducing their family size as well as their compatriots (6).
Research findings reported that social norms and individual factors often discouraged HIV infected people from having children and childbearing decisions. As the prevention of the mother to child transmission programs provide for both prevention of HIV transmission from mother to child and enrollment of infected pregnant women and their families into antiretroviral treatment, the government of Ethiopia made an effort to mitigate the impacts of the epidemic in the general population and amongst children in particular(7).
A better understanding of the reproductive choices of HIV positive individuals is important, especially as antiretroviral medication is becoming more accessible. Accurate descriptions of the childbearing intentions and desires of HIV infected individuals is necessary because it may help them achieve their fertility desires without scarifying the health and wellbeing of their new born (8).
In case women living with HIV desire to have children, counselling by their health care providers has a critical role in assuring the planned pregnancies, and improving the prevention of mother to child transmission and reducing new infant infections (9).
Although Ethiopia has made efforts to mitigate the impacts of the epidemic in the general population (9), many women are living with HIV/AIDS. In spite of advances in ART and prevention of mother-tochild transmission services, women in developing settings still struggle with decisions to have children. More importantly, little is known about the prevalence and determinants of fertility intentions among HIV infected women who are receiving ART. Therefore, this study was conducted to assess fertility desires and associated factors among HIV positive women at the University of Gondar comprehensive specialized hospital.

Study setting and design
Institution based cross sectional study from May to June 2019 was conducted at the University of Gondar comprehensive specialized hospital, which is in North Gondar zone, Amhara regional state of Ethiopia, 174 km from Bahir Dar, the capital of the regional state and 720 km from Addis Ababa, the

Study population
Study population were those sampled reproductive age HIV positive women at University of Gondar comprehensive specialized hospital enrolled on ART treatment during the study period.

Sample size determination and sampling technique
A total of 351 HIV positive women were recruited by the single population proportion formula using Zscore at 95% confidence level (1.96) and 70.59% proportion from study conducted in TesfaGoh association of Bahirdar, Ethiopia on HIV positive women in ART units (21), d = 0.05 (5% margin of error) and 10% non-response rate. The participants were selected using the systematic random sampling technique.

Operational definitions
Desire for child or children: Women on follow up care who would like to have a children in the future (yes/no).

Data collection tools and procedures
A structured interviewer administrated questionnaire was used to collect data from participants. The questionnaire was adopted by reviewing variety of literature (5, 20 21) and modified and conceptualized into the local setting. The preparation followed the logical order from simple to complex with sensitive questions at the end. The questioner had such four sections as Sociodemographic characteristics, information on HIV/AIDS and related characteristics, perceived social pressure and information on knowledge of HIV transmission.

Data management/processing and analysis procedures
Data were coded, cleaned and entered into Epi-info seven and exported to the Statistical Package for Social Sciences (SPSS) version 23 for analysis. Frequencies and percentages were generated. Tables and graphs were used for data presentation. The bi-variable logistic regression method was used to select candidate variables. Independent variables resulting in a p-value of less than 0.2 in the bivariable analysis were considered in the multivariable logistic regression analysis for further analysis.
Adjusted Odds Ratio (AOR) with a 95% confidence interval (CI) at 5% level of significance was used to measure the strength and significance of associations.

Socio-demographic characteristics of the respondents
In this study, 351 respondents were participated with a response rate of 100%. Of the participants, 137(39.0%) were in the age group of 30-39 years with a median age of 33.03(40-27 IQR) years. Out of the respondent, 144(41%) were married; 87.7% were Orthodox Christian, 27.9% were elementary (1-8) school completed. The majority 293(83.5%) of the women were lived in urban areas, 313(89.2%) were Amhara by ethnicity (Table1).

Fertility desire of respondents
The fertility desire of the participants was 183(52.1%) CI: (47.3, 57.8), and the most common reason (46.4%) were to strengthen marriage. Out of 351 respondents, 234(66.7%) tested before two years, 295(84%) were disclosed their HIV status and 90(25.6%) discussed their desire with health professional/counselors. Out of the total interviewed WLHIV, 100(54.6%) want to have one or two live biological children, whereas, 78(42.6%) wanted to have three to four children. One hundred thirty eight (39.3%) of the respondents knew their partners HIV status, 105(29.9%) were using contraceptive during the study period (table 2).

Perceived pressure from external others and related characteristics
Of the participants, 74.1% and 74.6% were pressured to have children by their families and the community, respectively.
Most of the respondents were living with their families, 61(17.4%) of the women were members of associations with PLWHA and 16(4.6%) had support from external bodies (table 3) Factors associated with fertility desire The bivariable and multivariable logistic regression analysis were conducted to see the presence of associations and to measure the relative effect of each independent variable on fertility desire.
Marital status, age, educational status, current pregnancy, previous pregnancy, income, external support, discussion with health professionals, partner desire to have children were variables taken into consideration for the multivariate analysis with p-value <0.2 .
In the multivariable analysis marital status, educational status, age, discussion with health professionals and partner desire to have children were statistically significant predictors of fertility desire. Women in the 15-19 age group were 6.88 times more likely to desire than those aged 40-49 years (AOR= 6.88,CI=1.84-25.79). Women who were married were 4.42 times more likely to desire than women who were widowed, (AOR=4.42, CI=1.47-13.28), women who could write and only read 7 were 83% less likely to desire than those who attended college and above (AOR=0.17, CI=0.17-0.52).
Respondents who did not discussed with health professionals were 69% less likely to desire fertility than their counterparts (AOR=0.31 CI=0.17-0.57). This study also revealed that women whose partner did not have desire had 96% decreased fertility desire than their counterpart (AOR= 0.04, CI=0.02-0.12) ( The difference could be due to difference, in the socio-demographic characteristics of the study participants and the difference in sample sizes. But it is almost comparable to the result of studies conducted in Spain and Switzerland, and noted 49 and 48% respectively (15, 16).
Women in the younger age group (20-29) and 30-39 were 6 and 4 times more likely to have fertility desire than the 40-49, respectively .This finding is higher than that of a study done in Finoteselam and found a magnitude of 42.1% (22). The possible explanation may be due to that relatively older women have already achieved, or closer to achieving their desired family size than younger women.
Married women's were 4.4 times more likely to have fertility desire than widowed. The reason might be due to support from spouses or family stability. This finding is lower than those of studies conducted in Uganda and Congo which noted 78 and 71.1%, respectively (22, 23). The reason behind might be the availability of facilities at the health service institutions.
In our study, educational status had positive association with fertility desire. Women who were not able to read and write were 61% decreased have fertility desire than those who attended college and above. Again, those who were able to read and write were also 83% reduced fertility desire than 8 those who attended college and above. This difference might be due to the fact that less educated participants had less expectations of health services, less information on PMTCT compared to women who had college and above education.
This finding also revealed that discussions with health care providers were significantly associated with fertility desire. Women who did not discussed with health professionals had 69% lower fertility desire than women who discussed. This finding was similar with the result seen in a study conducted in Nekemte (Western Ethiopia) and Northwest Ethiopia (19, 24). This could be due to health care provider give advice to clients that promote fertility or might be that those women who had fertility desire seek advice from service provider.
In this study a significant association was also observed between fertility desire and partners need for children. Women whose partner did not have desire had 96% decreased fertility desire than their counterpart. This finding is in line with finding in Ethiopia (22, 25). This suggests that family planning and fertility related issues information should focus on partner as well.

Limitation
Since the study was conducted in a public health institution, it may lack generalization about HIV positive women in the reproductive age group of the town. Besides, as the study is cross-sectional the association observed may not be casual enough. Finally the study might also subjected to recall bias.

Conclusion
This finding revealed that more than half of the HIV positive women under antiretroviral treatment at Gondar comprehensive specialized hospital had fertility desire for children. Being young age, marital status, educational status of women, partner pressure, discussion with health care providers were significant factors of fertility desire. Therefore, provision of health information and education about fertility desire and other reproductive issue to the client will be pivotal. Gondar hospital ART. All reproductive age group mothers to participate in the study were asked for their willingness to participate in the study. All the reasons why reproductive age group mothers are chosen and why the research is done were explained in the questionnaire. Oral consent was obtained from each reproductive age group mothers before the data collection and the data was collected anonymously to maintain confidentiality of the client. On the other hand simple explanation about aim of the study was provided to those under 16 years of age to obtain their initial approval. Then, an informed consent including simple explanation about the aim of the study was given to be signed by the parent/guardian.

Funding
No fund was obtained for this study.