The human devastation being shaped by the Human Immune Virus and Acquired Immune-Deficiency Syndrome [HIV/AIDS] in sub-Saharan Africa (SSA) and other regions, and the ripple effect that this epidemic is having on communities around the world presents one of the greatest challenges to global public health. Nearly 40 years after the first case, HIV has continued to spread world over and it is now firmly established as an important public health issue and can still be considered a strong predictor of fertility world over. HIV is one of the most significant causes of illness and death in human life history . The burden is, however, heaviest in SSA ; with approximately 58% of adults living with HIV and 53% of all adult deaths in the region are women . In Zambia, for example, (14.2%) of women 15-49 compared to (7.5%) of men in the same age group are living with HIV (Zambia Statistical Agency . Since a larger proportion of these women are in the reproductive age (15-49), they risk infecting their newborn babies and sexual partners and thus face difficult choices about childbearing.
Over the past two decades, the HIV epidemic in many parts of the world has drastically reduced, but in Africa the situation is very different. In 2010 UNAIDS reported that SSA still remains the region most heavily affected by HIV, accounting for 67% of the global prevalence of infections with women in the reproductive age being the majority of the population living with HIV in the region (UNAIDS, 2010). In 2015, WHO highlighted that Africa is the leading continent and remains the center of HIV epidemic in the world due to high poverty levels, lack of innovation, lack of capacity, and government commitments to fight against HIV . Since the beginning of the epidemic, it is estimated that more than 70 million people have been infected with HIV in Africa and about 35 million people have died due to HIV infection in this continent. In 2008, UNAIDS estimated that three quarters of the 3.3 million pregnant women infected with HIV who gave birth each year lived in Africa, where most (700,000) of the annual new infections of HIV in children occurred . Another report by the UNAIDS in 2012 showed that about 70% of the 34 million people living with HIV globally resided in SSA, with women comprising 58% of persons HIV infected .These disproportionately higher rates of HIV among women of reproductive ages in SSA have implications not only for health but also life course transitions such as childbearing.
Generally, the effects of HIV infection on fertility have been extensively studied in generalized HIV epidemic settings in SSA . Principally, this has been to help forecast the demographic impacts of hyperendemic HIV  and because HIV prevalence among pregnant women has been widely used for estimating general population HIV prevalence levels and trends . Existing literature, largely based on cross sectional data, has demonstrated that the relationship between HIV infection and fertility depends strongly on age. For instance, studies conducted by Chen et al., 2010 on the impact of HIV on fertility in Africa using cross sectional data revealed that younger (15-24 years) women had higher antenatal care (ANC) when compared to other women in the reproductive ages. Their findings further indicated that higher ANC was associated with pregnancy and HIV risks which mostly occurred among the subset of women who are sexually active while among older age groups (25-49 years), the Fertility Rate Ratio (FRR) of the HIV-positive women tended to increase lower relatively to their HIV-negative counterparts. This understanding is critical, because from this pivotal study, it is indicative that in some way HIV have a negative influence on fertility desires especially to those living with HIV.
Another study by Marston (2016) and colleagues was carried out to determine the effects of HIV on fertility by infection duration in Uganda using evidence from the population cohorts among the HIV-positive women. Interestingly, their findings revealed that longer duration of infection was significantly associated with greater relatively fertility reduction for HIV-positive women (Marston, 2016). Marston’s findings were in tandem with those by Chen et al., 2003 as they all postulated that HIV infection tend to reduce fertility desires among HIV-positive women which may also be suggesting possible influence of HIV infection on fecundity. In this regard, the current study considers these study findings critical in its assessment of fertility intentions among HIV-positive and treats HIV infection a strong influence on the fertility desires among those living with HIV.
Other studies have also indicated that without intervention, HIV has between a 25% to 50% chance of infecting an HIV-positive mother’s baby . These findings are crucial since they establish important information on the implication of HIV infection on the general population. Further, this information can help family planning programme planners at country level assess the desire for children, the extent of mistimed and unwanted pregnancies, and the demand for contraception to space or limit births. Although several studies have generated important nexus between HIV and fertility desires among those living with HIV, other existing research on fertility intentions of HIV-infected women in SSA shows considerable diversity in perspectives on future fertility intentions due to the advent of Anti-Retroviral Therapy [ART].
In SSA, for instance, some studies conducted have indicated that with the advent of ART, the quality of life for people living with HIV has also improved, potentially impacting fertility intentions among HIV-infected individuals [12, 1, 10, 7]. From these study findings, it can be deduced that the introduction of free ART means having HIV is no longer a big barrier to having children. Although this may be anticipated, the change seems to have enormous implications for reproductive decisions and behaviors of HIV-infected individuals. Further, issues of fertility and childbearing among HIV-positive women have received relatively little attention in Zambia and information on this topic is still scanty. For example, available evidence from all the six DHSs in Zambia collected information from women age 15-49 about their preferred total number of children in their lifetime. Even though this information is based on a hypothetical situation, it provides two important measures. Firstly, for women who have not yet started a family, the data provides an idea of future fertility. Secondly, for older and high-parity women, the excess of past fertility over ideal family size provides a measure of unwanted fertility. Results in figure 1 indicate that in 1992 DHS the average number of desired children was highest while the average number of desired children remained the same between 1996 and 2018. On the other hand, figure 2 show the trend on the percentage of who want no children from the first ZDHS to the most recent one. Results show that women age 15-49 who want no more children increased from 24% in 1996 to 38% in 2018 .
Though Zambia recorded some improvements in reducing fertility desires among women over the two decades, investigating the influence of HIV status on the desire for children among women of reproductive ages in Zambia is critical to strengthen family planning. Therefore, this study assesses the fertility intentions among HIV-positive and HIV-negative women using evidence from latest Zambia Demographic Health Surveys, 2013-14 and 2018. Specifically, the study seeks to identify the socio-economic characteristics of the HIV-positive women and their fertility intentions, and finally, compares the fertility intentions between the infected and non-infected women of the reproductive ages.
Considering that Zambia’s long-term vision (known as Vision 2030) is to become a prosperous middle-income nation by 2030, a research of this nature will be of great benefit, especially in the academic spheres and in the facet of reproductive health in the country as it is a crucial part of the general health. Additionally, the results of this study will contribute to update existing knowledge and inform the healthy policy makers and programmes to promote efforts for provision of safer and healthier reproductive options among HIV positive women in Zambia. It is also envisaged that the study would be relevant to HIV/AIDS programmes especially on interventions on preventing mother-to-child transmission (PMTC) of the HIV virus and serve as a guide in designing possible interventions for people living with HIV in Zambia as well as enriching demographic literature on fertility intentions, contraceptive use and HIV/AIDS in Zambia and sub-Saharan Africa.