“Life is still going on”: Reproductive intentions among HIV-positive women and men in South Africa

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Abstract

This article reports on qualitative research investigating HIV positive individuals’ reproductive intentions and their influencing factors in Cape Town, South Africa.

In-depth interviews were held with 61 HIV positive women and men; at the time of interview, half had been receiving antiretroviral treatment (ART) for over 6 months and half were not receiving ART.

Being HIV positive modified but did not remove reproductive desires, and diversity existed in reproductive intentions. Some HIV positive individuals wished to avoid pregnancy. Fears of partner and infant infection and having a previously infected baby were important factors deterring some individuals from considering having children. There was also strongly perceived community disapproval associated with HIV and reproduction.

Strong desires to experience parenthood, mediated by prevailing social and cultural norms that encouraged childbearing in society more broadly, were reported by others. Motherhood was an important component of married women's identity and important for women's social status. Family, husbands’ and societal expectations for childbearing were important influences on women's reproductive intentions, for some counterbalancing HIV as a factor discouraging reproduction.

There was evidence that prevention of perinatal transmission programs in combination with ART may alter women and men's attitudes in favour of childbearing. Most HIV positive women had not discussed their reproductive desires and intentions with health care providers in HIV care or general health services because of anticipated negative reactions. The few who had done so perceived the counselling environment to be mostly unsupportive of open discussion on these issues.

The findings highlight the need for explicit policies recognizing reproductive rights and choice. They support the need for health counselling and service interventions that advance safer and healthier reproductive options for HIV positive individuals in this region of the world which is experiencing a generalised and advanced HIV/AIDS pandemic.

Introduction

Approximately 40 million people are currently living with HIV/AIDS worldwide and sub-Saharan Africa is the epicentre of the epidemic, home to 60% of those living with HIV/AIDS and 75% of the global population of HIV positive women (UNAIDS, 2005). South Africa has one of the fastest growing HIV epidemics, with prevalence among pregnant women increasing from less than 1% in 1990 to 30% in 2005 (Department of Health and Republic of South Africa, 2006). This dramatic increase in HIV infection rates has resulted in the country having the largest population of HIV positive people in the world, with an estimated 5.5 million people (Department of Health and Republic of South Africa, 2006) or approximately one in eight of its population infected with HIV. In sub-Saharan Africa, the majority of HIV positive individuals are women in their reproductive years (UNAIDS, 2005), and a substantial proportion are young women in their early reproductive years (Department of Health and Republic of South Africa, 2006).

To date, worldwide and especially in developing countries, health services for HIV positive individuals have focused primarily on providing prophylaxis against and care for opportunistic infections and delivery of antiretroviral treatment (ART). Less attention has been given to provision of appropriate reproductive health services for HIV positive women and men.

Globally, public health and individual health risks have led to reproduction in the context of HIV being a contested area. Because unprotected sexual activity carries significant risks for sexual transmission, re-infection with different viral strains of HIV and perinatal HIV infection (Thornton, Romanelli, & Collins, 2004), until the late 1990s, medical and public health concerns underpinned policies that discouraged HIV positive people from considering having children (Centres for Disease Control and Prevention, 1985; Kass, 1994). The substantial stigma and discrimination associated with an HIV infection has also impacted on views toward reproduction in the context of HIV (United Nations, 2004).

While these health risks in particular deter some HIV positive individuals from considering reproduction, these concerns may be overridden for others by strong personal desires to experience biological parenthood, which are influenced by social values that encourage childbearing. Indeed, evidence from developed countries, paralleling findings from Brazilian research (Paiva, Latorre, Gravator, & Lacerda, 2002), shows that a substantial proportion of HIV positive women continue to desire children despite their HIV positive status (Chen, Philips, Kanouse, Collins, & Miu, 2001; Kirshenbaum et al., 2004; Magalhaes, Amaral, Giraldo, & Simoes, 2002; Smits et al., 1999). The little research carried out among HIV positive men in developed countries and Brazil shows that they too may continue to desire having a child after learning of their HIV status (Chen et al., 2001; Paiva, Filipe, Santos, Lima, & Segurado, 2003; Sherr & Barry, 2004).

Motherhood is seen as normative for married women in most societies (Kirshenbaum et al., 2004), and in strongly pro-natal societies such as in Africa, Asia and Latin America, pressures on women to have children are particularly strong. Cultural values placed on women's fertility assign significant social status to women who bear children and childlessness often carries negative social consequences (Doyal & Anderson 2005; Dyer, Abrahams, Hoffman, & van der Spuy, 2002; Papreen et al., 2000; Santos, Ventura-Filipe, & Paiva, 1998; Sonko, 1994; ). There is evidence that men in these regions may also perceive their adult male status to be enhanced through having children (Dyer, Abrahams, Mokoena, & van der Spuy, 2004; Santos et al., 1998). This underscores the dilemmas large numbers of HIV positive women and men may experience in making decisions about reproduction within these social and cultural contexts.

In developed countries recommendations have shifted regarding reproductive counselling for HIV positive women and men, and a more nuanced, flexible approach toward reproductive choice is advocated (Barreiro, Duerr, Beckerman, & Soriano 2006; Semprini & Fiore, 2004). This has been informed by a reproductive rights approach (Center for Reproductive rights, 2005; de Bruyn, 2004) as well as being fuelled by a sharp reduction in the health risks posed by reproduction in HIV positive individuals as a result of the availability of new technologies and procedures. In these settings, near universal access to interventions for the prevention of mother-to-child HIV transmission (PMTCT), antiretroviral therapy (ART) and the availability of assisted reproductive techniques have dramatically reduced the chances of sexual and perinatal HIV transmission (da Silveira Rossi, Fonsechi-Carvasan, Makuch, Amaral, & Bahamondes, 2005; de Bruyn 2004; Thornton et al., 2004; Williams et al., 2003). In the context of the wider reproductive options available to HIV positive individuals, evidence emerging from research in developed countries indicates that ART may encourage HIV positive individuals receiving treatment to reconsider their reproductive choices in favour of childbearing. This is related to perceptions that ART allows them to live longer, have more ‘normal’ social and sexual lives, and possibly have healthy, HIV negative children (Williams et al., 2003).

In a number of countries in Southern Africa (WHO, 2005), including South Africa (Department of Health Republic of South Africa, 2005), governments have introduced public sector PMTCT programs and are extending access to free public sector ART. However, little research is available on the reproductive choices of HIV positive women and men in this region, where people of reproductive age are most heavily affected by the epidemic (Aka-Dago-Akribi et al., 1997; Meursing & Sibindi, 1995; Nebie et al., 2001; Saada et al., 2000). Nor has the impact of the availability of PMTCT or ART on their reproductive decision-making been explored. Although these issues have received increasing attention in developed countries, whether results can be generalized to African populations remains unclear.

This article reports on qualitative research that examined HIV positive women and men's reproductive intentions and factors influencing reproductive decision-making in Cape Town, South Africa. The research formed part of a broader study in which public sector health policy-makers, managers and health care providers and, key informants in non-governmental organizations working in HIV/AIDS were also interviewed.

Given the scale of the epidemic, an understanding of reproductive choices and intentions of HIV positive people in this region is vital to ensure the delivery of appropriate reproductive health care services to the sizeable proportion of women and men of reproductive age already infected with HIV. It is intended that this research will address gaps in knowledge and inform the development of policy and programs to support safer and healthier reproductive options among HIV positive individuals in this developing country setting.

Section snippets

Methods

The study was conducted between May 2004 and January 2005 at two public sector health centres providing HIV care and ART in the Cape Town metropolitan area. Both health centres serve predominantly black urban and peri-urban working class communities, and are broadly representative of the types of services available for HIV positive individuals in this setting. In both areas about a quarter of residents have no high school education, nearly 50% are unemployed and approximately 40% of households

Results

Forty HIV positive women and 20 HIV positive men were interviewed. In Cape Town, a greater proportion of women attend public sector HIV care and treatment services than men (this is in a ratio of approximately 3:1). In addition, funding exigencies allowed for fewer men than women to be interviewed. Half of these respondents (20 women and 10 men) had been receiving ART for longer than 6 months and half were not receiving ART. Table 1 summarizes the background demographic characteristics of

Discussion

This study provides qualitative insights into the reproductive intentions of a group of urban South African HIV positive women and men as well as factors influencing their reproductive decision-making. It is one of the first studies on this topic among HIV positive men in this region. Understanding HIV positive men's reproductive intentions are important in their own right as well as for the influence they are likely to have on their female partners’ reproductive intentions (Chen et al., 2001;

Conclusion

The results of this study underscore the need for closer attention towards the integration of HIV care and treatment with reproductive health care in health services in South Africa and other countries heavily affected by the HIV pandemic. While currently enormous inequity exists between developed and developing countries in access to PMTCT and ART, growing access to these interventions in developing countries provides new issues for service providers and health care systems in these settings.

Acknowledgements

The study was supported by the William and Flora Hewlett Foundation, the Medical Research Council of South Africa and the University of Cape Town. The authors thank: T. Mgoqi and P. Ngubane for the interviews; the Western Cape Province and City of Cape Town Health Departments and managers, staff and participants at the two research health facilities; the Desmond Tutu HIV Centre and Population Council, New York, colleagues for their insights.

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